Chapter 9. DISEASES OF THE ESOPHAGUS

Motor-evacuatory

Movement of the bolus due to the esophageal peristalsis and the force of gravity.

Secretory

Discharge of the mucus which envelops the bolus and contributes to its movement.

Defensive-barrier

The upper esophageal sphincter prevents the reflex of the contents into the pharynx, oral cavity and respiratory tracts; the lower sphincter prevents the reflux of the gastric contents into the esophagus. The main condition of physiological functioning of the lower esophageal sphincter is the presence of sharp angle of His.

Diagnostics

Total and biochemical blood analysis

Stage I: leukocytosis, shift of the leukocytic formula to the left, increase of ESR, elevation of hematocrit.

Stage III: hypo- and dysproteinemia, hyperkalemia, hypochloremia and hyponatremia, metabolic acidosis. The indices characterize the degree of cachexia in stenosis.

Roentgenological investigation

In stage III singular or multiple sites of esophageal strictures of various length are fixed. The investigation characterizes the degree and extent of stenosis.

Esophagoscopy

In stage I the performance of endoscopy is dangerous because of possible esophageal perforation.

In stage II the sites of various extent covered with the crust are revealed. In stage III the investigation helps to detect the degree of stenosis.

Bougienage of the esophagus

Types

Indications

Prophylactic

Early bougieurage is used to prevent scarry stenosis of the esophagus. It is performed after subsiding of acute inflammatory phenomena, beginning from the 7^th day; in burns of severe degree - from the 15th day after burning, the procedure being performed during 1-1.5 months.

Therapeutic

It is performed to the patients in case of the development of scarry stenosis (usually from the 7^th week after burning), in whom prophylactic bougieurage has failed to be effective.

Definition and statistical data

Cardiac achalasia is a disease which is characterized by steady spastic narrowing of the terminal part of the esophagus with impairment of reflex opening of the lower esophageal sphincter, manifesting itself as dysphagia.

The morbidity constitutes 0.6-2.0 per 100 000 of the population. Women aged 20-40 are affected more frequently. The incidence of the disease occurrence reaches 20%. Among esophageal diseases achalasia takes the second place after cancer.

Signs and symptoms

Heartburn

It occurs after meals, intensifies in lying position, when bending forward, lifting loads. It is connected with irritation of the esophagus by acidic gastric contents.

Pain

It is localized behind the breastbone and irradiates to the back (interscapular region). It is connected with pronounced esophagitis, spastic esophageal contractions.

«Wet pillow» symptom

Spontaneous leakage of liquid (refuctant) out of the mouth during sleep.

Cough

It intensifies in lying position. It is connected with irritation of the respiratory tracts by the refuctant.

Complications:

- aspiration pneumonia with the development of the lungs' destruction;

- esophagitis with the development of ulcers, hemorrhage, scarry stenosis, dysphagia;

- Barret's esophagus with possible malignization (up to 15%).

Definition and statistical data

Esophageal diverticulum is a steady sac-like protrusion of the mucous membrane through the defect in the muscular membrane of the esophagus into the mediastinal cavity.

Esophageal diverticula occur in 1.5-2% of the population, mostly in men aged 45-60 years. In 7-20% of cases diverticulum is combined with other diseases (achalasia, chalasia of the cardia, chronic cholecystitis, chronic pancreatitis, ulcerous disease, etc.).

Clinical picture and diagnostics

Symptoms

Zenker's diverticulum

Bifurcational diverticulum

Epiphrenal diverticulum

Dysphagia

It is pronounced.

It is pronounced insignificantly, because the diverticulum is well drained (the diverticulum fundus is fused with the mediastinal organs and it is located above the opening).

It is pronounced in significant sizes.

Feeling of "the lump in the throat"

It is typical.

It is not typical.

Regurgitation

It is typical, it makes the patient's condition easier.

It is not typical.

It is pronounced in significant sizes.

Pain

At the onset of the disease there is the "scratching" feeling in the throat at meals.

It is localized behind the breastbone.

Putrefactive odor from the mouth in prolonged retention of food in the diverticulum

It is typical.

It is not typical.

It is pronounced in significant sizes.

Peculiarities

The volume of the diverticulum may reach 1-1.5 l. There is a protrusion on the left lateral surface of the neck which decreases in size at pressing. Due to the fulfilment of the sac with food and air there occur gurgling sounds heard at the distance. Tracheal constriction causes difficulty at breathing; constriction of the recurrent nerve causes hoarseness of the voice.

Symptoms of adjacent organs' constriction are detected: palpitation, dyspnea.

Complications

Regurgitation and aspiration of the diverticulum contents result in bronchites, pneumonias, lung abscesses.

Perforation. Mediastinitis, esophago-bronchial fistulas. Erosive hemorrhage from the superior vena cava or from the aorta is possible.

Perforation. Mediastinitis, esophagobronchial fistulas.

In small sizes diverticula have no clinical manifestations.

Definition and statistical data

It is a malignant tumor of esophageal epithelium.

Cancer of the esophagus constitutes 60-80% of all esophageal diseases and more than 95% of other malignant esophageal tumors. The morbidity incidence is up to 20 people per 100 000 of the population. Males fall ill 2-3 times more frequently than females. People over 60 years old constitute up to 80% of the patients.