Disorder of Esophagus

Esophagus
It is a mucus-lined, muscular tube that carries food
from the mouth to the stomach.
It begins at the base of the pharynx and ends about 4
cm below the diaphragm.
Its ability to transport food and fluid is facilitated by
two sphincters.
A. Upper esophageal sphincter (hypopharyngeal
sphincter): is located at the junction of the
pharynx and the esophagus.
B. Lower esophageal sphincter (gastroesophageal
sphincter or cardiac sphincter): is located at
the junction of the esophagus and the stomach.
12/10/2018 By Seifu Nig 2
 Esophagus…

It pierces the diaphragm through an opening called

the esophageal hiatus and ends in the superior
portion of the stomach
An incompetent lower esophageal sphincter allows
reflux (backward flow) of gastric contents.
There is no serosal layer of the esophagus; therefore,
if surgery is necessary, it is more difficult to perform
suturing or anastomosis.

12/10/2018 By Seifu Nig 3

Cont…d
At rest, the upper & lower
esophageal sphincters are
closed.

Thus no backflow of gastric

contents occur except during
belching or vomiting.

Movement of food in the

esophagus is initiated
voluntarily and then it
becomes involuntary.
4
 Disorders of the Esophagus
Include:
Motility disorders (achalasia, diffuse spasm)
Hiatal hernias
Diverticula
Perforation
Gastroesophageal reflux disease (GERD)
Barrett’s esophagus
Benign tumors
Carcinoma

12/10/2018 By Seifu Nig 5

 ACHALASIA
ê A Greek word to mean failure to relax
ê Is absent or ineffective peristalsis of the distal
esophagus, accompanied by failure of the
esophageal sphincter to relax in response to
swallowing.
ê It is a disorder in which the lower esophageal
sphincter(LES) fails to relax during swallowing.

BY: Mohammed A. 6
Narrowing of the esophagus just above the stomach results
in a gradually increasing dilation of the esophagus in the
upper chest.
Cause include the following:
¥ Primary (idiopathic)
¥ Degeneration and loss of ganglion cells cause a defect in
the innervations of the esophagus.
¥ Resulting absence of complete LES relaxation and absence
of peristalsis

BY: Mohammed A. 7
C/ Manifestations
 The primary symptom is difficulty in swallowing
both liquids and solids.(Dysphagia)
 The patient has a sensation of food sticking in the
lower portion of the esophagus.
 Chest pain and heartburn (pyrosis).
 Pain may or may not be associated with eating
 Retrosternal discomfort in early stages

BY: Mohammed A. 8
 The gradual dilatation of the esophagus and food
retention in the esophageal lumen can lead to
regurgitation and possible aspiration pneumonia.

 Esophageal dilatation, food fermentation, and acid

production within the lumen can lead to chest pain and
heartburn.

 Weight loss can be a late manifestation.

BY: Mohammed A. 9
 Assessment and Diagnostic Findings

X-ray, Barium swallow, computed tomography (CT)

of the chest, and endoscopy may show esophageal
dilation above the narrowing at the gastroesophageal
junction.

12/10/2018 By Seifu Nig 10

Assessment and Diagnostic Findings
• Radiographic studies
– Barium Swallow (Bird`s beak appearance)

õ The classic “rat tail” narrowing is

observable with barium studies.

õ Endoscopy

BY: Mohammed A. 11
BY: Mohammed A. 12
Endoscopy is done to rule out cancer particularly
in persons >50 years

Endoscopy Showed that tight cardiac and food

remains in the esophagus ,

BY: Mohammed A. 13
Patient undergoing endoscopy

BY: Mohammed A. 14
Treatment

 There is no curative treatment for Achalasia

 The aim is to decrease the LES pressure either

chemically(medications) or mechanically (by
forceful stretching) .

BY: Mohammed A. 15
 TREATMENT OF ACHALASIA

• Medical: Smooth muscle relaxants

• Balloon Dilatation
• Surgical myotomy
 Management
As a temporary measure, calcium channel blockers
and nitrates have been used to decrease esophageal
pressure and improve swallowing.
Injection of botulinum toxin (Botox) into quadrants
of the esophagus via endoscopy to inhibit contraction
of smooth muscle.
– Periodic injections are required to maintain
remission.

12/10/2018 By Seifu Nig 17

 Management …
Treat conservatively by pneumatic dilation to stretch the
narrowed area of the esophagus.
High success rate.
Perforation is a potential complication, although its
incidence is low.
Since it is painful procedure moderate sedation in the
form of an analgesic or tranquilizer, or both, is
administered
Surgically treated by esophagomyotomy usually performed
laparoscopically, either :
with a complete lower esophageal sphincter myotomy
and an antireflux procedure or
without an antireflux procedure. 18
Pneumatic dilation: A–C, The dilator is passed, guided by a previously
inserted guide wire. D, When the balloon is in proper position, it is
distended by pressure.
Nursing care of patient’s with achalasia
 The patient should be instructed to eat slowly and
to drink fluids with meals
 Semisoft ,warm foods are better tolerated than cold,
hard foods ,the client should avoid hot, iced foods
as well as alcohol and tobacco
 All foods should be chewed thoroughly to add saliva
to mixture, providing lubrication and allowing the
bolus to pass more easily

BY: Mohammed A. 20
 To prevent nocturnal reflux of food the client

should sleep with head of the bed elevated.

 Nursing diagnosis nutrition ,altered less than

body requirements R/T dysphasia

BY: Mohammed A. 21
Diffuse Esophageal Spasm
 Diffuse Esophageal Spasm
Is a motor disorder of the esophagus.
Cause is unknown, but stress may be a factor.
More common in women and usually manifests in
middle age.

12/10/2018 By Seifu Nig 23

 Clinical Manifestations
Dysphagia or Odynophagia on swallowing
Chest pain similar to that of coronary artery spasm.

12/10/2018 By Seifu Nig 24

 Assessment and Diagnostic Findings

Esophageal manometry, which measures:

motility of the esophagus and
pressure within the esophagus,
• Indicates that simultaneous contractions of the
esophagus occur irregularly.
Diagnostic x-ray studies after ingestion of barium
show separate areas of spasm.

12/10/2018 By Seifu Nig 25

12/10/2018 By Seifu Nig 26
 Management
Conservative therapy : sedatives and long-acting
nitrates to relieve pain.
Ca channel blockers (eg, nifedipine, verapamil ): to
manage diffuse spasm.
Small, frequent feedings and a soft diet: to decrease
esophageal pressure and irritation that lead to spasm.
Dilation performed by bougienage (use of
progressively sized flexible dilators), pneumatic
dilation, or esophagomyotomy: if pain becomes
intolerable.

12/10/2018 By Seifu Nig 27

 Management…

If none of the conservative approaches is successful

in managing symptoms, surgery may be considered.
An esophageal Heller myotomy (a surgical
procedure in which the cardiac sphincter is cut,
allowing food and liquids to pass into the stomach)
by a minimally invasive approach.

12/10/2018 By Seifu Nig 28

Hiatal Hernias
 What is a hernia?
It is an abnormal weakness or hole in an anatomical
structure which allows something inside to protrude
through.
It is commonly used to describe a weakness in the
abdominal wall.
Hernias by themselves usually are harmless, but
nearly all have a potential risk of having their blood
supply cut off (becoming strangulated).
If the blood supply is cut off at the hernia opening in
the abdominal wall, it becomes a medical and surgical
emergency.
 HIATAL HERNIA
HIATAL HERNIA( diaphragmatic Hernia and esophageal Hernia)

 Is the herniation of the stomach or lower esophagus through the

diaphragm in to the thorax.

 The esophagus enters the abdomen through an opening in the

diaphragm and empties at its lower end into the upper part of the
stomach.

 Normally, the opening in the diaphragm encircles the esophagus

tightly, and the stomach lies completely within the abdomen.

BY: Mohammed A. 32
Hiatus (or hiatal) hernia, the opening in the
diaphragm through which the esophagus passes
becomes enlarged, and part of the upper
stomach tends to move up into the lower
portion of the thorax.

Etiology: The actual cause of hiatal hernia is

unknown.

BY: Mohammed A. 33
Predisposing factors

Structural changes: such as weakening of the

muscles in the diaphragm around the
esophagogastric opening.

Factors that increase intra-abdominal pressure:

Obesity, pregnancy, ascites,and tumors.

BY: Mohammed A. 34
BY: Mohammed A. 35
Clinical manifestation  Dysphagia,
 Vary in kinds and  Substernal pain,
severity burning, non-
 In sliding hernia radiating, positiona-
 50% patients are dependent epigastric
asymptomatic pain, substernal
tightness
 Heart burn,
Regurgitation  Symptoms may be
exacerbated by
gastric
irritants(alcohol,
tobacco, caffeine)
BY: Mohammed A. 36
Type II(paraesophageal hernia),Rolling hernia

ê Occurs when all or part of the stomach pushes

through the diaphragm beside the esophagus.

ê Accounts 10% of the total hernia

ê Depending on the extent of herniation,

ê Gastroesophageal junction is blow the diaphragm

BY: Mohammed A. 37
BY: Mohammed A. 38
Clinical Manifestations
¥ A sense of fullness after eating
¥ Chest pain
¥ Reflux usually does not occur, because the
gastroesophageal sphincter is intact.
¥ Complication for both (type I and II)
¥ Hemorrhage, obstruction, and strangulation can
occur with any type of hernia.

BY: Mohammed A. 39
 Assessment and Diagnostic Findings

Diagnosis is confirmed by:

– X-ray studies,
– Barium swallow, and
– Fluoroscopy

12/10/2018 By Seifu Nig 40

Management
Frequent, small feedings that can pass easily through
the esophagus.
No food intake several hours before bed
Weight reduction
Sleep with head at 300
Avoid gastric irritants,alcohol,tobacco,and caffeine)
Regular use of antiacids

BY: Mohammed A. 41
 The patient is advised not to recline for 1 hour
after eating, to prevent reflux or movement of
the hernia,

Surgical Management

 Nissan fundoplication(an abdominal approach is

usually used and the fundus is wrapped 360
degree around the lower esophagus

BY: Mohammed A. 42
 ESOPHAGEAL DIVERTICULUM

12/10/2018 43
 Questions that should be answered at the end

What is a diverticulum?
How are diverticula classified?
What are the relevant anatomy and physiology of the
hypopharynx and esophagus?
What causes esophageal diverticula?
What are the signs and symptoms of esophageal
diverticula?
How should these patients be investigated?
How should these patients be treated?
12/10/2018 44
 DIVERTICULUM
It is an out pouching of mucosa and submucosa
that protrudes through a weak portion of the
musculature.

Esophageal diverticula may be congenital or

acquired, and the acquired esophageal diverticulum
may be single or multiple.

BY: Mohammed A. 45
 Cont…d

terminologies
 Diverticula = pouches
 Diverticulosis = condition of
having diverticula

 Diverticulitis =inflammation
of diverticuli

12/10/2018 46
 Types of esophageal

 Esophageal Diverticula may occur in one of the three

areas of the esophagus—
The pharyngoesophageal or upper area of
the esophagus,
The midesophageal area,
The epiphrenic or lower area of the and
Intramural pseudodiverticulosis

12/10/2018 47
 Types cont…d

I. Zenker's diverticulum (also referred to as a

hypopharyngeal or pharyngoesophageal diverticulum)
 The most common type of diverticulum, which is found
three times more frequently in men than in women, is
verticulum or a pharyngeal pouch).
 It occurs posteriorly through the cricopharyngeal muscle
in the midline of the neck.
 The diverticulum is referred to as a pulsion diverticulum.

12/10/2018 48
12/10/2018 49
 Types …
Midesophageal (traction) diverticula
II. Midthoracic diverticulum is usually a traction
diverticulum produced by continued peristalsis of
the esophagus against a fixed esophageal adhesion.
 It occurs as a result of previous mediastinal
inflammatory disease.
 Pulsion diverticulum also occur in the midthoracic
esophagus.

12/10/2018 50
 Midesophageal Diverticula

12/10/2018 51
 Types …

III. Epiphrenic diverticulum is located in the distal

esophagus and contains some attenuated muscle
layer in its wall.
• It is also a pulsion diverticulum.
IV. Intramural diverticulosis consists of tiny, multiple
out-pouchings along the course of the esophagus.

12/10/2018 52
 Clinical manifestations

Many small diverticula are asymptomatic.

Midesophageal diverticula are most
commonly asymptomatic.
1/3 of patients with epiphrenic diverticula
are asymptomatic, and
2/3 complain of dysphagia and chest pain.
Dysphagia is the most common complaint
of patients with intramural diverticulosis.

12/10/2018 53
 Clinical manifestation
¥ Difficulty of swallowing and Fullness in the neck

¥ Complain of regurgitation of undigested food.

¥ When the patient is recumbent position undigested

food is regurgitated and may also cause coughing
because of irritation of the trachea.

¥ Halitosis and a sour taste in the mouth are also

common

BY: Mohammed A. 54
 Assessment and Diagnostic Findings

Barium swallow: to determine the exact nature and

location of a diverticulum.
Manometric studies: for patients with epiphrenic
diverticula to rule out a motor disorder.
Esophagoscopy: usually is contraindicated because
of the danger of perforation of the diverticulum, with
resulting mediastinitis
Blind insertion of a nasogastric tube should be
avoided.

12/10/2018 55
 Management
• Surgical removal of the diverticulum is the only
means of curative measures.

BY: Mohammed A. 56
Gastro-esophageal Reflux
Disease (GERD)
 DEFINITIONS

• Gastroesophageal reflux: Reflux of gastric

contents to the esophagus
• Gastroesophageal reflux disease (GERD):
Any significant symptomatic clinical
condition or histopathological changes
resulting from reflux.
 Path physiology of GERD
• Normally, the LES maintains enough pressure around
the lower end of the esophagus to close it and prevent
reflux.
• Typically the sphincter relaxes after each swallow to
allow food into the stomach.
• In GERD, the sphincter does not remain closed
(usually due to deficient LES pressure or pressure
within the stomach exceeding LES pressure) and the
pressure in the stomach pushes stomach contents into
the esophagus.
• The high acidity of the stomach contents causes pain and
irritation when it enters the esophagus.
BY: Mohammed A. 59
 GERD
Some degree of gastroesophageal reflux (backflow of
gastric or duodenal contents into the esophagus) is
normal in both adults and children.
Excessive reflux may occur because of:
An incompetent lower esophageal sphincter
Pyloric stenosis, or
A motility disorder
Its incidence seems to increase with aging.

12/10/2018 By Seifu Nig 60

 Clinical Manifestations

Pyrosis (burning sensation in the esophagus)

Dyspepsia (indigestion)
Regurgitation
Dysphagia or odynophagia (pain on swallowing)
Hypersalivation
Esophagitis
The symptoms may mimic those of a heart attack.

12/10/2018 By Seifu Nig 61

 Assessment and Diagnostic Findings

Diagnostic testing may include an endoscopy or

barium swallow to evaluate damage to the esophageal
mucosa.
Ambulatory 12- to 36-hour esophageal pH
monitoring is used to evaluate the degree of acid
reflux.

12/10/2018 By Seifu Nig 62

 Management

Life- style modification

Begins with teaching the patient to avoid situations that
decrease lower esophageal sphincter pressure or cause
esophageal irritation.
Instruct the patient to:
Eat a low-fat diet
Avoid caffeine, tobacco, beer, milk, foods containing
peppermint or spearmint, and carbonated beverages
Avoid eating or drinking 2 hours before bedtime
Maintain normal body weight
Avoid tight-fitting clothes
Elevate the head of the bed on 6- to 8-inch (15- to 20-
cm) blocks; and to elevate the upper body on pillows. 63
 Management …

If reflux persists, antacids or H2 receptor antagonists,

such as famotidine (Pepcid), nizatidine (Axid), or
ranitidine (Zantac), may be prescribed.
Proton pump inhibitors (medications that decrease the
release of gastric acid, such as lansoprazole
[Prevacid], rabeprazole [AcipHex], esomeprazole
[Nexium], omeprazole [Prilosec], and
pantoprazole [Protonix]) may be used.
– However, these products may increase intragastric
bacterial growth and the risk of infection.

12/10/2018 By Seifu Nig 64

 Nissen Fundoplication
♠ If medical management is unsuccessful, surgical
management involves a Nissen fundoplication (wrapping
of a portion of the gastric fundus around the sphincter
area of the esophagus).
– Can be performed by the open method or by
laparoscopy.

12/10/2018 By Seifu Nig 65

Barrett’s Esophagus
 Barrett’s Esophagus
It is a condition in which the lining of the esophageal
mucosa is altered.
It typically occurs in association with GERD; indeed,
longstanding untreated GERD may lead to Barrett’s
esophagus.
Reflux eventually causes changes in the cells lining
the lower esophagus.
The cells that are laid to cover the exposed area are
no longer squamous in origin.
These precancerous cells initiate the healing process
and can be a precursor to esophageal cancer.
12/10/2018 By Seifu Nig 67
 Clinical Manifestations

Symptoms of GERD, notably frequent heartburn.

Symptoms related to peptic ulcers or esophageal
stricture, or both.

12/10/2018 By Seifu Nig 68

 Assessment and Diagnostic Findings
An esophagogastroduodenoscopy (EGD) usually
reveals an esophageal lining that is red rather than
pink.
Biopsies are performed, and high-grade dysplasia
(HGD) is evidenced by the squamous mucosa of the
esophagus replaced by columnar epithelium that
resembles that of the stomach or intestines.
HGD has been found to be associated with a 30% risk
of development of cancer.

12/10/2018 By Seifu Nig 69

 Management

Monitoring varies depending on the extent of cell

changes.
Follow-up endoscopy is performed within 6 months
if there are minor cell changes.
Treatment is individualized for each patient.
The options include:
a. Intensive surveillance with biopsies,
b. Endoscopic ablation therapy (eg, photodynamic
therapy), and
c. Esophagectomy,
12/10/2018 By Seifu Nig 70
THANKS
FOR

YOUR
ATTENTION