ESOPHAGEAL DISORDERS

A. VAYDA

department of surgery with urology and anesthesiology

Esophageal diverticula

The esophageal diverticula are the sacciform outpouchings of the esophageal wall, which filled with

mucus and undigested food.

Etiology and pathogenesis

Pulsion diverticula - increase of intraesophageal pressure proximal to muscle sphincters.

Traction diverticula - paraesophageal inflammatory and sclerotic processes.

Classification 1.According to the origin: a)congenital; b)acquired. 2. According to the histological structure: a)true (have all layers of esophageal wall); b)false (absent muscular layer of esophageal wall). 3. According to the localization: a)pharyngoesophageal (Zenker's); b)bifurcational; c)epiphrenic. 4. According to the clinical course: a)complicated; b)uncomplicated.

Signs and clinical course

salivation, cervical dysphagia, difficult swallowing and cough.

Complications

diverticulitis. perforation of diverticulumbleedingmalignancy

The diagnostic program

1. Anamnesis and objective examination. 2. General blood and urine analyses. 3. Coagulogram. 4. Chest X-radiography. 5. Contrast roentgenoscopy of esophagus and gastrointestinal tract. 6. Fibrogastroduodenoscopy.

Zenker’s Diverticulum Midesophageal Diverticulum

Epiphrenic Diverticulum

X-ray examination

Fibrogastroduodenoscopy examination

Differential diagnostics

Stenocardia.

Tactics and choice of treatment

Achalasia of the cardiaAchalasia of the cardia is the disease, which is characterized by failure of the lower esophageal sphincter to relax with swallowing.

Etiology

The cause of this disease is still unknown. Among the underlying mechanisms are:•psycho-emotional trauma, •disturbance of parasympathetic and sympathetic innervation•influence of vegetotrophic substances on muscular fibers.

Symptomatology and clinical course Dysphagia.

Dysphagia.

Esophageal vomiting (regurgitation).

Splashing sounds and gurgling behind breastbone.

The sign of nocturnal cough.

Pain.

Loss of weight.

Classification 1)functional spasm without esophageal dilation; 2)constant spasm with a moderate esophageal dilation and maintained peristalsis; 3)cicatricial changes of the wall with expressed esophageal dilation, the peristalsis is absent; 4)considerable esophageal dilation with S-shaped elongation and the presence of erosive changes of esophageal mucosa.

The diagnostic program 1.Anamnesis and physical findings. 2.General blood and urine analyses. 3.Chest X-radiography. 4.Esophagogastroscopy.

5.Contrast roentgenoscopy (barium swallow).

Differential diagnostics

•Cancer of the lower part of esophagus and cardial part of stomach. •Pneumothorax.

•Diet.

•The conservative

treatment.

•Cardiodilatation.

Tactics and choice of treatment

Helerovsky's method.

Surgical treatment.

Heller's method (esophagomyotomy).

Esophageal stricture

The cicatrical esophageal stenosis can arise owing to chemical, thermal and radial burns, and as a result of esophagitis or peptic ulcers. The most frequent cause of cicatrical strictures is considered to be chemical burns of esophagus, which are usually the result of accidentally or purposely (suicide) drink of acids or alkalis.

CLASSIFICATION According to clinical course: I. The period of acute manifestation. ІІ. The latent period (false improvement). ІІІ. The period of cicatrization.

According to the depth of lesion: I degree – superficial burn with the damage of epithelial layer of esophagus; ІІ degree – the burn with the damage of entire mucosa of esophagus; ІІІ degree – the burn damage of all layers of esophagus; ІV degree – the spread of postburn necrosis on paraesophageal tissue and adjacent organs.

Tactics and choice of treatment neutralizing solutions the treatment of shock and hypovolemia antibacterial therapy is nominated for prevention of infection complications. parenteral feeding prophylaxis of cicatrical stenosis of esophagus

elastic thermoslabile bougies.

esophagoplasty by stomach, small and large intestine.

Diaphragmatic hernia

Diaphragmatic hernia represents herniation of abdominal organs through natural openings of diaphragm, its weak places or ruptures.

Etiology and pathogenesis diaphragmatic anomalyage-dependent involution of the diaphragmvisceral ptosis increase of intraperitoneal pressureobesityoverfeedingconstipationpregnancy.

The cause of sliding hernias can be draw of esophagus upward in reflux esophagitis owing to intensive contraction of its longitudinal musculature.

Diaphragmatic hernia.

Sliding (axial) diaphragmatic hernia:

•Diaphragmatic hernia of paraesophageal type

Classification

pain behind breastbone. heartburn. belching. Regurgitation, the sign of "lacing shoes". nausea and vomiting. dysphagia.

roentgenological signs: 1) the sign of "bell"; 2) blunt His angle; 3) lack of air bubble of the stomach.

Clinical manifestation

Differential diagnostics

Stenocardia.

Peptic ulcer.

Lung atelectasis, pleurisy, pneumonia.

Tactics and choice of treatment

Conservative therapy:

1)the diet the same, as in peptic ulcer; 2) elevated upside position of the patient; 3)suppression of gastric secretion by administering of Н2-blockers; 4)neutralization of gastric acid; 5)intensifying of evacuation of the food from stomach; 6)avoid of constipation; 7) sedative agents.

Surgical treatment. Stages of the operation:

1.Drawing of the stomach into abdominal cavity.

2.The plastics of esophageal hiatus of the diaphragm

(cruroplasty).

3. Nissen fundoplication.

4.Gastropexia – fixation of gastric wall to parietal

peritoneum.