Esophageal Motility Disorders

2. Histology and Final Development

4. Lymphatics:

5. Innervation

6. Nerves: central

7. Peristalsis

8. Normal function

9. Esophageal Body

10. Lower esophageal sphincter (LES)

11. Diagnostic Techniques

12. Oropharyngeal Dysphagia

13. Idiopathic Motor Disorders

14. Achalasia

16. CXR: widened mediastinum; air-fluid level in posterior mediastinum; absence of gastric bubble

18. Esophageal myotomy: improves obstructive symptoms more effectively than dilatation

19. Diffuse Esophageal Spasm

21. Treatment

22. Nutcracker or Supersqueeze Esophagus

23. Treatment

24. Idiopathic Gastroesophageal Reflux

27. Idiopathic Gastroesophageal Reflux

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1. Anatomy

a) Begins (transition from pharynx to esophagus) at lower end of sixth cervical vertebra/cricoid cartilage

b) Ends (transition to stomach) at 11th thoracic vertebra

c) Esophagus is midline, passing to the left in lower neck and upper thorax, then back to midline, then to left again in lower thorax to pass through diaphragmatic hiatus

d) Follows curve of vertebral column except to pass anteriorly to pass through diaphragmatic hiatus

e) Sites of perforation during rigid esophagoscopy:

i) Cricopharyngeus

ii) Terminal left anterior deviation

f) Measurements

i) Incisors to cardia = 38-40cm (men), 36-38 (women)

ii) Cricopharyngeus to cardia =23-30cm, avg. 25

iii) Incisors to cricopharyngeus = 14-15cm

iv) Incisors to tracheal bifurcation/indentation of aortic arch = 24-26cm

g) Anatomic relations of esophagus

i) Trachea and cervical spine

ii) Recurrent laryngeal nerves - in tracheoesophageal groove - left is closer to esophagus

iii) Above tracheal bifurcation, esophagus passes to the right of the aorta

iv) From arch down, esophagus lies to the right of the aorta

v) 8th vertebra - left wall of esophagus is covered only by mediastinal pleura - common site of perforation in Boerhaave’s syndrome

vi) Passing through diaphragmatic hiatus, phrenoesophageal membrane surrounds

vii) 2cm of abdominal esophagus between membrane and cardia - subjected to positive pressure

viii) Thoracic duct - through diaphragm behind aorta - in thorax, dorsal to esophagus, from 5th thoracic vertebra up, it passes to left, then departs from esophagus in neck to join L SCV at junction of IJV

h) Musculature of the esophagus

i) Opening is collared by cricopharyngeus muscle

ii) Outer longitudinal layer and inner circular layer

iii) Circular muscle is elliptical

iv) Upper esophagus is only striated muscle

v) At upper/middle 1/3 junction - 50% smooth muscle

i) Arterial supply of the esophagus

i) Cervical = inferior thyroid artery (mainly) + common carotid, SCA

ii) Thoracic = bronchial arteries (75% have one R and 1-2 L)

iii) Abdominal = branches of left gastric and inferior phrenic arteries

iv) After penetrating esophagus, arteries branch in T to form longitudinal anastomoses

v) Esophagus can be mobilized from stomach to aortic arch w/o devascularization

j) Venous drainage

i) Cervical = inferior thyroid

ii) Thoracic = bronchial, azygos and hemiazygous veins

iii) Abdominal = cardiac vein

k) Innervation

i) Parasympathetic = vagus

ii) Cricopharyngeus and cervical esophagus - recurrent laryngeal nerves

iii) RLN injury causes vocal cord paralysis and dysfunction of cricopharyngeus and of cervical esophageal motility, predisposing to aspiration

iv) Esophageal plexus receives fibers from vagus and from thoracic sympathetic chain

l) Lymphatic drainage

i) Submucosal plexus - lymph flow is longitudinal - extensive submucosal spread (of tumor) can occur

2. Normal structure and function

a) Pharyngeal phase of swallowing

i) Tongue is piston - propels food bolus as soft palate is closed

ii) Swallowing is reflex, once initiated

iii) Larynx is elevated and epiglottis covers opening of larynx

iv) Pharyngeal pressure increases to 45mm Hg

v) Food propelled by pressure gradient into thoracic esophagus

vi) Upper, striated portion of esophagus relaxes, then contracts within 0.5 seconds to twice its resting level of 30mm Hg

vii) A peristaltic wave of 30mm Hg begins in the esophagus

viii) Afferent nerves of pharynx are glossopharyngeal and superior laryngeal branch of vagus

ix) Efferent nerves arise from CN V, VII, X, XI, XII and C1-3

x) Motor disorders of pharyngeal swallowing:

a) Incomplete upper sphincter relaxation

b) Loss of skeletal portion of cervical esophagus

b) Esophageal phase of swallowing

i) Pressure gradient of -6mm Hg in thoracic esophagus to +6mm Hg intraabdominal

ii) Lower 1/3 of esophagus is most important

a) Peristaltic wave of 30-120 mm Hg

b) Rises to a peak in 1 sec, lasts 0.5 sec, then subsides in 1.5 sec

c) Wave moves down the esophagus at 2-4 cm/sec, reaches distal esophagus 9 sec after swallow starts

d) Vagal modulated wave

e) If vagi are preserved, muscle can be divided and propagate wave

f) Vagal fibers end in myenteric plexus

g) No known sympathetic innervation of the esophagus

iii) Pathologic states

a) Diffuse esophageal spasm - simutaneous contraction

b) Achalasia - failure of LES relaxation

c) Scleroderma - loss of contraction of smooth muscle portion of esophagus

3. The antireflux mechanism

a) LES

i) No distinct anatomic sphincter, but muscular architecture of cardia acts like a sphincter

ii) Gastric contraction results in increased LES pressure

b) Resting LES pressure

i) Correlates with incidence of GERD

ii) Truncal vagotomy has no effect

iii) Atropine (and other anti-cholinergics) reduces LES tone but does not cause GER

iv) In pharmacologic doses:

a) Secretin, cholecystokinin, glucagon, prostaglandins reduce LES pressure

b) Gastrin, bombesin, motilin augment it

v) Low LES tone in GERD is probably due to abnormal myogenic function

vi) Results of antireflux operations are independent of changes in resting LES pressure

vii) Myotomy can be performed along the length of the LES without resulting in reflux

c) Phrenoesophageal ligament

d) Intra-abdominal esophagus

i) Laplace’s law - pressure required to distend a soft tube is inversely proportional to its diameter

ii) Small-diameter esophagus requires high intragastric pressure to allow reflux

iii) LES competence directly proportional to length of intra-abdominal esophagus in cadaver studies by DeMester

4. GERD

a) Results from decrease in LES pressure, shortening of the intra-abdominal esophagus or both

b) Competence of cardia

i) Requires adequate LES pressure + intrabdominal length

ii) 80% prob of GERD when LES <5mmHG (independent of length)

iii) 80% prob of GERD when length <1cm (independent of pressure)

iv) Low incidence when pressure > 20mmHg and >2cm abd length

c) Gastric function

i) Delayed gastric emptying

ii) ­ intragastric pressure and distention shorten intraabdominal length

d) Overall LES length is also a factor in GERD

e) Esophageal clearance

i) Gravity, salivation and swallowing

ii) Pts w/complications of GERD (Barrett’s and stricture) have higher proportion of weak amplitude and simultaneous contractions

iii) ­ frequency of swallows (0.87à 2.59/min) during episodes of reflux

iv) Any impairment of motility may ­ exposure time

f) LES relaxation-abnormal will à increased exposure

g) Hiatal hernia

i) Phrenoesophageal ligament and snug hiatus prevent distention of abdominal esophagus

h) Antirreflux operations restore to normal the failed components of a mechanically defective sphincter

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5. Objective assessment of esophagus

a) Esophageal and upper GI barium studies

i) ­ accuracy with video/cine

ii) ­ accuracy with solid and liquid boluses

iii) Intraluminal abnormalities, landmarks

iv) Some motor dysfunction - spastic contractions

v) Mucosal lesions better seen with double contrast

vi) GERD- reflux only seen in 40% of those with manometry proven

b) Esophagoscopy

i) Any patient who reports dysphagia

ii) Confirm structural abnormalities w/bx

iii) Hiatal hernia = a pouch lined with gastric rugal folds lying 2cm above crural indentation (identify w/a sniff)

iv) Esophagitis

a) Grade I= reddening w/o ulceration

b) Grade II= erosive and invasive, not circumferential

c) Grade III= confluence of erosions (cobblestone) - no stricturing

d) Grade IV= complications

v) Stricture

a) Multiple biopsies

b) Dilate

vi) Barrett’s

a) Difficulty visualizing squamo columnar jxn

b) Mucosa is red, more luxuriant

c) Biopsy proximal to lesion to determine junction w/nl squamous mucosa

d) Surveillance = 4 circumferential biopsies a t 2cm intervals

vii) Submucosal lesions - do not biopsy

c) The acid perfusion test

i) 0.1N HCl or H2O infused 15 cm above LES

ii) Pt reports symptoms

iii) Positive test is pt reporting symptoms w/acid relieved by saline

iv) Reduced sensitivity in pts w/stricture or Barrett’s

d) Manometry

i) Indications

a) Motor abnormality of esophagus suspected

b) Dysphagia or odynophagia w/o definite structural abnormality on Ba swallow

c) Confirm dx of achalasia, esophageal spasm, scleroderma

d) GERD - assess esophageal clearance prior to surgery

e) Determine LES pressure, total and intra abdominal length

ii) Pressure-measuring catheter is withdrawn rapidly or stepwise across cardia

iii) Measurements

a) Relaxation of LES to gastric levels during swallow

b) Respiratory inversion point - reference point for LES

c) Response to 10 pharyngeal swallows-wet swallows are more sensitive

iv) Achalasia (Fig 39-21)

a) LES does not fully relax

b) All waves in body are simultaneous

c) No primary peristaltic waves are seen

d) Resting pressure of body is usually elevated

v) Scleroderma (Fig 39-22)

a) All muscular function of distal esophagus is obliterated

b) No high pressure zone

c) No contractions in body (lower 2/3 of esophagus)

vi) Simultaneous, repetitive or broad-based powerful contractions

a) Partial obstruction

b) Esophageal spasm

e) 24-hour esophageal motility monitoring

i) Advantages

a) Multiplies amount of data

b) Various physiologic conditions

ii) Limitations of stationary monitoring

a) Pt is supine

b) Limited to 10 swallows

iii) Technique

a) Drugs are stopped 48h before test

b) 3 transducers - 5, 10, 15 cm above upper border of LES

c) Pt diary of eating, position, sleeping, symptoms

iv) Diagnostic criteria (Table 39-2)

v) Little correlation with stationary manometry - especially for normal or nutcracker by ambulatory

vi) Primarily useful in pts with noncardiac chest pain

a) Amplitude and duration of contractions associated w/ pain are similar to asymptomatic

b) Frequency of contractions prior to episodes is increased

c) Esophageal claudication

d) Long esophageal myotomy can eliminate ability of esophagus to produce these bursts of abnormal activity

vii) Other findings

a) Esophageal contractility deteriorates with mucosal injury

b) Assess esophageal clearance function = peristaltic contractions with amplitude > 30mm Hg

f) 3-D imaging of LES

i) Overall length or intra abdominal length below 5th percentile can nulify normal LES pressure

ii) Increases the sensitivity of esophageal manometry in identifying pts who will benefit from “early” antireflux surgery (i.e., before the development of mucosal injury)

g) Esophageal pH tests

i) pH electrode withdrawl test

a) Normal is sharp rise in pH from stomach to 5-7 in esophagus

b) 20% false poitive - abandoned

ii) SART

a) pH electrode 5cm above LES - 0.1N Hcl infused into stomach - pt performs maneuvers

b) > 2 drops in pH = abnormal cardia

iii) Acid clearance test

a) Performed after SART

b) Acid infused into esophagus

c) Normal=pH > 5 with < 10 swallows

iv) 24-hour pH monitoring

a) Most sensitive method for reflux-related problems

b) Indications

(1) GERD symptoms, other tests equivocal

(2) Prior to antireflux operation

(3) Atypical GERD symptoms

(4) Dysphagia and motor disorder (?GERD)

(5) Recurrent symptoms after esophageal or gastric surgery

c) Technique

(1) pH electrode 5cm above LES

(2) Acid reflux = pH <4

(3) Alkaline reflux = pH >7

(4) Restrict intake to food pH 5-6

d) Measure

(1) Cumulative time pH < 4 as percentage of time supine, total, upright

(2) Frequency of episodes of pH<4/24h

(3) Duration of longest episode

4) Number of episodes > 5 min

h) Radionuclide studies

i) Localization of Barrett’s - not used

ii) Dx and quantitation of GERD - not physiologic

iii) Measure esophageal transit - ?screening test prior to manometry

iv) Measurement of gastric emptying

i) Bilirubin monitoring with fiberoptic probe

i) Complications are related to acid and alkaline reflux

ii) 5cm above LES

iii) Uses bilirubin as a marker of exposure to duodenal contents

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Last revised Apr-24-2002
Revised by Stephen H. McKellar.
© 2002 Cardiothoracic Surgery Network.