Özefagus Hastalıkları Prof. Dr. Öge TAŞCILAR

Özefagus Hastalıkları Farinks ile mide arasında Musküler, elastik, kontraktil tüp Uzunluk 25-30 cm. Önce orta hat, sonra sağ, alt 1/3 sol Hiatustan geçip mide

Özefagus Hastalıkları Trake, troid, boyun damarları D.Torasikus, aorta ile komşu 4 Bölüm Faringoözefagiayal Servikal Torakal Abdominal

Özefagus Hastalıkları Özefagus seyri boyunca 3 darlık: Servikal(Krikoid kıkırdak altında) Torakal(Sol ana bronş ve aorta) Abdominal darlık(D. Hiatus geçildiği yer AÖS).

Özefagus Hastalıkları Mukoza Submukoza Muskularis Propria Seroza(adventisiya) İntraepitelyal Mukoza Epitel Bazal Membran Lamina Propria Muskularis Mukoza

Özefagus Hastalıkları Özefagus Motilite Bozuklukları Akalazya Diffüz Özefagiyel Spazm Özefagus Divertikülleri Hiatal herni Gastroözefajiyel Reflü Hastalığı Barret Özefagus Özefagus Kanserleri

Özefagus Hastalıkları Semptom: Disfaji Regürjitasyon Retrosternal yangı Göğüs ağrısı

AKALAZYA Rare, chronic disorder 1 in 100,000 Özefagus Motilite Bozukluğudur Rare, chronic disorder 1 in 100,000 Affects all ages and both genders Triad: Disfaji-regurjitasyon-kilo kaybı

Achalasia Etiology and Pathophysiology Primer Akalazya Sekonder Akalazya Malignite Chagas Hastalığı Diyabet

Achalasia Etiology and Pathophysiology Peristalsis of lower two thirds of esophagus absent Impairment of neurons that innervate esophagus Unopposed contraction of LES LES pressure ↑ Incomplete relaxation of LES Obstruction occurs at/near diaphragm

Achalasia Etiology and Pathophysiology Gıdalar ve sıvı özefagusta birikir. Özefagus genişler

Achalasia Fig. 42-9

Achalasia Clinical Manifestations Symptoms Dysphagia Most common symptom Intermitant Paradoxal dysphagia(katı geçer Sıvı geçmez) Substernal chest pain During/after a meal

Achalasia Clinical Manifestations Inability to belch GERD Regurgitation Weight loss

Achalasia Clinical Manifestations Gece regurjitasyon Aspirasyon Pnömoni Bronşit Akciğer abse

Achalasia Diagnostic Studies Radiologic studies Manometric studies of lower esophagus Endoscopy

Achalasia Diagnostic Studies Gögüs grafisi: Mediastinal genişleme Post. Medias. Hava sıvı seviyesi Aspirasyon olursa Pnömoni Bronşit Bronşektazi

Achalasia Diagnostic Studies Endoskopi Özefagus dilatasyonu Gıda retansiyonu Manometri AÖS basıncı yüksek(>25 mm Hg) Relaksasyon olmaması Aperistaltizm

Achalasia Komplikasyonlar: Respiratuar sistem en sık Pnömoni Atelektazi, bronşit, abse Bronşektazi Hemoptizi Etrafa bası Premalign lezyon(%1-10)

Achalasia Treatment Cause unknown Paliative treatment Goals Relieve symptoms Improve esophageal emptying Prevent development of megaesophagus

Achalasia Treatment Drug therapy Symptomatic relief Smooth muscle relaxants Uzun etkili nitratlar Ca channel blockers Nitrogliserin Botulinum toxin injection 1 to 2 years relief Symptomatic relief Semisoft diet Eating slowly Drinking with meals

Achalasia Treatment Endoscopic pneumatic dilation Outpatient procedure LES disrupted using balloons of progressively larger diameters Repeat dilations are often required

Pneumatic dilatation to Treat Achalasia Fig. 42-10

Achalasia CERRAHİ ENDİKASYON Ciddi özefajit İnfant Çok ilerlemiş, çok dilate, tortios Hasta cerrahi istiyorsa Takibi zor olgularda

Achalasia Surgical therapy Heller myotomy Zaaijer myotomi Özefagokardiyal myotomi Done laparoscopically LES surgically disrupted Often has antireflux surgery at same time 1 to 2 weeks for recovery Evre 4 olgularda özefajektomi

Diffüz Özefagus Spazmı Ciddi disfaji, göğüs ağrısı. Anjinayı taklit edebilir. Stress ile artar. Birlikte psikosomatik ağrılar sıktır.

Diffüz Özefagus Spazmı DÖS tanısı manometri ile konur. AÖS normal Yüksek amplitütlü, hipertonik kontraksiyon Radyoloji: Daralma,segmenter spazm,türbişon görünümü. Özefagus duvarında düz kas hipertrofisi.

Diffüz Özefagus Spazmı Tedavi: Drug therapy Uzun etkili nitratlar Ca channel blockers Nitrogliserin Botulinum toxin injection 1 to 2 years relief Balon dilatation

Diffüz Özefagus Spazmı Cerrahi Tedavi: Medikal tedavi başarısız ise Epiprenik divertikül oluşmuş ise Cerrahi Teknik; Tercihen laparoskopik Uzun bir özefagomyotomi

Esophageal Diverticula Saclike outpouchings of one or more layers of esophagus

Esophageal Diverticula Occur in three main areas Zenker’s diverticulum Most common location Traction diverticulum Near esophageal midpoint Epiphrenic diverticulum Above the LES

Sites for Occurrence of Esophageal Diverticula

Esophageal Diverticula Clinical Manifestations Traction diverticulum: May not have signs and symptoms Symptoms Dysphagia Regurgitation Chronic cough Aspiration Weight loss

Esophageal Diverticula Complications Malnutrition Aspiration Perforation

Esophageal Diverticula Diagnostic Studies Endoscopy Barium studies Zenker Divertikülü: Pasaj grafisi rutin. Endoskopi Perforasyon riski var.

Esophageal Diverticula Surgery Zenker: Krikofaringeal myotomi >2 cm ise Divertikülektomi+Krikofaringeal myotomi

Hiatal Hernia Herniation of portion of the stomach into esophagus through an opening or hiatus in diaphragm

Hiatal Hernia Two types 1. Sliding Stomach slides into thoracic cavity when supine, goes back into abdominal cavity when standing upright Most common type GÖ bileşke diyafragmanın üstüne çıkmıştır.

Hiatal Hernia 2. Paraesophageal or rolling Esophageal junction remains in place, but fundus and greater curvature of stomach roll up through diaphragm FOL kusurlu Yaşlılarda sık

Hiatal Hernia Clinical Manifestations May be asymptomatic Symptoms include Heartburn After meal or lying supine Dysphagia

Hiatal Hernia Diagnostic Studies Barium swallow May show protrusion of gastric mucosa through esophageal hiatus Endoscopy Visualize lower esophagus Information on degree of inflammation or other problems

Hiatal Hernia Complications GERD Esophagitis Hemorrhage from erosion Stenosis Ulcerations of herniated portion

Hiatal Hernia Complications Strangulation of hernia Regurgitation with tracheal aspiration Increased risk of respiratory problems

THERAPY Lifestyle modifications Eliminate alcohol Elevate HOB Stop smoking Avoiding lifting/straining Weight reduction, if appropriate

Hiatal Hernia Surgical Therapy Goals Reduce hernia Provide acceptable lower esophageal sphincter (LES) pressure Prevent movement of gastroesophageal junction

Hiatal Hernia Surgical Therapy Reduction of herniated stomach into abdomen Herniotomy Excision of hernia sac Herniorrhaphy Closure of hiatal defect

Hiatal Hernia Surgical Therapy Antireflux procedure Gastropexy Attachment of stomach subdiaphragmatically to prevent reherniation

Hiatal Hernia Surgical Therapy Laparoscopically performed Nissen and Toupet techniques are standard antireflux surgeries Thoracic or open abdominal approach used in select cases

Nissen Fundoplication Fig. 42-5

GERH Reflü sonucunda distal özefagusta oluşan kimyasal özefajit. GERH 3 neden AÖS mekanik bozukluğu Yetersiz özefagus temizlenmesi İntragastrik basınç artışı

GERH AÖS 3 komponent var 1. Total uzunluk 2 cm olmalı 2. Abdominal uzunluk 1 cm olmalı 3. İstirahat basıncı >6 mmHg

GERH Üst GIS grafi Endoskopi Özefagus manometri 24 saat özefagus pH testi

GERH Üst GIS grafi Anatomik yapının belirlenmesinde Özefagus-kardiya diyafragma ilişkisi Endoskopi Diğer patolojilerin ekarte edilmesinde Özefajit tespitinde Özefagus manometri 24 saat özefagus pH testi

GERH Komplikasyonlar barret ülser kanama perforasyon striktür fibrozis

GERH Medikal Tedavi: Pozisyon Beslenme AÖS basıncını artırmak Mide asidini azaltmak Mide içi basıncı azaltmak Antiasit H2 blokör, PPI Metpamid, Sisaprid

GERH Tedavi: Nissen Fundoplikasyon

Esophageal Cancer Adenocarcinomas Squamous cell Arise from glands lining esophagus Resemble cancers of stomach and small intestine 30% to 70% of esophageal cancers Incidence in distal esophagus currently ↑ Squamous cell Incidence currently ↓ in United States

Esophageal Cancer Etiology and Pathophysiology Risk factors Smoking Excessive alcohol intake Barrett’s esophagus Diets low in fruits and vegetables Plummer Wilson sendromu Lökoplaki Mantar toksinleri vb.

Esophageal Cancer Etiology and Pathophysiology Risk factors (cont’d) Certain minerals and vitamins Exposure to lye, asbestos, and metal History of achalasia

Esophageal Cancer Etiology and Pathophysiology Majority of tumors located in middle and lower portion of esophagus Malignant tumor Usually appears as ulcerated lesion Obstruction in later stages

Esophageal Cancer Clinical Manifestations Symptom onset is late Progressive dysphagia is most common( Sıvı geçer katı geçmez) Initially with meat, then soft foods and liquids Pain develops late Substernal, epigastric, or back areas Increases with swallowing May radiate

Esophageal Cancer Clinical Manifestations Weight loss Regurgitation of blood-flecked esophageal contents

Esophageal Cancer Diagnostic Studies Endoscopy with biopsy Necessary for definitive diagnosis Endoscopic ultrasonography (EUS) Important tool to stage Barium swallow with fluoroscopy

Esophageal Cancer Diagnostic Studies Computed tomography (CT) Magnetic resonance imaging (MRI) PET Bronchoscopic examination Detect involvement of lung

Esophageal Cancer Complications Hemorrhage If erodes into aorta Esophageal perforation with fistula formation Esophageal obstruction Metastasis Liver and lung common

Esophageal Cancer Surgical procedures Esophagectomy Removal of part or all of the esophagus Esophagogastrostomy Resection of a portion of esophagus and anastomosis of remaining portion to stomach

Esophageal Cancer Endoscopic mucosal resection (EMR) Removes superficial lesions Submucosal neoplasms

Not candidates for surgery Radiation alone Combination chemoradiation

Chemoradiation Additional 69 patients were treated with the same combined therapy and were analyzed. Similar results were obtained Median survival : 17.2 months 3-year survival : 30% 5 yr survival :14%

NORMAL ESOPHAGUS Normal double contrast esophagram (barium coating and air distention) Effervescent granules release air with ingestion. 71

PATHOLOGY/RADIOLOGY CORRELATION image X ray image 72

ESOPHAGEAL CANCER Typical squamous cell carcinoma Poor prognosis from local extension into critical mediastinal structures. (esophagus lacks a serosa) . 73

ESOPHAGEAL CANCER Distal malignancy may be adenocarcinoma due to Barrett’s esophagus - dysplastic change caused by chronic reflux of gastric contents. 74

CT ESOPHAGEAL CANCER PET/CT CHEST CT

ESOPHAGEAL VARICES LINEAR TUBULAR FILLING DEFECTS represent distended veins from shunting due to cirrhosis and portal hypertension 76

CANDIDA ESOPHAGITIS Extensive NODULAR filling defects in the esophagus in an immunocompromised patient are typical for candida esophagitis. 77

ACHALASIA Distended esophagus with distal stricture due to Achalasia - Failure of lower sphincter to relax – causing obstruction. Etiology is unknown. BIRD BEAK APPEARANCE Stricture due to cancer or reflux caused scarring have to be considered first. Barium filled esophagus 78

MALLORY-WEISS TEAR Esophagus shows a linear tear of mucosa of distal esophagus due to vomiting with barium tracking into the wall. Full thickness tear or rupture (Boerhaave’s syndrome) can lead to mediastinitis and death. 79

HIATAL HERNIA NORMAL ESOPHAGUS *Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus. DIAPHRAGM DIAPHRAGM 80

HIATAL HERNIA CXR FINDINGS L Mass on chest X- ray posterior to heart may be a large hiatal hernia. 81

CT HIATAL HERNIA

SMALL BOWEL OBSTRUCTION Ng tube ERECT Multiple Dilated Loops of Small Bowel with Air/Fluid Levels Present at Different Heights 83

SMALL BOWEL OBSTRUCTION

SMALL BOWEL OBSTRUCTION String of Pearls Sign UPRIGHT

* PARTIAL SMALL BOWEL OBSTRUCTION DILATED BOWEL * OBSTRUCTION ZONE OF TRANSITION NON DILATED BOWEL Proximal loops are dilated and distal loops are collapsed indicating an obstruction. 86

PROXIMAL DILATED BOWEL CT- SMALL BOWEL OBSTRUCTION Proximal loops are dilated and distal loops are collapsed indicating an obstruction. Obstruction most likely due to adhesions in a patient with history of abdominal surgery ZONE OF TRANSISITON PROXIMAL DILATED BOWEL DISTAL NORMAL BOWEL 87

SM. BOWEL BARIUM STUDY HERNIA CT Note hernia in right lower quadrant on both exams accounting for obstruction. Hernia is likely cause if there is no history of prior surgery. 88

POST – OP ADYNAMIC ILEUS COLON LARGE AND SMALL BOWEL SM. BOWEL SYMMETRIC dilatation of large and small bowel is seen normally as a post operative ileus. 89

POST – OP ADYNAMIC ILEUS sutures Colon resection 90

CHROHN’S DISEASE normal Narrowed distal ileum due to chronic inflammation is typical for Crohn’s disease. 91

APPENDICOLITH Occasionally a calculus (appendicolith) is seen as the source of appendicitis due to obstruction of the appendix and inflammation. 92

DISTENDED APPENDIX WITH LOCAL ACUTE APPENDICITIS NORMAL DISTENDED APPENDIX WITH LOCAL INFLAMATION. 93

ABSCESS Catheter has been placed by radiologist using CT guidance draining abscess collection DRAINAGE 94

SPLENIC FLEXURE NORMAL COLON HEPATIC FLEXURE TRANSVERSE COLON DESENDING COLON ASCENDING COLON Normal air contrast barium enema (double contrast-air and barium per rectum) shows filling of colon with air and barium retrograde to the cecum with reflux into the terminal illeum TERMINAL ILEUM CECUM 95

PEDUNCULATED COLON POLYP (DESCENDING COLON) stalk on polyp--pedunculated 96

COLON POLYP Polyp on wall, sessile, without stalk is coated and outlined by barium 97

Distension extends to distal descending colon. OBSTRUCTION Distension extends to distal descending colon. 98

COLON CANCER Barium enema showing an ”APPLE -CORE” constricting lesion with proximal dilatation of colon 99

COLON SIGMOID VOLVULUS “COFFEE BEAN SIGN” Dilated coffee bean shaped sigmoid colon due to volvulus. “COFFEE BEAN SIGN” 100

Barium fills to point of obstruction and twist of sigmoid colon SIGMOID VOLVULUS “BEAK SIGN” Barium fills to point of obstruction and twist of sigmoid colon 101

NECROTIZING ENTEROCOLITIS #1 #2 Air in bowel wall is due to Necrotizing Enterocolits. #1- an infectious complication of premature infants. Air has tracked into the Portal Vein and is seen in #2. 102

CT - PNEUMATOSIS Air in the bowel wall Small tiny bubbles in the wall bowel loop – Red arrows

Barium extends from lumen outward into diverticulum. DIVERTICULOSIS Barium extends from lumen outward into diverticulum. 104

DIVERTICULITIS Extensive inflammation, wall thickening and spasm can simulate carcinoma with colonoscopy required to confirm. 105

DIVERTICULITIS Single arrow thickened LB; DBL arrow air in tic 106

DIVERTICULITIS Black arrow thickened bowel wall, white arrow air in tic

NORMAL SMA ARTERIOGRAM Catheter is placed in superior mesenteric artery showing normal filling of small and large intestinal branches. 108

ABNORMAL SMA ARTERIOGRAM GI BLEED Subtracted SMA arteriogram shows contrast collecting at site of active bleeding in Rt. lower quadrant. 109

Technetium-labeled RBC’S NUCLEAR MEDICINE Technetium-labeled RBC’S Labeled red blood cells are imaged over 1 hour showing extravasation in Rt. colon steadily increasing indicating active bleeding. 110

AIR UNDER THE DIAPHRAGM NORMAL GAS PATTERN AIR UNDER THE DIAPHRAGM Perforation of GI tract leads to pneumoperitoneum collecting subdiaphragmaticly on upright x-ray 111

ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR UNDER THE DIAPHRAGM. UPRIGHT ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR UNDER THE DIAPHRAGM. DECUBITUS LEFT LATERAL DECUBITUS (left side dependent) shows air along liver margin. This is the preferred x-ray if the patient cannot stand. 112

Rigler’s Sign – See both sides of the bowel wall. Triangle Sign – Small triangles of air

Cupula – Continuous Diaphragm Sign Rigler’s Sign – Double Wall Sign

Green Circle – Football Sign Magenta – Continuous Diaphragm Sign Red – Falciform ligament Yellow – Double Wall Sign or Rigler’s Sign

CT – FREE AIR

CT – FREE AIR