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The oesophagus and swallowing 

The oesophagus and swallowing
Chapter:
The oesophagus and swallowing
Author(s):

Giles Warner

, Andrea S. Burgess

, Suresh Patel

, Pablo Martinez-Devesa

, and Rogan Corbridge

DOI:
10.1093/med/9780199230228.003.0106
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date: 12 July 2020

  • Gastro-oesophageal reflux disease (GORD) [link]

  • Neurological causes of swallowing problems [link]

  • Post-cricoid web [link]

  • Achalasia [link]

  • Pharygneal pouch [link]

  • Oesophageal tumours [link]

Gastro-oesophageal reflux disease (GORD)

Demographics

  • Most common upper-gastrointestinal (GI) disorder in the Western World.

  • Experienced by 20–40% of adults.

  • Prevalence likely to be higher than reported.

  • Increases with age.

  • Sex ratio ♂ = ♀.

  • More common during pregnancy.

Pathogenesis

  • Abnormal retrograde flow of gastric contents into the oesophagus resulting in symptoms, mucosal damage, or both.

  • Most commonly due to a defective lower oesophageal sphincter (LES).

  • In 40–60% of patients, abnormalities of oesophageal peristalsis are also present. These patients also have more atypical symptoms, such as a cough or hoarseness.

  • Hiatus hernias also contribute to reflux by altering the relationship between the LES and oesophageal crus.

Symptoms and signs

  • Typical (oesophageal):

    • Heartburn.

    • Regurgitation.

    • Dysphagia.

  • Atypical (extra-esophageal):

    • Cough.

    • Wheeze.

    • Chest pain.

    • Hoarseness.

    • Dental erosions.

    • Laryngitis and sore throat.

    • Vocal cord glanuloma.

    • Globus.

    • Otitis media.

Investigations

  • Barium swallow is useful for detecting hiatus hernia and strictures.

  • Endoscopy is useful for detecting complications of GORD.

  • Oesophageal manometry provides information on the LES.

  • Ambulatory pH monitoring is the most reliable test (sensitivity and specificity of 92%).

Treatment

Non-surgical

  • Life-style modifications—frequent, small meals; avoid fatty foods, spicy foods and chocolate; last meal of the day at least 2h before going to bed; elevate head of bed; stop smoking; lose weight.

  • Antacids.

  • H2 antagonists.

  • Proton-pump inhibitors.

Surgical

  • Laparoscopic fundoplication—90% success rate in patients with typical symptoms.

Neurological causes of swallowing problems

The swallowing mechanism is a complex process involving both sensory and motor functions. It is initiated voluntarily but progresses as a dynamic reflex. A neurological condition that affects a patient's motor or sensory function may ∴ also cause problems with swallowing.

Neurological causes of swallowing problems

  • CVA (stroke).

  • Bulbar palsy.

  • Motor neurone disease.

  • Multiple sclerosis.

  • Tumours of the brain stem.

  • Cranial nerve lesions, e.g. vagal neuroma.

  • Systemic neurological conditions, e.g. myasthenia gravis.

Investigations

  • Assessment will involve taking a detailed swallowing history and asking the patient about any coughing or choking attacks, indicating aspiration.

  • A general neurological examination and a specific cranial nerve examination should be done.

  • A CXR may show lower-lobe collapse or consolidation if aspiration is present.

  • A video swallow gives detailed information about the function of the oesophagus (such as delay, pooling, unco-ordination, spasm, etc).

  • Functional endoscopic evaluation of swallowing (FEES) gives real-time information on laryngeal penetration and aspiration.

Treatment

Wherever possible the patient's underlying condition should be treated, but there will be times when treatment aims to control the symptoms. This could involve:

  • Swallowing therapy as directed by a speech and language therapist.

  • Dietary modification, such as thickened fluids.

  • Cricopharyngeal myotomy.

  • Vocal cord medialization procedures.

  • Tracheostomy.

  • Percutaneous endoscopic gastrostomy (PEG).

  • Tracheal diversion or total laryngectomy (see The oesophagus and swallowing p. [link]).

Post-cricoid web

  • This is a rare condition and its cause is unknown.

  • An anterior web forms in the lumen at the junction of the pharynx and oesophagus, posterior to the cricoid cartilage.

  • Patterson Brown–Kelly (UK) and Plumber–Vinson (USA) both describe this condition—their names are frequently used in association with the syndrome.

  • A post-cricoid web is linked with iron-deficiency anaemia, and it has the potential to become malignant ∴ an endoscopy and a biopsy is recommended.

  • It may also cause dysphagia and can be seen on a barium swallow.

  • The web may be dilated and/or divided with the help of an endoscope.

Achalasia

  • This is a rare condition where there is absence of oesophageal peristalsis and hypertonia in the lower oesophageal sphincter muscle that fails to relax completely on swallowing.

  • ♂ = ♀.

  • Any age.

  • 1 in 100 000.

  • Aetiology is unclear, but a degeneration of the myenteric plexus of Auerbach has been documented, with loss of post-ganglionic inhibitory neurones resulting in increased LES resting pressure and insufficient relaxation.

Signs and symptoms

  • Progressive dysphagia.

  • Regurgitation.

  • Weight loss.

  • Aspiration when supine.

  • Heartburn.

  • Chest pain.

Investigations

  • A barium swallow may show a narrowing at the level of the gastro-oesophageal sphincter.

  • A dilated, sigmoid oesophagus may be present in patients with long-standing achalasia.

  • An endoscopy is needed to exclude an oesophageal tumour as this can produce similar radiological appearance and symptoms.

  • Absence of peristalsis is seen on manometry.

  • Ambulatory pH monitoring is performed to rule out abnormal gastro-oesophageal reflux.

Treatment

Non-surgical

  • Calcium-channel blockers.

  • Intra-sphincteric injection of botulinum toxin.

  • Pneumatic dilatation.

Surgical

  • Laparoscopic Heller myotomy (involves a controlled division of the muscle fibres of the lower oesophagus and proximal stomach follwed by a partial fundoplication.

  • Bypass procedures.

Pharygneal pouch (Zenker diverticulum)

  • Originates from the posterior wall of the oesophagus in a triangular weakness limited inferiorly by the cricopharyngeus muscle and superiorly by the inferior constrictors (i.e. Killian's triangle).

  • As the diverticulum enlarges it tends to deviate towards the left.

  • Thought to be due to either a hyperactive upper-oesophageal sphincter or lack of pharyngeal co-ordination.

  • There is progressive herniation of mucosa and submucosa through Killian's triangle resulting in the diverticulum lying between the pharyngo-oesophagus and the prevertebral fascia.

Incidence

  • 1 case per 100 000 per annum in the UK.

  • ♂ : ♀, 2 : 1.

  • Most commom between 6th and 9th decades.

  • Mainly affects Caucasians.

Symptoms and signs

  • Dysphagia.

  • Regurgitaion of undigested food (with risk of aspiration).

  • Gurgling sounds in the neck.

  • Halitosis.

  • Pulmonary complications from aspiration.

Investigations

  • A barium swallow will clearly demonstrate the position and size of the diverticulum.

  • A video swallow gives information about the function of the pharyngeal muscles as well as the presence or absence of gastric reflux.

  • Either study should include an examination of the oesophagus and stomach to exclude a synchronous carcinoma.

Treatment

  • It is important to consider the overall health of the patient as well as assessing the effect the pouch is having on the individual's quality of life.

  • Traditional external-approach surgery has now been mostly superceded by the use of trans-oral approaches.

  • However, ENT surgeons should be familiar with both approaches since complications from trans-oral approaches may require external exploration.

Surgery for pharyngeal pouch

Open approach

Pre-operatively

  • Treat any malnutrition, chest infection, dehydration, or GORD.

  • Clear fluids 24h prior to surgery.

Procedure

  • Pharyngoscopy to aspirate any contents and to exclude any malignancy.

  • Pack the pouch with ribbon gauze.

  • 32Fr bougie is inserted into the oesophagus.

  • The neck is extended on a head ring and shoulder bag.

  • Left-transverse cervical incision at the level of the cricoid cartilage through platysma.

  • Raise subplatysmal flaps.

  • Divide the investing layer of deep cervical fascia along the anterior border of sternomastoid.

  • Identify and divide omohyoid and middle-thyroid vein.

  • Rotate the ipsilateral lobe of the thyroid forward to expose the posterolateral surface of the pharynx and the oesophagus within the operative field.

  • Enter the retropharyngeal space anterior to the vertebral bodies at a level superior to the inferior cornu of the thyroid cartilage, thus avoiding injury to the recurrent laryngeal nerve.

  • Identify the sac in the midline and deliver into field identifying the neck of the sac by sweeping away tissue until only musosa is seen protruding through the muscular defect of the pharynx.

  • Cricopharyngeal myotomy is performed prior to excision of the sac to prevent recurrence.

  • The sac is then excised (diverticulectomy) and sent for histology. The defect is closed with a continuous inverting Connell suture placed in the horizontal plane and reinforced with a second layer of interrupted sutures. Other second-line procedures, such as sac inversion and suspension (diverticulopexy), have been described.

  • Haemostasis.

  • Suction drain.

  • Close wound in layers.

  • Patient should be fed via a nasogastric tube for 5 days and then a water-soluble contrast study performed to exclude a leak.

Complications

  • Recurrent laryngeal nerve palsy.

  • Cervical emphysema.

  • Mediastinitis.

  • Pharyngo-cutaneous fistula.

  • Pharyngeal stenosis.

Endoscopic approach (Dolman's procedure)

  • The diverticuloscope is introduced to expose the hypopharyngeal bar.

  • The scope has blades which can be manoeuvred to give optimum exposure.

  • Clear food from the pouch using a soft-tip sucker.

  • Inspect the lining of the pouch with a Hopkins’ telescope and biopsy any suspicious lesions.

  • The bar is divided with either diathermy, laser, or staples.

  • Assuming there is no chest pain, surgical emphysema, or tachycardia, the patient can commence on free fluids initially and then soft diet the following day.

Advantages

These include:

  • Shorter procedure and anaesthetic (these patients are usually elderly and have several co-morbidities).

  • Less invasive.

  • Quicker resumption of oral intake and shorter stay in hospital.

Oesophageal tumours

Benign oesophageal tumours are rare and arise from the local tissue elements, e.g. leiomyoma, adenoma, lipoma.

Barrett's oesophagus

  • Metaplasia of the oesophageal mucosa caused by the replacement of the physiological squamous epithelium with columnar epithelium due to GERD.

  • More common in caucasians over 50.

  • May progress to high-grade dysplasia and eventually adenocarcinoma.

  • Endoscopy reveals a salmon-pink epithelium.

  • Treatment consists of proton-pump inhibitors or a fundoplication and regular follow-up with endoscopy and biopsy.

Malignant oesophagal tumours

Risk factors

  • Smoking.

  • High alcohol intake.

  • Achalasia.

  • Plummer–Vinson syndrome (squamous).

  • Caustic injuries (squamous).

  • GERD (adeno).

Demographics

  • 80% of malignant tumours occur in males over 60 years old.

  • Squamous cell carcinoma of the thoracic oesophagus used to be the most common but now adenocarcinoma of the lower-third of the oesophagus accounts for over 50%.

Signs and symptoms

  • Weight loss.

  • Pain in the throat and/or epigastrium.

  • Progressive dysphagia initially for solids.

Investigations

  • Barium swallow may show a stricture or mucosal abnormality suggesting a malignant tumour.

  • Endoscopy and biopsy will confirm the diagnosis.

  • CT scan of the chest and abdomen assesses the extra-mucosal extent and metastatic spread of the tumor (PET can also be used).

  • Endoscopic ultrasound is the most sensitive test to determine the penetration of the tumour, the presence of enlarged perioesophageal lymph nodes, and invasion of structures adjacent to the oesophagus.

Treatment

All tumours must be discussed at the upper-gastrointestinal multidisciplinary team meeting.

Curative

  • Trans-hiatal oesophagectomy (abdominal and cervical incisions).

  • Trans-thoracic oesophagectomy (abdominal and thoracic incision).

  • These may be offered with pre-operative chemotherapy (neoadjuvant), and post-operative chemo- and/or radiotherapy (adjuvant), but no increase in survival has been shown in randomized controlled studies, to date.

Palliative

Because most patients already have lymph-node metastases at the time of surgery, the 5-year survival rate remains poor at 25–30%. Options include:

  • Radiotherapy.

  • Laser-debulking of the mass (Nd:YAG).

  • Endoscopic stenting with expandable, coated, metallic stents.

  • PEG tube for long-term feeding.