Esophageal atresia

Embryology
One tube → Transverse septum → 2 tubes (So usually associated with TE fistula)

Types
1. Atresia + Fistula with lower pouch (I)
2. Atresia + Fistula with upper pouch (II)
3. Atresia + Fistula with both pouches (III)
4. Atresia Without fistula (IV)
5. Fistula Without atresia (V)
6. Stenosis only

Clinical picture
(Start at birth) → Continuous pouring of saliva and regurgitation of any fluid taken.
• Upper fistula → Cough, Choking, Cyanosis
• Lower fistula → Bile stained sputum , Abdominal distension

Investigations
• Nasogastric tube N10 → Stop 10 cm away from nostril
• Gastrograffin → Blind pouch or Fistula

Treatment
Surgical emergency → NPO, Continuous suction of saliva, Antibiotics
• Right thoractomoy → Excision of fistula
• Primary anastomosis, If gap found → Circumferential myotomy, If still short → 2 stages:
◦ Oesophagostomy + Feeding gastrostomy
◦ Somach pull up or colon bypass

VACTERL is usually associated with Esophageal atresia.

• Vertebral anomalies → Spina bifigda, Meningeomyelocele
• Anal → Imperforate anus
• Cardiac
• Tracheo-esophageal fistula
• Renal agenesis
• Limb anomalies (Radial club hand)

GERD

Factors preventing reflux

1. Lower 5 cm of esophagus are intra-abdominal (High pressure 25 mmHg)
2. Angle of His
3. Pinch-cock action of right crus of diaphragm
4. Rosette shaped mucosa at cardia
Causes
• Primary : SHH, No SHH (Smoking, Obesity, Alcohol)
• Secondary : Delayed gastric emptying → Pyloric spasm and Stenosis
Clinical picture
• Classic presentation
◦ Heart burn: 2 hours after meal, increase by 3 F (Flat lying, Forward leaning and Fatty
meal)
◦ Regurgitation, Retrosternal pain
◦ Dysphagia (Late complicated cases)
• EERD (Extra-esophageal reflux disease)
◦ Cough, Chocking, Cyanosis
◦ Atypical Chest pain
◦ Hoarseness
Complications
• Anemia, Pneumonia
• Barrette's esophagus (Columnar metaplasia), Adenocarcinoma
• IC muscles (Strictures, Schatizki ring), OL (Short esophagus)

Investigations:
• Barium swallow in trendlenberg and antitrendlenberg position (If reflux in trendlenberg
position only → Reflux, Both → Combined refluxor → Surgery)
• Endoscopy → Cardia open during inspiration, Biopys, Belsey grading
◦ I → Hypremia
◦ II → Erosions
◦ III → Ulceration
◦ IV → Complicated
• 24 hours PH monitorign (Gold standard) → Pain with Acid (Reflux symptomatic), Pain with
Alkaline (Reflux, Pain due to other cause)
• Manometry → Low LES pressure, Absent 2ry peristalsis, Assessment of 1ry peristalsis (If
good → Nissen fundoplication, If bad → Toupet or Floppy Nissen)
• Abdominal US → Saint's triad (HH, CC, DD)

Treatment:
• Conservative: Weight reduction, Decrease smoking, Alcohol, Small frequent meals avoid
before sleeping 3hours, Semisetting position after meals and after sleeping, H2 Blockers
(Famotidine), PPI (Omeprazole)
• Surgical:
◦ Indications:
▪ Failed conservative
▪ Complicated
▪ Combined refluxor
◦ Nissen fundoplication: Wrap fundus 360 degrees around lower 5 cm of esophagus →
Low recurrenc
▪ Disadvantage: Dysphagia, Gas-bloat syndrome
◦ Floppy nissen: As Nissen + Floppy large bougie insertion
◦ Toupet partial fundoplication: 270 degree leaving part of esophagus exposed
anteriorly
◦ Belsey mark IV, Hill's cardiopexy

Hiatus hernia
Herniation of cardia and part of stomach into the posterior mediastinum
Cause: Dilated diaphragmatic hiatus, Muscle degeneration with age, Increase intra-abdominal
pressure
Clinical picture: Asymptomatic → GERD

Paraoesophageal hiatus herni (True hernia, Sac of peritoneum Containing greater curvature)
Clinical picture: No reflux (Cardia is in place !) → Intermittent achalasia, Hiccough (Phrenic
nerve), Cardiac symptoms
Investigations: As reflux
Complications: Perforation, Strangulation
Treatment: Surgical → Herniotomy then Nissen or Belsy mark
Motility disorders
• Primary
◦ Cardiac achalasia
◦ Diffuse esophageal spasm
◦ Nut-cracker esophagus
• Secondary
◦ Scleroderma, Chaggas disease, Myopathy

Cardiac achalasia

Definition
Failure of relaxation of LES in response to swallowing due to degeneration of ganglion cells of
Auerbach plexus.
Clinical picture: Middle age female
• Dysphagia: Intermittent, Long standing, More to fluids at first then fluid and solids.
• Regurgitation, Retrosternal pain, Atypcial chest pain
Complications (As above but no Barrette's nor Adenocarcinoma, SCC can occur and
Diverticulosis)
Investigations
• Barium swallow: Dilated esophagus and narrow lower part (Parrot's Beak appearance),
Dilated mediastinum.
• Endoscopy: Closed cardia
• Manometry: Failure of relaxation of LES in response to swallowing, Absent primary
peristalsis