3. Diseases of the oesophagus

Last updated on April 18, 2019 at 20:52

This topic covers these pathologies that can occur with the esophagus:

  • Congenital malformations
  • Functional disorders
  • Vascular diseases
  • Inflammations
  • Tumors

Now let’s get started!

Congenital malformations

1. Atresia and fistulas

This happens when the congenital segmental closure of oesophagus fails for some reason. This often ends up with fistulas which connect the upper or lower pouches of oesophagus to the trachea or even to the bronchus.

These types of malformations are usually discovered when the baby gets repeated aspiration pneumonia from breast feeding. Surgery is needed to fix this problem.

Functional disorders

1. Achalasia

In achalasia is the lower oesophageal sphincter tone strongly increased. Food can’t pass through to the stomach normally which results in a megaoesophagus and can lead to more severe complications like perforation. There is also a small chance (5 %) for carcinoma.

We have two types, primary and secondary. Primary is idiopathic, and is caused by failure of distal inhibitory neurons, so the muscles cannot relax. Secondary type usually arises with Chagas disease, where the myenteric plexus fails. I believe that this is not so important.

Achalasia is a rare disease.

2. Hiatal hernia

In hiatal hernia will a portion of the stomach herniate through the hiatus in the diaphragm that the oesophagus goes through. This is more frequent than achalasia and is a result of weak muscular tone of the lower sphincter of the oesophagus.

We distinguish between two types: Rolling (paraesophageal) and sliding (axial). The rolling type may actually cause 2/3 parts of the stomach to roll up to the thoracic cavity though the diaphragm! This phenomenon is called the “up-side-down-stomach”.

Herniations should be surgically treated as they compress the other structures in the thoracic cavity.

3. Diverticular diseases

A diverticulum is a circumscribed outpouching of the wall of a hollow organ. Oesophageal diverticula may be true diverticula, where all layers of the wall are pouched out, or pseudodiverticula, where the mucosa and submucosa herniate through a weakness in the muscularis propria.

Living with a diverticulum can be hard for a patient as food can get stuck inside and can rot. This may lead to very uncomfortable situations, like dysphagia, aspiration, vomiting and bad breath (halitosis). It can also lead to inflammation of the diverticulum, called diverticulitis. The presence of diverticula is called diverticulosis.

Let’s look at the different types:

Zenker’s diverticulum is a pseudodiverticulum and is found above the upper oesophageal sphincter. It’s the most common type. The outpouching always protrudes posteriorly and can lead to mediastinitis if the diverticulum gets inflamed (diverticulitis).

It’s also a pulsion diverticulum, meaning that it can be caused by increased intraluminal pressure due to inadequate relaxation of the oesophageal sphincter (e.g. caused by achalasia or spastic motility).

Traction diverticulum

This type is formed by the pulling force of the contracting adhesion bands and occurs mainly in the distal oesophagus next to the tracheal bifurcation. It’s a true diverticulum. It’s usually associated with tuberculosis or mediastinal lymphadenitis, where scarring happens.

Epiphrenic diverticulum

This is also a pulsion diverticulum, meaning it’s a pseudodiverticulum. It is located in the distal most part of oesophagus and is a result of dysfunctions of the lower oesophageal sphincter, like in achalasia.

Vascular diseases

Oesophageal bleedings can actually be a medical emergency. Let’s look at the different types and find out why.

1. Oesophageal varices

Varices are big vessels formed due to portocaval shunts in patients with portal hypertension. They are usually found in the lower third of the oesophagus and can rupture and cause massive bleedings.
The causes for this are alcoholic liver cirrhosis (90 %) and schistosomiasis/snail fever (10%).

2. Mallory-Weiss syndrome

Usually when we vomit will our gastroesophageal musculature relax as a reflex for preventing rupture. If we vomit a lot however can this reflex fail, and the mucosal wall can stretch and tear. These tears are longitudinal (they follow the axis of the oesophagus) and heal by themselves. Haematemesis usually occurs.

3. Boerhaave syndrome
If the oesophagus ruptures and perforates due to vomiting is the condition called Boerhaave syndrome. It may result in mediastinitis. It’s different from Mallory-Weiss syndrome in that the tears are transmural in Boerhaave syndrome. It’s an emergency condition and is deadly without surgical intervention.

Inflammations

1. Reflux oesophagitis

This is the most frequent cause of esophagitis and is caused by reflux of gastric contents into the lower oesophagus, like gastric acid and food. The oesophageal mucosa is vulnerable to acid as it was never intended to be exposed to it. The clinical condition where reflux occurs frequently is called gastro-oesophageal reflux disease (GERD).

Risk factors:

  • Hyperacidity – don’t drink too much coke or Red bull y’all.
  • Alcohol, tobacco
  • Outflow stenosis or obstruction of the stomach
  • Oesophageal hernias
  • Increased intraabdominal pressure, which occurs in obesity

Chronic GERD may lead to Barrett’s metaplasia and even carcinoma.

2. Infectious oesophagitis

This may occur in healthy individuals but is most frequent in immunosuppressed patients.

We can have:

  • Soor oesophagitis (oesophageal candidiasis) – Caused mostly by the Candida fungus but can also be caused by Aspergillus.
  • Herpes oesophagitis – Causes pouched-out ulcers.
  • Cytomegalovirus oesophagitis – Shallow ulcers and the characteristic Owl-eye appearance can be seen in histology.

3. Eosinophilic oesophagitis

This is actually a pretty recent disease, and is recognized in more and more people. It involves a pronounced eosinophilic infiltration in the oesophagus. Food or other allergens, like pollen, sensitize the patient and leads to Th2-activation. A genetic predisposition is a cause for this as well.

This disease dominates in males, and pollen is usually the reason behind.

Neoplasms

1. Preneoplastic lesions – Barrett oesophagus

This is a consequence of chronic GERD where we can see intestinal metaplasia within the oesophageal squamous mucosa. In histology can goblet cells be seen in the oesophagus.

It exists in both long-segment Barrett, where the segments are longer than 3 cm, and short-segment Barrett, where the segments are shorter than 3 cm. The long segment-Barrett is the most severe case. This also predominates in males.

2. Papilloma

Papillomas are benign epithelial tumours, which usually occur in the middle of the oesophagus. They are associated with HPV.

3. Adenocarcinoma

This evolves from the Barrett-mucosa and is the most common type in the developed world. It’s usually found in the lower part of the oesophagus.

They are usually found in the lower third of the oesophagus and in the esophagogastric junction. We use the Siewert Classification to classify if the cancer is oesophageal, cardial or subcardial depending of where the epicentre of the tumour is found.

  • AEG I: Barrett-carcinoma/oesophageal carcinoma – within the proximal 2 cm of the cardia.
  • AEG II: Cardial carcinoma – 2 cm further away from esophagogastric junction
  • AEG III: Subcardial cancer of stomach

It’s usually asymptomatic until the late stages, where it may present with non-specific symptoms like weight loss.

4. Squamous cell carcinoma (SCC)

This type is more common than the adenocarcinoma in developing countries and is predominant in males. It’s also more common in Asian countries, so its strongly connected to eating habits where nutritional deficiencies are more normal to have. It’s usually found in the middle and upper parts of the oesophagus.

Risk factors:

  • Alcoholism
  • Smoking
  • Poverty
  • Achalasia
  • HPV
  • Deficiencies
    • Vitamin A
    • Zink
    • Folic acid
    • Iron
  • Frequent consumption of very hot beverages, like the coffee at McDonalds.

The oesophagus with SCC will be covered by grey-white plaque-like thickenings. The oesophagus becomes rigid and the lumen narrows as the cancer grows. The cancer can spread to nearby structures like the lungs, causing pneumonia, the aorta or the mediastinum and pericardium.

Common symptoms include dysphagia and odynophagia (pain when swallowing).


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2. Pathology of the salivary glands

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4. Inflammatory and ulcerative disorders of the stomach

2 thoughts on “3. Diseases of the oesophagus”

  1. “inflammation of the diverticulum, called diverticulosis”
    It’s called diverticulitis, I’m sure it’s just a misspelling 🙂

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