Motility
Disorders of the motility of the esophagus tend to be either caused by or aggravated during times of stress. Eating rapidly is another trigger, as this demands more precise and rapid changes in muscle activity than eating slowly. Achalasia, formerly called cardiospasm, is a primary disturbance in the peristaltic action of the esophagus that results in failure to empty the organ of its contents. The lower sphincteric portion of the esophagus does not receive its normal signal to relax and, over time, may become hypertonic, resisting stretching. A cycle occurs in which the main portion of the esophagus slowly becomes distended, holding a column of fluid and food that it cannot propel downward to a lower esophageal sphincter that stays closed because of a failure in its neural system. In most persons with this disorder, there is a shortage or disease of ganglion cells of the myenteric plexus (Auerbach plexus), or a disease of the network of nerves within the muscles of the esophagus, so that coordinated peristalsis becomes impossible. In Chagas disease, parasites called trypanosomes invade the neural tissue and directly destroy ganglion cells. These organisms are not present in the temperate zones of the world, however, and the reason for ganglion cell degeneration in achalasia is generally unknown. Effective treatment is achieved by destroying the ability of the lower esophageal sphincter of the esophagus to contract. This may be done by forcible dilatation, using a balloon, of the esophagus in the area that is tonically contracted. The objective is to rupture the circular muscle at the site, and this is generally achieved with one or two dilatations. If this fails to overcome the contraction or if the contraction recurs, surgery is required that involves opening the abdomen and cutting through the circular muscles from the outside of the esophagus. The disadvantage of both methods of treatment is that the anti-reflux mechanism is thereby destroyed. Consequently, if precautions are not taken, the individual may lose the symptoms and risks of achalasia but may develop the symptoms and signs of reflux peptic esophagitis.
Gastroesophageal reflux
In healthy individuals, reflux of gastric contents into the esophagus occurs occasionally. This causes the burning sensation behind the sternum that is known as heartburn. Some of the refluxed material may reach the pharynx where it also may be felt as a burning sensation. Reflux is most likely to occur after large meals, especially if physical activity, including bending, stooping, or lifting, is involved. In these circumstances, the esophagus responds with peristaltic waves that sweep the gastric contents back into the stomach, with relief of the heartburn.
Persistent reflux symptoms are invariably due to inadequate functioning of the anatomical components, such as the lower esophageal sphincter, which keep the contents of the stomach below the diaphragm, delayed esophageal clearance of the refluxed material, and delayed emptying of the stomach. The disorder can also be caused by obesity. Excessive fat on the trunk is almost always accompanied by large deposits of fat within the abdomen, especially in the mesentery (the curtainlike structure on which most of the intestine is hung). Consequently, when intra-abdominal pressure is increased, such as in physical activity, there is insufficient room within the abdomen to accommodate the displacement of the organs, and the resulting pressure forces the stomach upward. The weak point is the centre of the diaphragm at the opening (hiatus) through which the esophagus passes to join the stomach. The upper portion of the stomach is pushed through the hiatus, and the distortion of the position of the organs brings about impaired functioning of the anti-reflux mechanisms. In the early stages the stomach may slide back into the abdomen when the increase in the intra-abdominal pressure eases, but eventually, if the circumstances are unchanged, the upper part remains above the diaphragm. A common contributory cause of gastroesophageal reflux in women is pregnancy. As the uterus containing the developing fetus comes to occupy a large part of the abdomen, the effect is the same as in obesity. Because gravity is the only force that keeps the gastric contents within the stomach, if a hernia develops, the reflux and the symptoms from it will promptly occur when the individual lies down. Persisting reflux of gastric contents with acid and digesting enzymes leads to chemical inflammation of the lining of the esophagus and ultimately to peptic ulceration. If inadequately treated, the process leads to submucosal fibrosis and stricturing, and, besides the symptoms of heartburn and regurgitation, the patient experiences pain on eating and swallowing.
The treatment of peptic reflux esophagitis includes losing weight, avoiding acidic and fatty foods and beverages, remaining upright for two to three hours after meals, giving up smoking, and raising the head of the bed high enough to discourage nocturnal gastroesophageal reflux. Antacids are effective, as are medications that reduce the secretion of acid by the stomach, such as histamine receptor antagonists and proton pump inhibitors, though the latter are associated with potentially serious side effects. If a stricture has formed, it can be dilated easily. If the disorder is not overcome with these conservative measures, surgical repair is performed through either the chest or the abdomen.
Some individuals with severe peptic reflux esophagitis develop Barrett esophagus, a condition in which the damaged lining of the esophagus is relined with columnar cells. These cells are similar to those lining the upper part of the stomach and are not the usual squamous cells that line the esophageal mucosa. In some persons in whom this transformation occurs, a carcinoma develops some 10 to 20 years later. The decision as to the treatment of a hiatal hernia by conservative means or by surgery is influenced by such factors as age, occupation, and the likelihood of compliance with a strict regimen.
There is a much less common form of hiatal hernia, called a paraesophageal hernia, in which the greater curvature of the stomach is pushed up into the thorax while the esophagogastric junction remains intact below the diaphragm. Such individuals experience dysphagia caused by compression of the lower esophagus by the part of the stomach that has rolled up against it. This rarer form of hernia is more dangerous, often being complicated by hemorrhage or ulceration, and requires relief by surgery.
Diverticula
Pouches in the walls of the structures in the digestive system that occur wherever weak spots exist between adjacent muscle layers are called diverticula. In the upper esophagus, diverticula may occur in the area where the striated constrictor muscles of the pharynx merge with the smooth muscle of the esophagus just below the larynx. Some males over 50 years of age show protrusion of a small sac of pharyngeal mucous membrane through the space between these muscles. As aging continues, or if there is motor disturbance in the area, this sac may become distended and may fill with food or saliva. It usually projects to the left of the midline, and its presence may become known by the bubbling and crunching sounds produced during eating. Often the patient can feel it in the left side of the neck as a lump, which can be reduced by pressure of the finger. Sometimes the sac may get so large that it compresses the esophagus adjacent to it, producing a true obstruction. Treatment is by surgery. Small diverticula just above the diaphragm sometimes are found after the introduction of surgical instruments into the esophagus.
Boerhaave syndrome is a rare spontaneous rupture to the esophagus. It can occur in patients who have been vomiting or retching and in debilitated elderly persons with chronic lung disease. Emergency surgical repair of the perforation is required. A rupture of this type confined to the mucosa only at the junction of the linings of the esophagus and stomach is called a Mallory-Weiss lesion. At this site, the mucosa is firmly tethered to the underlying structures and, when repeated retching occurs, this part of the lining is unable to slide and suffers a tear. The tear leads to immediate pain beneath the lower end of the sternum and bleeding that is often severe enough to require a transfusion. The circumstances preceding the event are commonly the consumption of a large quantity of alcohol followed by eating and then vomiting. The largest group of individuals affected are alcoholic men. Diagnosis is determined with an endoscope. Most tears spontaneously stop bleeding and heal over the course of some days without treatment. If transfusion does not correct blood loss, surgical suture of the tear may be necessary. An alternative to surgery is the use of the drug vasopressin, which shuts down the blood vessels that supply the mucosa in the region of the tear.
Cancer
Esophageal tumours may be benign or malignant. Generally, benign tumours originate in the submucosal tissues and principally are leiomyomas (tumours composed of smooth muscle tissue) or lipomas (tumours composed of adipose, or fat, tissues). Malignant tumours are either epidermal cancers, made up of unorganized aggregates of cells, or adenocarcinomas, in which there are glandlike formations. Cancers arising from squamous tissues are found at all levels of the esophagus, whereas adenocarcinomas are more common at the lower end where a number of glands of gastric origin are normally present. Tumours produce difficulty in swallowing, particularly of solid foods; they are much more common in men than in women, and they seem to vary greatly in their worldwide distribution. In North China, for example, the incidence of esophageal cancer in men is 30 times that of white men in the United States and 8 times that of black men. The exact causes of esophageal cancer are not known. Risk factors may include age, sex, smoking, excessive consumption of alcohol, Barrett esophagus, and a personal history of cancer.
In women, cancer of the upper esophagus is more common than in men, and women may be predisposed by long-standing iron deficiency, or Plummer-Vinson (Paterson-Kelly) syndrome. Dysphagia is the first and most prominent symptom. Later swallowing becomes painful as surrounding structures are involved. Hoarseness indicates that the nerve to the larynx is affected. The diagnosis is suggested by X ray and proved by endoscopy with multiple biopsies from the area of abnormality. Diagnosis can be reinforced by removing quantities of cells with a nylon brush for examination under a microscope (exfoliative cytology). The prognosis is poor because the tumour has usually been growing for one or two years before symptoms are apparent. The channel of the esophagus is encroached upon and can be almost entirely obstructed. Esophageal cancer is usually accompanied by considerable weight loss, but nutrition may be restored by nutritional supplements. In advanced cases, a tube may be inserted into the esophagus to keep it open. Where the channel is greatly narrowed, the size of the tumour can be reduced by destroying the tissue with lasers. Radiotherapy is used for malignancies of the upper esophagus and as treatment for those at the lower end. A combination of radiotherapy followed by surgical excision may also be used. The five-year survival rate for esophageal cancer remains very low. Lessening the effects of the disease, with restoration of eating ability, is very important, because otherwise the inability to swallow even saliva is distressing and starvation may result.
