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Dr. Ghaze Qasaimeh Ro’aa Rawagah Definition Anatomy of oesophagus Physiology of oesophagus Causes of Dysphagia Clinical presentation Investigation Modality of treatment Anatomy of oesophagus - The oesophagus is a musucular tube, approximately 25 cm long occupying the posterior mediastinum and extending from cricopharyngeal sphincter to the cardia of stomach ; 2 cm of this tube lies below the diaphragm. - The musculature of upper 5% including the upper oesophageal sphinecter is striated the middle 40% has mixed striated and smooth muscle with proportion of smooth muscle increasing distally and the distal 55% is smooth muscle . There are upper and lower oesophageal sphinecters the upper sphinecter consist of powerful striated muscle wheres lower sphinecter is much more subtle . The main function of oesophagus is to transfer food from mouth to the stomach in coordinated fashion . the initial movement of food from mouth is voluntary. the pharayngeal swallow response is triggered by stimulation of pharynx and involve sequential contraction of oropharyngeal musclature togother with closure of nasal and respiratoy passage and opening of upper oesophageal sphinecter. the body of the oesophagus propels the food bolus by primary peristalisis through relaxed lower oesophageal sphinecter in to the stomach taking air with it upper oesophageal sphinecter is normally closed at rest and it serves as a protective mechanism against regurgitation of oesophageal contents in to respiratory passage and stop air entering the oesophagus other than small amount that enters during swallowing Los prevents gastric and duodenal contents from reflexing in to lower oesophagus Dysphagia means difficulty in swallowing. may or may not be associated with pain on swallowing. may be associated with ingestion of solids or liquids, or both. should be distinguished from pain alone on swallowing (odynophagia), which doesn’t interfere with the act of swallowing. Congenital: -esophageal atresia. Acquired: 1-Oral -Painful mouth ulcer. 4-Outside the wall -mouth or throat infection. -paraesophageal (rolling) hiatus hernia. -goiter. 2-In the lumen -pharyngeal pouch. -food bolus. -mediastinal tumors: -foreign body. bronchial carcinoma. lymphadenopathy. 3-In the wall -enlarged left atrium (mitral stenosis). -inflammatory stricture: -thoracic aortic aneurysm. GERD, caustic stricture, candidiasis. -dysphagia lusoria (rare). -diverticula. -Achalasis. -carcinoma. 5-Neuromuscular disorders -Plummer-vinson syndrome. -bulbar palsy. -irradiation. -Guillian-Barre’ syndrome. -scleroderma. -CVA. -Chagas’ disease (rare). -motor neuron disease. -myasthenia gravis. blind-ending esophagus from atresia with fistula to trachea. (1500 to 3000 births) 90% associated with tracheoesophageal fistula. May be associated with maternal polyhydramnios. associated anomalies VACTERL. Types (A-E), type C /common( blind proximal pouch with distal tracheoesophageal fistula). Sign: the newborn baby will show dribbling of saliva, inability to swallow feeds, production of frothy mucus, choking attacks, cyanotic attacks and chest infections, obvious respiratory compromise (aspiration pneumonia), gastric distention as air enters the stomach directly from the trachea. Treatment: - Initially; suction blind pouch (NPO), upright position of child, prophylactic antibiotic (ampicilin, gentamicin). - surgical correction via a extrapleural thoracotomy, usually through the right chest with division of fistula and end-to-end esophageal anastomosis. Within 1-2 day of birth Following recovery form immediate post operative period the long term prognosis is excellent The two most feared complications are pneumonia and leakage from anastomosis All manner of foreign bodies have become arrested in the esophagus. 1-The most common impacted material is food (meat bolus) may be the first presentation of a benign stricture or a malignant tumor (signifies underlying disease). 2-button batteries and coins may be a troublesome problem in children (be aware). 3-false teeth. 4-others. -plain radiography are often useful. (modern denture material are not always radiopaque) -Treatment: flexible endoscopy. If food bolus then we break it up by given fluid or by endoscopy. - We should know the cause of impaction after treatment (stricture , tumor..etc) Gasrtoesophageal reflux: Reflux of gastric contents to the esophagus Gastroesophageal reflux disease (GERD): Any significant symptomatic clinical condition or histopathological changes resulting from reflux. Reflux esophagitis: GERD patients with histopathologically demonstrable changes in the esophageal mucosa. -due to loss of competence of the LES. -may associated with hiatus hernia (sliding or rolling-paraesophagus) Epidemiology: -Heartburn is a very common condition: 3% of population experience heartburn daily 7% frequently 15% weekly 25% monthly -Most common in pregnant women: 80% -Common in obese and smokers. Mechanism of GERD 1-Transient LES relaxation 2-Hypotensive LES 3-Decreased esophageal acid clearance 4-Hiatus hernia 5-Impaired salivation. Symptoms: HEARTBURN REGURGITATION Dysphagia Chest pain Water brash Nausea and vomiting Belching Hicough. Exraesophageal symtoms. Diagnosis: Clinical picture. UGI endoscopy. 24 hour pH monitoring* the gold standard Radioisotope scanning Barium swallow. Complication: 1-Stricture formation* 2-Chronic blood loss 3-Barrett’s epithelium 4-Adenocarcinoma May be acute condition in a small percentage Mostly chronic condition with recurrent symptoms Majority can be controlled on drugs Majority may require a sort of acid suppressive therapy at 5 years No clear relation exists between symptoms of reflux, amount of reflux or degree of esophagitis. 1-lifestyle modification. - avoid smoking and alcohol . - Weight loss . - Tilting the bed . 2-pharmacology (antacid, H2 blocker, PPI). 3-Surgery: -Nissen:360 degree fundoplication; wrap fundus of stomach all the way around the esophagus. * Belsey : thoracis procedure in which the oesophagus is sutured to the diaphram and to the fundus of stomach to reduce any hiatus hernia and produce 240 anterior fuonduplication . * Hill: cardia is tightened and fixed to the preaortic fascia. Reflux-induced stricture occur mainly in the late middle-aged and elderly, but they may present in children. immediately above the esophagus junction. peptic stricture respond well to dilatation and long-term treatment with a PPI. OTHER CAUSES: malignancy, radiation. -fungal and viral infections are common. -in immunocompromised. -esophagitis due to Candida albicans is relatively common in patient taking steroid & chemotherapy. -it may present with dysphagia or odynophagia. -endoscopy shows numerous white plaque that can’t be removed. -Biopsy is diagnostic. -Treatment: topical antifungal agent.
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