Diseases of The Oesophagus mmary box
Symptoms of oesophageal disease:
- Difficulty in swallowing described as food or fluid sticking
(oesophageal dysphagia) . - Pain on swallowing (odynophagia) Suggests inflammation and ulceration - Regurgitation or reflux (heartburn) is common in gastro-oesophageal reflux disease.
- Chest pain difficult to distinguish from cardiac pain.
Dysphagia: it is difficulty in swallowing. The causes may be local or general ,the local causes of obstruction of any tube in the body are subdivided into those in the lumen, those in the wall and those outside the wall.
Local causes:
In the lumen*foreign body. In the wall*Congenital atresia *inflammatory stricture, secondary to reflux oesophagitis. *caustic stricture. *achalasia. *plummer-vinson syndrome with oesophageal web. *pharyngeal pouch. *tumour of oesophagus or cardia.
Outside the wall *pressure of enlarged lymph nodes(malignant or one of the lymphomas ).*thoracic aortic aneurysm.*bronchial carcinoma. Retrosternal goiter.
General causes *myasthenia gravis. *bulbar palsy. *bulbar poliomyelitis. *diphtheria *hysteria.
Malignant stricture has a short history, occurs usually in elderly people and is associated with severe weight loss.
Swallowed foreign bodies : they are swallowed either accidently, usually by children, or deliberately by mentally distributed people, prison inmates.
Obstruction of the oropharynx and tracheal opening by a large portion of meat can rapidly become fatal . a sharp blow just below the xiphoid, Heimlich’s manoeuvre causing a sudden rise in intra-abdominal pressure may dislodge the plug and save the patient’s life.
Unless they are sharp or irregular amazingly large foreign bodies will pass into stomatch if a smooth such as a bolus of food impacts in the oesophagus one must suspect the presence of a stricture. Occasionally ,for example a carcinoma of the oesophagus presents as an acute dysphagia when a morsel of food lodges above it. Absolute dysphagia with failure to swallow even saliva is then characteristic.
The presenting feature is painful dysphagia. The danger depends on the nature of the body. Perforation may occur with resultant mediastinitis rarely perforation of the aorta occurs with fatal haematemesis . the diagnosis may be conifirmed by a plain x-ray if the foreign body is radio-opaque, otherwise it may be shown up on a barium swallow.
Treatment: oesophagoscopic removal is indicated where the foreign is stuck in the oesophagus. Occasionally oesophagotomy is required. The great majority of foreign bodies once they have passed into the stomach proceed uneventfully along the alimentary canal and are passed per rectum. Occasionally a sharp foreign body penetrates the wall of the bowel (there is a particular tendency for it to lodge in and pierce a Meckel’s diverticulum ).the treatment of the foreign body that has passed the cardia is initially conservative. The patient is watched and serial x-rays taken to observe the object’s progress if it is radio-opaque. operation is performed if a sharp object fails to progress or if abdominal pain or tenderness develop. Where the foreign body is potentially toxic when ingested, emetics or laxatives may be indicated.
Perforations of the oesphagus Classification : from within *swallowed foreign body ---may occur anywhere in the oesophagus. *rupture at oesophagoscopy ---usually at the level of circopharyngeus or above a stricture. *rupture at a dilatation or biopsy ---usually at the lower end of the oesophagus and especially likely in the pr esence of oesophageal disease (carcinoma or stricture).
From without Spontaneous *lower thoracic oesophagus (Boerhaave’s syndrome*).
Clinical features :After instrumentation, perforation is suspected if the patient complains of pain in the neck chest or upper abdomen together with dysphagia and pyrexia. Diagnosis is certain if surgical emphysema is felt in the supraclavicular area.
Spotaneous rupture of the oesophagus occurs rarely and associated with vomiting after a large meal (Boerhaave’s syndrome )there is severe pain in the chest the dorsal region of the spine or the upper abdomen (acute mediastinitis ). The patient is collapsed and cyanosed. The abdomen may be rigid and often a false diagnosis of perforated peptic ulcer of myocardial infarction is made. Surgical emphysema (subcutaneous crepitation) is usually palpable in the neck due to gas escaping into the mediastinum.
Special investigations *chest x-ray shows gas in the neck and mediastinum and there may fluid and gas in the pleural cavity.
*gastrograffin swallow (a water soluble contrast fluid) will confirm the perforation and define its position
Treatment Cervical perforation is managed conservatively with parenteral antibiotics, nil by mouth and intravenous drip. Abscess formation in the superior mediastnum requires drainage via a supraclaviacular incision. thoracic rupture is treated by immediate suture (or resection if a carcinoma is instrumentally perforated). The prognosis from spontaneous rupture is inversely related to the time to surgery, and after 12 hours is very poor.
Caustic stricture of the oesophagus This follows accidental or suicidal ingestion of strong acids or alkalis (particularly caustic soda and ammonia). It often occur in children. In the acute phase there are associated burns of the mouth and pharynx. The mid and lower oesophagus are usually affected as these are the sites of temporary hold-up of the caustic material where the oesophagus is crossed by the aortic arch and at the cardiac sphincter.
Treatment :The damaged oesophagus is rested by instituting feeding via a gastrostomy nil being given by mouth. Systemic steroids are given to reduce scar formation. If a stricture develops gentle dilatation with bougies is commenced after 3or 4 weeks. An established impassible is treated by a bypass operation, a loop of colon or small bowel being brought up on its vascular pedicle between the stomach below the upper oesophagus above.
Achalasia of the cardia This is a neuromuscular failure of relaxation at the lower end of the oesophagus with progressive dilatation tortuosity in coordination of peristalsis and often hypertrophy of the oesophagus above.
Clinical features :Achalasia may occur at any age but particularly in the third decade. Regurgitation of fluids from the dilated oesophageal sac may be followed by an aspiration pneumonia. Occasionally malignant change occurs in the dilated oesophagus.
Special investigations *chest x-ray may reveal the dilated oesophagus as a mediastinal mass with an air-fluid level and pneumonitis from aspiration from oesophageal contents. (Note that there are three other ‘pseudotumours” scoliosis tuberculous paravertebral abscess and thoracic aortic aneurysm , all of which may simulate a mediastinal tumour on a chest x-ray *barium swallow shows gross dilatation and tortuosity of the oesophagus leading to an unrelaxing narrowed segment at the lower end(said to resemble a bird’s beak) *oesophagoscopy demonstrates an enormous sac of oesophagus containing a pond of stagnant food and fluid.
Treatment Satisfactory results are obtained by Heller’s operation which is a cardiomyotomy dividing the muscle of the lower end of the oesophagus and the upper stomach down to the muscosa in a similar manner to Ramstedt’s operation for congenital pyloric hypertrophy. This procedure may now be performed thoracosocopically reducing morbidity. The same effect may be achieved by forcible dilatation of the oesophagogastric junction by means of a hydrostatic bag. Although this avoids open operation. It is accompanied by the risk of rupture of the oesophagus.
Plummer- vinson syndrome : a syndrome dysphagia and iron-deficiency an-aemia (with its associated smooth tongue and koilonychias ---spoon shaped nails) usually in middle-aged or elderly females. The dysphagia is associated with hyperkeratinization of the oesophagus and often with the formation of a web in the upper part of the oesophagus. The condition is premalignant and associated with the development of a carcinoma in the circopharyngeal region.
Treatment: the dysphagia responds to treatment with iron although the web may require dilatation through an oesophagoscope.