كلية الطب البشري قسم الجراحة الدكتور عاصم قبطان The esophagus 1 st Lecture MAKubtan 1 The anatomy and physiology of the esophagus Their relationship to disease ID: 777323
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Slide1
الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان
The esophagus1st Lecture
M.A.Kubtan
1
Slide2The anatomy and physiology of the esophagusTheir
relationship to diseaseThe clinical features.
Investigations .
T
reatment of benign and malignant disease with particular reference to the common adult disorders
M.A.Kubtan
2
LEARNING OBJECTIVES
To understand
Slide3The esophagus is a muscular tube.
Approximately 25 cm long .Mainly
occupying the posterior
mediastinum .
Extending from the upper esophageal sphincter (the cricopharyngeus muscle)
in the
neck to the junction with the cardia of the stomach.M.A.Kubtan
3
Surgical anatomy
Slide4The upper esophagus, including the upper sphincter
, is striated.This is followed by a transitional zone of both
striated and smooth muscle .
There is only smooth muscle in the
lower half of the esophagus .M.A.Kubtan4
Muscular Type
Slide5It is lined throughout with squamous epithelium.
M.A.Kubtan5
Histological lining
Slide6The parasympathetic nerve supply is mediated by branches of the vagus nerve .
Has synaptic connections to the myenteric (Auerbach’s) plexus.
Meissner’s
sub mucosal plexus
is sparse in the esophagus.M.A.Kubtan6
Nerve supply
Slide7The upper sphincter consists of powerful striated muscle.The lower sphincter is more subtle, and is created by the
asymmetrical arrangement of muscle fibers in the distal esophageal wall
just above the
esophagogastric
junction.M.A.Kubtan7Esophageal sphincters
Slide8Remember the distances 15, 25 and 40
cm for anatomical locationduring endoscopy
M.A.Kubtan
8
Slide9The main function of the esophagus is to transfer food from
the mouth to the stomach in a coordinated fashion.The initial
movement from
the mouth is voluntary
.M.A.Kubtan9
Physiological Function
Slide10Sequential contraction of the oropharyngeal musculature .
Closure of the nasal and respiratory passages .Cessation of breathing .
Opening
of the upper
esophageal sphincter .Beyond this level, swallowing is involuntary.The body of
the esophagus propels the bolus through a relaxed
lower esophageal
sphincter (
LES) .
M.A.Kubtan
10
The pharyngeal phase of swallowing
Slide11M.A.Kubtan11
Slide12The coordinated esophageal wave that follows a conscious swallow is called primary peristalsis.It is under
vagal control .Also there are specific neurotransmitters that control the LES.
M.A.Kubtan
12
primary peristalsis
Slide13The upper esophageal sphincter is normally closed at restServes as a protective mechanism against regurgitation of esophageal contents into the respiratory passages.
It serves to stop air entering the esophagus other than the small amount that enters during swallowing.M.A.Kubtan
13
Upper Esophageal Sphincters Function
Slide14The LES is a zone of relatively high pressure that prevents gastric contents from refluxing into the lower esophagus .It opens in response to a primary peristaltic wave .
It relaxes to allow air to escape from the stomach and at the time of vomiting.M.A.Kubtan14
LES Function
Slide15Food .Gastric distension . Gastrointestinal hormones .
Drugs and smoking.M.A.Kubtan
15
Factors influence LES sphincter tone
Slide16The arrangement of muscle fibers, their differential responses to specific neurotransmitters. The relationship to diaphragmatic contraction.The normal LES is 3–4 cm long .
LES has a pressure of 10–25 mmHg.M.A.Kubtan
16
Factors contributing to LES Function
Slide17Dysphagia .Odynophagia .Regurgitation and reflux .Chest pain .
M.A.Kubtan17
Esophageal Symptoms
Slide18Described as difficulty with swallowing.Food fails to enter the esophagus .Food stays in the mouth .
Food enters the airway causing coughing or spluttering.M.A.Kubtan
18
Dysphagia
Slide19Oral or pharyngeal .Food fails to enter the esophagus .Stays in the mouth or enters the airway causing coughing or spluttering.
Causes are chronic neurological or muscular diseases or inflammatory or traumatic origin.M.A.Kubtan19
Dysphagia in Voluntary Phase
Slide20characterized by :A sensation of food sticking.Is often informative of the likely diagnosis.
M.A.Kubtan20
dysphagia occurs in the involuntary phase
Slide21Acute .Chronic .Can affect solids .Can affect fluids .
Can affect solids & fluids .Can be intermittent .Can be progressive.
M.A.Kubtan
21
Mode of Dysphagia
Slide22pain on swallowing.Patients with reflux esophagitis often feel retrosternal discomfort .Is a feature of infective esophagitis and may be particularly severe in chemical injury.
M.A.Kubtan22Odynophagia
Slide23Regurgitation should strictly refer to the return of esophageal contents from above a functional or mechanical obstruction.Reflux is the passive return of gastro duodenal contents to the mouth as part of the symptomatology of gastro esophageal reflux disease (GERD).M.A.Kubtan
23Regurgitation and reflux
Slide24Loss of weight .Anemia .Cachexia .Change of voice .
Cough or dyspnoea .M.A.Kubtan
24
Symptoms & Signs accompany regurgitation and/or reflux.
Slide25Similar in character to angina pectoris .M.A.Kubtan25
Chest pain
Slide26Radiography .Endoscopy .Endosonography .Esophageal manometry .
24-hour pH recording .M.A.Kubtan
26
Investigations
Slide27M.A.Kubtan27
Slide28Dilatation of strictures .Thermal recanalisation .M.A.Kubtan
28Therapeutic procedures
Slide29Difficulty in swallowing described as food or fluid sticking (esophageal dysphagia) Must rule out malignancy .Pain on swallowing (Odynophagia)Suggests inflammation and ulceration .Regurgitation or reflux (heartburn) Common in gastro-esophageal reflux disease .
Chest pain Difficult to distinguish from cardiac pain M.A.Kubtan
29
Correlation of Symptoms of esophageal disease
Slide30The most common impacted material is food.Usually occurs above a significant pathological lesion .Plain radiographs are often useful for foreign bodies .Modern denture materials are not always radiopaque
.Diagnosis made by endoscopy .M.A.Kubtan
30
FOREIGN BODIES IN THE ESOPHAGUS
Slide31M.A.Kubtan31
Slide32M.A.Kubtan32
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Slide35M.A.Kubtan35
Slide36الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان
The esophagus2nd Lecture
M.A.Kubtan
36
Slide37Perforation of the esophagus is usually iatrogenic (instrumental perforations at therapeutic endoscopy) it can be managed conservatively ( not all the time ).Barotrauma’ (spontaneous perforation). is often a life-threatening condition that regularly requires surgical intervention .
M.A.Kubtan37PERFORATION
Slide38Potentially lethal complication due to mediastinitis and septic shock .Numerous causes, but may be iatrogenic .Surgical emphysema is virtuall
pathognomonic .Treatment is urgent; it may be conservative or surgical, but requires specialised care .
M.A.Kubtan
38
Perforation of the esophagus
Slide39Boerhaave syndrome :This occurs classically when a person vomits against a closed glottis.
The pressure in the esophagus increases rapidly, and the esophagus bursts at its weakest point in the lower third sending a stream of material into the mediastinum and often the pleural cavity .Boerhaave syndrome is the most serious type of perforation . This causes rapid chemical irritation in the mediastinum and pleura followed by infection if untreated.
M.A.Kubtan
39
Barotrauma
(spontaneous perforation)
Slide40M.A.Kubtan40 Barotrauma
has also been described in relation to other pressure events when the patient strains against a closed glottis (e.g.defaecation, labour
, weight-lifting).
Slide41The clinical history is usually of severe pain in the chest or upper abdomen following a meal or a bout of drinking.Associated shortness of breath is common.There may be a surprising amount of rigidity on examination of the upper abdomen, even in the absence of any peritoneal contamination.
The diagnosis can usually be suspected from the history and associated clinical features.
M.A.Kubtan
41
Diagnosis of spontaneous perforation
Slide42A chest X-ray is often confirmatory with air in the mediastinum, pleura or peritoneum.Pleural effusion occurs rapidly .A contrast swallow or CT is nearly always required to guide management
M.A.Kubtan42
Continue
Slide43M.A.Kubtan43severe subcutaneous emphysema 33 years old woman
secondary to prolonged labor during normal vaginal delivery
Slide44M.A.Kubtan44
Slide45M.A.Kubtan45A contrast swallow
Slide46M.A.Kubtan46
Slide47Aero digestive fistula is most common and usually encountered in primary malignant disease of the esophagus or bronchus.Erosion into an adjacent structure with fistula formation is more common.Free perforation of ulcers or tumors of the esophagus into the pleural space is rare .
Coughing on eating and signs of aspiration pneumonitis may allow the problem to be recognized .M.A.Kubtan
47
Pathological perforation
Slide48Covering the communication with a self-expanding metal stent is the usual solution.Erosion into a major vascular structure is invariably fatal.M.A.Kubtan
48Continue
Slide49Foreign bodies : The esophagus may be perforated during removal of a foreign body .Occasionally, an object that has been left in the esophagus for several days will erode through the wall.Instrumental perforation :
Instrumentation is by far the most common cause of perforation.Perforation can occur in the pharynx or esophagus, usually at sites of pathology or when the endoscope is passed blindly.Perforation may follow biopsy of a malignant tumor.
M.A.Kubtan
49
Penetrating injury
Slide50The esophagus may be perforated by guide wires, graduated dilators or balloons, or during the placement of self-expanding stents. The risk is considerably higher in patients with malignancy.M.A.Kubtan
50Continue
Slide51Forceful vomiting may produce a mucosal tear at the cardia rather than a full perforation.In Mallory–Weiss syndrome, vigorous vomiting produces a vertical split in the gastric mucosa.Tear immediately below the squamocolumnar junction at the cardia in 90% of cases.
In only 10% is the tear in the esophagus .M.A.Kubtan
51
MALLORY–WEISS SYNDROME
Slide52M.A.Kubtan52
Slide53Perforation of the esophagus usually leads to mediastinitis.The aim of treatment is to limit mediastinal contamination and prevent or deal with infection. The event causing the perforation (spontaneous vs. instrumental) .
Underlying pathology (benign or malignant) .The status of the esophagus before the perforation (fasted and empty vs. obstructed with a stagnant residue).M.A.Kubtan
53
Factors influencing Treatment of esophageal perforations
Slide54attempted suicide.Accidental ingestion occurs in children and when corrosives are stored in bottles labeled as beverages.All can cause severe damage to the mouth, pharynx, larynx, esophagus and stomach.
In general, alkalis are relatively odorless and tasteless, making them more likely to be ingested in large volume.M.A.Kubtan
54
CORROSIVE INJURY
Slide55Significant stricture formation occurs in about 50% of patients with extensive mucosal damage .M.A.Kubtan55
Continue
Slide56M.A.Kubtan56
Multiple stricture of the body of esophagus
Slide57Most congenital malformations develop during embryonic life between the third and eighth weeks of gestation.M.A.Kubtan57
CONGENITAL MALFORMATIONS
Slide58A blind proximal pouch with a distal tracheo-esophageal fistula is the most common type. Affected infants typically present Soon after birth with frothy saliva .
cyanotic episodes, exacerbated by any attempt to feed.The preceding pregnancy may have been complicated by maternal polyhydramnios.
M.A.Kubtan
58
Esophageal atresia
Slide59M.A.Kubtan59
Slide60Is confirmed by failure to pass a 10 Fr oro-gastric tube into the stomach .The tube is visible within an upper esophageal pouch on the chest radiograph.
The presence of abdominal gas signifies the tracheo-esophageal fistula.Associated anomalies are common and include cardiac, renal and skeletal defects.
M.A.Kubtan
60
Diagnosis
Slide61Surgical repair : The esophageal ends are anastomosed.Division and repair of tracheo – esophageal tract .
M.A.Kubtan61
Treatment of Esophageal Atresia
Slide62Infants with pure esophageal atresia and no tracheo-esophageal fistula . Usually best managed by a temporary gastrostomy .Delayed primary repair.Except for very-low-birth weight babies and those with major congenital heart disease, most infants with repaired esophageal atresia have a good prognosis.
M.A.Kubtan62
Continue
Slide63Anastomotic leak .Stricture .
Recurrent fistula formation .Gastro- esophageal reflux.M.A.Kubtan
63
Potential postoperative complications
Slide64الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان
The esophagus3rd LectureM.A.Kubtan
64
Slide65May result from absence of an intra - abdominal length of esophagus .The phreno-esophageal ligament is weak .
The crural opening widens allowing the upper stomach to slide up through the hiatus.
Sliding hiatus hernia alone should not be viewed as the cause of reflux.
As long as the LES remains competent, pathological GERD does not occur.
M.A.Kubtan65
Sliding hiatus hernia
Slide66True par esophageal hernias in which the cardia remains in its normal anatomical position are rare.The vast majority of rolling hernias are mixed hernias in which the cardia is displaced into the chest and the greater curve of the stomach rolls into the mediastinum
M.A.Kubtan66PARAOESOPHAGEAL (‘ROLLING’) HIATUS
HERNIA
Slide67M.A.Kubtan67
Slide68The symptoms are mostly due to twisting and distortion of the esophagus and stomach.Dysphagia is common.Chest pain may occur from distension of an obstructed stomach.
Classically, the pain is relieved by a loud belch.Strangulation, gastric perforation and gangrene can occur.M.A.Kubtan
68
The symptoms of rolling hernia
Slide69Chest X Ray .Barium meal study .Esophagoscopy .
M.A.Kubtan69
Investigations
Slide70M.A.Kubtan70
Slide71M.A.Kubtan71
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Slide73M.A.Kubtan73
Slide74M.A.Kubtan74
Slide75M.A.Kubtan75GASTRO-ESOPHAGEAL REFLUX DISEASE ( GERD )
Slide76Normal competence of the gastro-esophageal junction is maintained by the LES.Is influenced by both its physiological function and its anatomical location relative to the diaphragm and the esophageal hiatus.As long as the LES remains competent, pathological GERD does not occur.
M.A.Kubtan76
Etiology
Slide77Most episodes of physiological reflux occur during postprandial transient lower esophageal sphincter relaxations (TLESRs).In the early stages of GERD, most pathological reflux occurs as a result of an increased number of TLESRs rather than a persistent fall in overall sphincter pressure. In more severe GERD, LES pressure tends to be generally low .
loss of sphincter function seems to be made worse if there is loss of an adequate length of intra-abdominal esophagus.M.A.Kubtan
77
Continue
Slide78The classical triad of symptoms is :Retrosternal burning pain (heartburn) .Epigastric
pain (sometimes radiating through to the back) .Regurgitation.Heartburn and regurgitation can be brought on by stooping or exercise.
Nocturnal reflux .
Some patients present with less typical symptoms such as angina-like chest pain .
Dysphagia is usually a sign that a stricture has occurred .M.A.Kubtan78
Clinical features of GERD
Slide79The most appropriate examination is endoscopy with biopsy.Widespread use of proton pump inhibitor PPIs, which cause rapid healing of early mucosal lesions.On the other hand, there is a strong correlation between worsening endoscopic appearances and the duration of esophageal acidification on pH testing.
M.A.Kubtan79
Diagnosis
Slide80M.A.Kubtan80
Slide81M.A.Kubtan81
Slide82M.A.Kubtan82
Slide83الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان
The esophagus4th LectureM.A.Kubtan
83
Slide84Benign tumors .Relatively rare.The majority of ‘benign’ tumors are not epithelial in originArise from other layers of the esophageal wall.
Most benign esophageal tumors are small and asymptomatic.large benign tumor may cause only mild symptoms .
The most important point in their management is usually to carry out an adequate number of biopsies to prove beyond reasonable doubt that the lesion is not malignant
.
M.A.Kubtan84NEOPLASMS OF THE OESOPHAGUS
Slide85M.A.Kubtan85Classic appearance of a large esophageal gastrointestinal
stromal tumor on barium swallow
Slide86M.A.Kubtan86An intraluminal
polyp that proved to be a leiomyosarcoma
Slide87Non-epithelial primary malignancies are rare.Secondary malignancies rarely involve the esophagus .Bronchogenic carcinoma by direct invasion of either the primary and/or contiguous lymph nodes.
M.A.Kubtan87Malignant tumors
Slide88Cancer of the esophagus is the sixth most common cancer in the world.It is a disease of mid to late adulthood .Only 5–10% of those diagnosed will survive for 5 years .
M.A.Kubtan88Carcinoma of the
oesophagus
Slide89Squamous cell usually affects the upper two-thirds; adenocarcinoma usually affects the lower third .Common etiological factors are tobacco and alcohol (squamous
cell) and GERD (adenocarcinoma) .The incidence of adenocarcinoma is increasing .Lymph node involvement is a bad prognostic factor .
Dysphagia is the most common presenting symptom, but is a late feature .
Accurate pretreatment staging is essential in patients thought to be fit to undergo ’curative’ treatment .
Adenocarcinoma now accounts for 60–75% of all esophageal cancers in several countries .M.A.Kubtan
89
Continue
Slide90M.A.Kubtan90
Slide91M.A.Kubtan91
Mid-esophageal mass tuberculosis
Slide92Endoscopy is the first-line investigation for most patients. Endoscopic ultrasound .Cytology and/or histology specimens taken via the endoscope are crucial for accurate diagnosis .
Histology and cytology increases the diagnostic accuracy to more than 95%. Transcutaneous ultrasound .
Computerised
tomography CT .
Magnetic resonance imaging scanning .Positron emission tomography (PET) . Bronchoscopy
M.A.Kubtan
92
Investigation
Slide93M.A.Kubtan93
Slide94M.A.Kubtan94
Slide95M.A.Kubtan95
Slide96General health and fitness for potential therapies.Indicate whether surgery alone or multimodal therapy is most appropriate.The aim is to provide the best chance of cure while
minimising perioperative risks.
Surgery alone should be reserved for patients with early disease .
Multimodal therapy should be used in patients with locally advanced disease .
M.A.Kubtan96General assessment and staging
Slide97Tis High-grade dysplasiaT1 Tumor invading lamina propria
or submucosaT2
Tumor
invading
muscularis propria
T3 Tumor invading beyond muscularis
propria
T4
Tumor
invading
adjacent structures
Tx
Primary tumor cannot be assessed
N0 No regional lymph node metastases
N1 Regional lymph node metastases
Nx
Lymph nodes cannot be assessed
M0 No distant metastases
M1(a)
Coeliac
node involved (for distal
oesophageal
tumours
)
Supraclavicular
node involved (for proximal tumors)
M1(b)
Coeliac
or
supraclavicular
node involved if not remote from tumor site (i.e. not 1a) All other distant metastases
Mx
Distant metastases cannot be assessed
M.A.Kubtan
97
TNM staging scheme for
oesophageal
cancer
Slide98At the time of diagnosis, around two-thirds of all patients with esophageal cancer will already have incurable disease.The aim of palliative treatment is to overcome debilitating or distressing symptoms while maintaining the best quality of life possible for the patient.The principal aim of palliation is to restore adequate swallowing.
Once esophageal neoplasms reach th
submucosal
layer of the esophagus, the tumor has access to the lymphatic system.The proximal extent of resection should ideally be 10 cm above the macroscopic tumor and 5 cm distal.M.A.Kubtan
98
Treatment of malignant tumors
Principles
Slide99Radical esophagectomy is the most important aspect of curative treatmentNeoadjuvant
treatments before surgery may improve survival in a proportion of patientsChemoradiotherapy alone may cure selected patients, particularly those with squamous
cell cancers
Useful palliation may be achieved by chemo/radiotherapy or endoscopic treatments
M.A.Kubtan99
Treatment of carcinoma of the oesophagus
Slide100الجامعة السورية الخاصةكلية الطب البشريقسم الجراحةالدكتور عاصم قبطان
The esophagus5th Lecture
M.A.Kubtan
100
Slide101Esophageal motility disorders :when a patient has dysphagia in the absence of a stricture .Can be correlated with a specific abnormality on oesophageal
manometry .Pain, with or without a swallowing problem, is frequently the dominant symptom .M.A.Kubtan
101
MOTILITY DISORDERS AND DIVERTICULA
Slide102Pathology and etiology :Achalasia is uncommon .It is due to loss of the ganglion cells in the myenteric (Auerbach’s) plexus .Histology of muscle specimens generally shows a reduction in the number of ganglion cells (and mainly inhibitory
neurones) with a variable degree of chronic inflammation.The physiological abnormalities are a non-relaxing LES and absent peristalsis in the body of the esophagus In some patients .
These uncoordinated contractions result in pain as much as a sense of food sticking.
M.A.Kubtan
102Achalasia
Slide103Is an achalasia-like disorder that is usually produced by adenocarcinoma of the cardia .M.A.Kubtan103
Pseudoachalasia
Slide104The disease is most common in middle life .It typically presents with dysphagia .Patients often present late .
Regurgitation is frequent .May be overspill into the trachea, especially at night.M.A.Kubtan
104
Clinical features
Slide105Achalasia may be suspected at endoscopy :By finding a tight cardia .
Food residue in the esophagus.Barium radiology may show hold-up in the distal esophagus .A tapering stricture in the distal esophagus, often described as a ‘bird’s beak .
The gastric gas bubble is usually absent.
A firm diagnosis is established b esophageal
manometry.M.A.Kubtan105
Diagnosis
Slide106The two main methods :Forceful dilatation of the cardia (Pneumatic dilatation ) .
Forceful dilatation is curative in 75–85% of cases.Heller’s myotomy , This involves cutting the muscle of the lower esophagus and
cardia
.
The major complication is gastro-esophageal reflux, and most surgeons therefore add a partial anterior fundoplication .It is successful in more than 90% of cases and may be used after failed dilatation.
M.A.Kubtan
106
Treatment
Slide107M.A.Kubtan107
Achalasia of the esophagus
(a) Barium swallow showing the smooth outline of the stricture, which narrows to a point at its lower end
(b)
Tortuosity and sigmoid appearance of the lower oesophagus.(c) Mediastinal shadow due to a large, fluid-filled esophagus.
Slide108M.A.Kubtan108Almost achalasia, but note the irregularity of the taper, which indicates carcinoma of the
cardia.
Slide109M.A.Kubtan109Balloon dilator for the treatment of achalasia by forceful dilatation.
Slide110M.A.Kubtan110Heller’s myotomy
. The incision should not go too far on to the stomach. The lateral extent must enable the mucosa to pout out, to prevent the edges healing together.
Slide111Diffuse esophageal spasm is a condition in which there are incoordinate contractions of the esophagus, causing dysphagia and/or chest pain.
Spastic pressures on manometry of 400–500 mmHg .marked hypertrophy of the circular muscle and a corkscrew esophagus on barium swallow .These abnormal contractions are more common in the distal two-thirds of the esophageal body .
M.A.Kubtan
111
Disorders of the body of the esophagus
Slide112M.A.Kubtan112Corkscrew esophagus in diffuse esophageal spasm.
Slide113Esophageal involvement is mainly seen in systemic sclerosis.Symptoms involve : Weak peristalsis.
Swallowing difficulties may be compounded by pharyngeal problems in the disorders that primarily affect skeletal muscle .M.A.Kubtan
113
Esophageal involvement in autoimmune disease
Slide114Esophageal involvement is mainly seen insystemic sclerosis, may be a feature of
polymyositis,
dermatomyositis
,
systemic lupus erythematosus, polyarteritis
nodosa
rheumatoid disease.
M.A.Kubtan
114
Continue
Slide115M.A.Kubtan115Advanced scleroderma of the esophagus. The esophagus dilates, and the lower esophageal sphincter is widely incompetent.
Slide116Pulsion diverticula :
develop at a site of weakness as a result of chronic pressure against an obstruction.Symptoms are mostly caused by the underlying disorder unless the diverticulum
is particularly large.
Traction
diverticula : much less common.Are mostly a consequence of chronic granulomatous
disease affecting the
tracheobronchial lymph nodes due to tuberculosis.
Fibrotic healing of the lymph nodes exerts traction on the esophageal wall
M.A.Kubtan
116
Pharyngeal and
oesophageal
diverticula
Slide117Esophageal diverticulum as it protrudes posteriorly above the
cricopharyngeal sphincter through the natural weak point .The dehiscence between the oblique and horizontal (
cricopharyngeus)
fibres
of the inferior pharyngeal constrictor .It involves loss of the coordination between pharyngeal contraction and opening of the upper sphincter.When the diverticulum
is small, symptoms largely reflect this incoordination
with predominantly pharyngeal dysphagia.
As the pouch enlarges, it tends to fill with food on eating, and the
fundus
descends into the
mediastinum
.
M.A.Kubtan
117
Zenker’s
diverticulum
(pharyngeal pouch)
Slide118M.A.Kubtan118Mid-esophageal
diverticulum with a tracheooesophageal fistula.
Mid-esophageal traction
diverticulum
with the mouth facing downwards.
Slide119M.A.Kubtan119
a small pharyngealpouch with a prominent cricopharyngeal impression and ‘streaming’ of barium, indicating partial obstruction;
b) a large pouch extendingbehind the esophagus towards the thoracic inlet.
Slide120M.A.Kubtan120Vascular abnormalities affecting the
oesophagusEsophageal varices with smooth outline of the filling defects.