The GIT Esophagus - anatomy Upper sphincter (cricopharyngeal muscle) Upper 2/3 - skeletal muscle, squamous epithelium Lower 1/3 - smooth muscle Lower sphincter (LES) Cylindrical epithelium in the terminal part II I ramwitlil 11M Ptj ■! I Fil l>H 1 mí Esophageal diverticula ■ true diverticula (traction) -include muscular layer ■ pseudodiverticula - only mucous layer (e.g. Zenker diverticulum) ■ Combined diverticula ■ Localization ■ Pharyngoasophageal ■ Midthoracic (epibronchial) ■ Epiphrenic true diverticulum pseudodiverticulum Dysphagia Functional ■ Inflammation in gastroesophageal reflux ■ Sclerodermia ■ Neuropathy (e.g. in diabetes) ■ Amyotrophic lateral sclerosis ■ Chagas disease ■ Achalasia Obstructive ■ Tumour Strictures Peptic ulcer Esophageal achalasia The lower sphincter is incapable of relaxation This leads into esophageal dilatation and loss of peristaltic movements The primary cause is the disorder of myenteric plexus (plexus Auerbachi), which produces NO Most often, it is caused by autoimune destruction Chagas disease ■ Infection by Trypanozoma cruzi ■ About 15 000 000 victims (mostly in latin America) ■ Acute stage: local oedema (often paraorbitally) ■ Chronic stage: megacolon, megaesophagus, malnutrition, Chaga cardiomyopathy, CNS involvment We will update this map regurlarly (version: June 2009) Estimated global population infected by Trypanosoma cruzi, 2009 H 10,001 -100.000 H 100,001 - 1,000.000 1,000,000 and above Sources: 1. QPS/HDM/CD/425-06 Estimación cuantitativa de la enfermedad de Chagas en las Americas 2. Guerri-Guttenberg RA. Grana D.R.. Giuseppe Ambrosio. Milei.J. Chagasic cardiomyopathy: Europe is not spared! European Heart Journal (2008): 29: 2587-2591 3 Schmunis G. A Epidemiology of Chagas Disease in non-endemic countries: the rote of international migration. Mem Inst Oswaldo Cruz. Rio de Janeiro. Vol. 102(Suppi I): 75-85. 2007. 4. DeAyala A.P Pěrez-Molina J.A. Norman F.. and López-Vélez R.Chagasic cardiomyopathy in inmigrants from Latin America to Spain. Emerging Infectious Disease Volume 15. Number 4-April 2009. 5. According to the numbers of inmigrants registered for2007in the website of the Japanese Ministry of Justice and estimated seroprevalence fornon endemic countries according to Pahcio-Talayero J.M. Vigilanda epidemioíóglca de la transmisión vertical de la enfermedad de Chagas en třes maternidades de la Comunidad Valenciana. Enferm Infecc Microbiol Clin 2008:26(10):609-13. Hiatal hernias sliding ■ Lower esophageal sphincter and upper part of stomach slides into thoracic cavity ■ Low external pressure in the thoracic cavity leads into the loss of function of LES and gastroesophageal reflux paraesophageal ■ Part of stomach's fundus squeezed into thoracic cavit paralelly with esophagus ■ This can lead into its incarceration or strangulati with necrosis (life-threatening ■ Mostly, it manifests by pain and vomiting Diaphragm - — Esophagus Stomach. Normal Esophagus and Stomach Sliding Hiatus Hernia Paraesophageal Hlalut Hernia Hiatal hernias - risk factors Wide hiatus Obesity High intraabdominal Gravidity Gastroesophageal reflux disease (GERD) Retrograde movement of gastric juice ■ Loss of anti-reflux barrier ■ LES ■ Peristalsis ■ Angie oerween esopnagus and fundus Aaaressive action of HCI and Onn proteases (pepsin) cause damage to the esophagus Sometimes, it occurs also in healthy people Frequently accompanies sliding hiatal hernia GERD - Symptoms Heartburn Chest pain (meal-related) Regurgitation - vomitin Dysphagia GERD - complications Reflux esophagitis Peptic ulcers in esophagus Strictures Bleeding Barrett's esophagus (up to 10%) Tumours Barrett's esophagus Intestinal metaplasia in chronic GERD Change in cellular diferentiation - squamous epithelium -> cylindr^1 (columnar) Precancerosis (cca 10 times higher relative risk of adenocarcinoma) Other risk factors: alcohol intake, high HCI secretion, decrease in motility Nature Reviews | Czincor Barreťs esophagus in gastroscopy Esophageal varices During portal hypertension (caused by e.g. liver cirhosis, liver tumour, portal thrombosis, schistosomiasis), blood flows through anastomoses between portal and systhemic circulation instead of through the liver That leads into remodelation of these collaterals and forming of varices They include esophageal varices, hemorrhoidal varices, swelling of paraumbilical veins („caput Medusae") and collaterals to vena azygos in the retroperitoneum Esophageal varices - complications Esophageal tumours Benign ■ Leiomyoma ■ Hemangioma ■ Fibroma Malignant ■ Adenocarcinom ■ Squamous cell T-N-M classification