A tracheoesophageal fistula may arise as a congenital connection between the esophagus and trachea that is often associated with esophageal atresia. It is often discovered soon after birth because of aspiration.
Congenital and mechanical disorders
A tracheoesophageal fistula may arise as a congenital connection between the oesophagus and trachea that is often associated with oesophagal atresia. It is often discovered soon after birth because of aspiration. In adults, the condition can occur secondary to malignancy, trauma, or iatrogenic causes.
Oesophagal webs are web-like protrusions of the oesophagal mucosa into the lumen which typically present with dysphagia. Plummer-Vinson syndrome is a disease of middle-aged women characterized by oesophagal webs, iron deficiency anaemia, and an increased risk of carcinoma. Schatzki rings are web-like narrowings at the gastro-oesophagal junction.
Achalasia is a failure of the lower oesophagal sphincter (LES) to relax with swallowing. The aetiology is unknown in most cases; in South America, achalasia may be caused by Chagas disease. Presentation is with progressive dysphagia. The oesophagus is characteristically dilated proximal to the lower oesophagal sphincter; barium swallow shows a “bird-beak” sign. Microscopically, there is a loss of ganglion cells in the myenteric plexus. Treatment is LES balloon dilation or myotomy. Achalasia carries an increased risk for oesophagal carcinoma.
Hematemesis and Esophageal Bleeding
Mallory-Weiss syndrome is oesophagal bleeding due to linear lacerations at the gastroesophageal junction from severe prolonged vomiting; the most common cause is acute alcohol ingestion and/or chronic alcoholism. Oesophageal rupture (Boerhaave syndrome) may result.
Oesophagal varices are dilated submucosal veins in the lower third of the oesophagus, usually secondary to portal hypertension. The most common cause is cirrhosis. Clinically, the presentation is asymptomatic, though there is massive hematemesis when the varices are ruptured. Complications include potentially fatal haemorrhage. Treatment is generally band ligation, sclerotherapy, or balloon tamponade.
Gastroesophageal reflux disease (reflux esophagitis) (GERD) is oesophagal irritation and inflammation due to reflux of gastric secretions into the oesophagus. Reflux typically presents with heartburn and regurgitation. Complications include bleeding, stricture, bronchospasm and asthma, and Barrett's oesophagus.
Barrett's oesophagus is metaplasia of the squamous oesophagal mucosa to a more protective columnar type (intestinal metaplasia). It occurs because of chronic exposure to gastric secretions, usually in the setting of GERD. The endoscopic appearance is of an irregular gastroesophageal junction with tongues of red granular mucosa extending up into the oesophagus. Barrett has an increased risk for dysplasia and oesophagal adenocarcinoma. The incidence of Barrett's oesophagus is increasing in the United States.
Squamous cell carcinoma (SCC) of the oesophagus is the most common type of oesophagal cancer in the world. It affects males more than females, and African Americans more than Caucasians; the typical age is usually age >50. Risk factors include:
- Heavy smoking and alcohol use
- Plummer-Vinson syndrome
- Lye ingestion
The presentation of squamous cell carcinoma of the oesophagus varies; it is often asymptomatic until late in the course. When symptoms do develop, they may include progressive dysphagia, weight loss and anorexia, bleeding, hoarseness, and cough. Diagnosis is by endoscopy with biopsy. Treatment is surgery though the prognosis is poor.
Adenocarcinoma of the oesophagus affects Caucasians more than African Americans. It arises in the distal oesophagus. The progression from Barrett metaplasia to dysplasia and eventually to invasive carcinoma occurs due to the stepwise accumulation of genetic and epigenetic changes. The prognosis is poor.
In the United States, adenocarcinoma and squamous cell carcinoma of the oesophagus occur with equal frequency.