Özefagus Hastalıkları

Özefagus Hastalıkları
Prof. Dr. Öge TAŞCILAR

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

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

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

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

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

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

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

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

Inability to belch GERD Regurgitation Weight loss

Gece regurjitasyon Aspirasyon Pnömoni Bronşit Akciğer abse

Achalasia Diagnostic Studies
Radiologic studies Manometric studies of lower esophagus Endoscopy

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

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

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.

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

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

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

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.

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

Reduction of herniated stomach into abdomen Herniotomy Excision of hernia sac Herniorrhaphy Closure of hiatal defect

Antireflux procedure Gastropexy Attachment of stomach subdiaphragmatically to prevent reherniation

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.

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

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

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

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