anatomy of oesopagus, achalasia cardia, carcinoma esophagus

1. ANATOMY OF OESOPHAGUS
Parul Gupta

2.  Oesophagus is a fibro-muscular tube, measuring
about 25cm in adults.
 It extends from lower end of pharynx (C6) to
cardiac end of stomach (C11).
 There are three normal constrictions which are at
following levels-
a. At pharyngo-oesophageal junction (C6) – 15cm
from the upper incisors.
b. At crossing the Arch of Aorta and left main
bronchus (T4) – 25cm from upper incisors.
c. Where it pierces the diaphragm (T10) – 40cm from
upper incisors.

3. It runs
vertically but
inclines to the
left from its
origin to
thoracic inlet
and from T7 to
oesophageal
opening in the
diaphragm.

4. Wall of Oesophagus
The wall of oesophagus consist of 4 layers from within
outwards -
 Mucosa- lines by non keratinised stratified squamous
epithelium.
 Submucous- contains mucous secreting oesophageal
glands.
 Muscular layer- made of inner circular and outer
longitudinal fibres.
Upper third – striated muscle fibres.
Middle third – both striated and smooth muscle fibres.
Lower third – smooth muscle fibres.

5. NERVE SUPPLY
o Parasympathetic – Vagus Nerve
o Sympathetic – Sympathetic trunk
LYMPHATIC DRAINAGE
o Cervical part – Deep cervical lymph nodes
o Thoracic part – posterior mediastinal LN
o Abdominal part – gastric(coeliac) LN

6. ARTERIAL SUPPLY
Blood supply –
o Cervical part (segment including up to arch of
aorta) – Inferior thyroid arteries.
o Thoracic part – Oesophageal branches of Aorta
o Abdominal part – Oesophageal branches of Left
gastric artery.
Venous drainage –
o Upper part – Brachiocephalic vein
o Middle part – Azygous vein
o Lower end – Left gastric vein

7. APPLIED PHYSIOLOGY
Manometric studies have shown 2 high pressure
zones in oesophagus and they form the
physiological sphincters-
1. Upper oesophageal sphincter- starts at the upper
border of oesophagus and is about 3-5cm in length
and functions during the act of swallowing.
2. Lower oesophageal sphincter- is situated at lower
portion of oesophagus. It is also 3-5cm in length
and functions to prevent oesophageal reflux.

8. ACHALASIA CARDIA
It is failure of relaxation
of Cardia (oesophago-
gastric junction) due to
disorganized
oesophageal peristalsis,
as a result of failure of
integration of the
parasympathetic
impulse causing
Functional Obstruction
and high resting
pressure in LES. LES
does not relax during
swallowing.

9. CLINICAL FEATURES
 More common in females of age group 20-40yrs.
 Dysphagia more to liquids than solids.
 Regurgitation of swallowed food particularly at
night.
 Odynophagia and weight loss.
 Malnutrition and general ill health.

10. DIAGNOSIS
 Radiography
Barium swallow shows-
1. pencil like smooth narrowing of lower
oesophagus (Rat Tail appearance).
2. dilatation of proximal oesophagus.
3. absence of fundic gas bubble.
4. sigmoid oesophagus or mega-
oesophagus

12.  Manometric studies
Shows low pressure in body of oesophagus
and high pressure at lower sphincter and
failure of the sphincter to relax.
 Oesophagoscopy is done to confirm the
diagnosis and rule out benign strictures or
carcinoma of oesophagus.

13. TREATMENT
Surgeries
1. Modified Heller’s operation (myotomy of narrowed
lower portion of the oesophagus).
2. Negus hydrostatic dilatation (rarely).
3. Laparoscopic/ thoracoscopic cardiomyotomy.
4. Resection only when failure of myotomes occurs or
when mega-oesophagus or metaplasia is present.
Drugs
a. Endoscopic injection of botulinum toxin to sphincter –
high recurrence rate.
b. Calcium channel blocker, nitroglycerine sublingually.

14. CARCINOMA OESOPHAGUS
It is the 6th most common cancer in world.
More common in China, Japan, USSR, South Africa
and Asian countries.
Five year survival is not more than 5 – 10%.

15. Smoking
Excessive alcohol
consumption
Tobacco chewing
Age > 45yrs
More common in Men
AETIOLOGY Pre-existing pathological
lesions as benign strictures
etc.
Plummer-Vinson syndrome

16. PATHOLOGY
 Squamous cell carcinoma is the most
common(93%) in India and other Asian countries.
 Adenocarcinoma (3%) is also seen, but in the lower
oesophagus.
Involvement of –
Middle third (50%)
Lower third (33%)
Upper third (17%)

17. TYPES
There are 5 main
types-
• Annular
• Ulcerative
• Fungating (cauliflower like)
• Polypoid
• Varicoid (diffuse
submucosal type)

18. SPREAD OF THE DISEASE
• The lesion may fill • Depending on site • Metastases may
the lumen and involved, cervical, develop in the liver,
infiltrate the wall of mediastinal or lungs, bone and
oesophagus. coeliac LNs may be brain.
• It may spread to involved.
adjoining spaces.
Recurrent laryngeal
nerve causes
aspiration problems.
Direct Lymphatic Blood borne

19. CLINICAL FEATURES
• Substernal discomfort.
Early symptoms • Preference for soft or liquid food.
Progressive
• Dysphagia first to solids and then to liquids.
dysphagia and • Weight loss leading to emaciation.
emaciation
• Usually signifies extension of tumor beyond the
Pain walls of oesophagus.
• It is referred to the back
Aspiration • Spread of cancer may cause laryngeal paralysis or
fistulae formation leading to cough, hoarseness of
problem voice, aspiration pneumonia and mediastinitis

21. Barium swallow X-Ray showing
irregular filling defect which is a
feature of Carcinoma of
Oesophagus

22. DIAGNOSIS
 Barium swallow – shows narrow and irregular
oesophageal lumen, without proximal dilatation of
the oesophagus.
 Oesophagoscopy – to see the site and the extent
of lesion and take the biopsy, done under GA.
 Bronchoscopy – helps to exclude extension of
growth into the trachea and bronchi.
 CT scan – useful to assess the extent of disease
and nodal metastases.

23. TREATMENT
Upper 2/3rd –
Surgery- difficult due to great vessels and involvement
of mediastinal nodes. Thus radiotherapy is the
treatment of choice.
Lower 1/3rd –
Surgery is preferred. Affected segment with a wide
margin of oesophagus proximally, and the fundus of
stomach distally, can be excised with primary
reconstruction of the food channel.
Advanced lesion –
Only palliation is possible.
Chemotherapy is used only as a palliative measure in
the locally advanced or disseminated disease.

24. AN ALTERNATIVE FOOD CHANNEL CAN BE
PROVIDE BY:
A. A by-pass operation.
B. Oesophageal intubation with Celestin or
Mousseau-Barbin or a similar tube.
C. Permanent gastrostomy or a feeding jejunostomy.
D. Laser surgery- oesophageal gwoth is burnt with
Nd:YAG laser to provide food channel.