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Paraesophageal hernia :
Gastroesophgeal junction is fixed but part
of the stomach herniates into the chest.
Normal GE junction
Sliding hiatal hernia
Paraesophageal hernia
Complications
- Gastric volvulus
- strangulation
- perforation
Investigations
- Plain X – ray chest & abdomen
- Barium swallow study
- Endoscopy
Treatment
- Medical
- Head end elevation
- Abstain from alcohol, smoking
- Antacids, PPI’s
- Surgery
- Reduction of hernial contents
- Nissen’s fundoplication
DIVERTICULA
A diverticulum is an out pouching of the
alimentary canal that contains all the
layers.
Types – true and pseudo
Pseudo diverticulum only mucosa and
sub mucosa.
According to site
Zenker diverticulum - pharyngoesophageal
Traction diverticulum - midpoint of
esophagus because of inflammation
Epiphrenic diverticulum – immediately
above LES.
symptoms
Asymptomatic
Dysphagia
Food regurgitation
Mass in the neck
Halitosis
Aspiration
Management
Barium swallow study
Endoscopy
Diverticulectomy
Lacerations
Mallory-weiss syndrome
Boerhaave’s syndrome
BARRETT’s ESOPHAGUS
The distal squamous mucosa is replaced
by metaplastic columnar epithelium as a
response to prolonged injury.
Single most important risk factor for
esophageal adenocarcinoma.
Occurs as a complication of long standing
GERD.
Types
Long segment - involving > 3 cms
Short segment – involving < 3 cms.
Criteria
Endoscopic evidence – Indocarmine spray
Histological evidence – multiple biopsies
Barrett’s esophagus
Pathogenesis
Chronic irritation leads to change in the
differentiation program of stem cells of the
esophagus mucosa.
Clinical features
Age – 40 to 60 yrs
More common in white males.
Symptoms of reflux esophagitis.
Complications
Bleeding, Ulceration, Stricture and
development of Adenocarcinoma.
Hence reflux esophagitis should be treated
aggressively with drugs and if needed
surgery to prevent Barretts’s esophagus
Endoscopic surveillance should be done in
patients with Barrett’s esophagus
Once high grade dysplasia is detected
treatment of choice is esophagectomy of
the segment
Photodynamic laser, thermo-coagulative
mucosal ablation, and endoscopic
mucosal resection are being evaluated as
alternatives
TUMOURS
Benign
Leiomyoma, fibroma, lipoma,
neurofibroma
Maliganant
SCC, Adeno Ca, Carcinoid, Melanoma,
lymphoma.
Benign tumors
The most common is leiomyoma
Fibroma, neurofibroma, lipoma,
hemangioma may also arise.
Polyps
Inflammatory pseudotumor
Leiomyoma esophagus
Malignant
Constitutes about 6% of GI malignancies.
Majority are epithelial.
Globally SCC is the commonest
esophageal carcinoma.
In US the incidence is almost same for
SCC and Adenocarcinoma.
Squamous Cell Ca
Most common type of carcinoma esophagus.
Age – over 50 years.
Incidence varies with country.
Blacks are at more risk compared to whites.
Seen in Upper & middle 1/3rd
Constitutes about 40% of esophageal ca.
Adenocarcinoma
The majority arises from barrett mucosa.
Tobacco, obesity are the risk factor
Usually located in lower end of esophagus
In contrast to SCC whites are more
affected than blacks.
5 year survival rate is under 20%.
Incidence is about 45%
Staging - TNM classification
T – Tumour size
N - Nodal involvement
M - Metastasis
Grading – Histopathological
- Well differentiated
- Moderately differentiated
- Poorly differentiated
Three morphological pattern
- Exophytic
- Flat
- Ulcerative.
Most are moderate to well differentiated.
AETIOLOGICAL FACTORS for SCC
Smoking
Alcohol excess
Chewing betel nuts or tobacco
Coeliac disease
Achalasia of the oesophagus
Post-cricoid web
Post-caustic stricture
Tylosis (familial hyperkeratosis of palms and
soles)
Aetiological factors
- Chronic GERD
- Barrett’s esophagus
- Tobacco & alcohol consumption
Clinical presentation
Barium swallow
Endoscopic biopsy
Endo ultrasonography with tissue biopsy
CT scan
MRI
Ba swallow – Ca esophagus
Ca Esophagus
Ca Esophagus
Treatment
Surgery remains the main stay with proper
clearance margin
Local and distant recurrence is common.
Five year survival rate is 75%.
Surgery
- Esophagectomy with surrounding lymph
node excision
Radiotherapy
- SCC more radiosensitive
- AdenoCa radioresistant
Chemotherapy
- 5 FU
- Cisplatinum
Palliative
- Metallic stenting
- Laser ablation