5

CASE 5


A 46-year-old woman presented to her physician complaining of dysphagia, regurgitation of undigested food and liquid and modest weight loss. The history revealed that the symptoms have lasted for 3 years and that she has a feeling of retrosternal fullness after meals. This feeling of fullness can be relieved at times by drinking a large glass of water and by standing with arms over her head. The radiographic imaging study (barium swallow and fluoroscopy) showed a dilated esophagus with a distinct air-fluid interface and a “bird’s beak” silhouette (Fig. 2-1) in the region of the lower esophageal sphincter (LES) and no significant peristalsis in the esophagus. Save for an inflamed esophageal mucosa, the endoscopic examination was unremarkable. Esophageal manometry showed incomplete relaxation of the LES and aperistalsis of the esophagus. The patient was diagnosed with primary achalasia (unknown etiology), which was successfully treated with pneumatic dilation of the LES.


image

FIGURE 2-1 Esophagogram showing the characteristic “bird’s beak” appearance of achalasia.


(Towsend C et al.: Sabiston Textbook of Surgery, 17e. WB Saunders, 2004. Fig. 39-11. Courtesy of Ronella A. Dubrow, M.D., MD Anderson Cancer Center, Houston, TX.)



WHAT ARE THE VERTEBRAL RELATIONSHIPS OF THE ESOPHAGUS?


The esophagus begins at the level of the sixth cervical vertebra, which corresponds to the level of the cricoid cartilage of the larynx. The esophagus descends in the superior and posterior (division of the inferior mediastinum) mediastina and passes through the esophageal hiatus at the level of the tenth thoracic vertebra. The cardia of the stomach receives the abdominal esophagus at the level of the eleventh thoracic vertebra.



WHAT IS THE BLOOD SUPPLY TO THE ESOPHAGUS?


The esophagus is richly supplied by arteries. These arteries are:


• Esophageal branches of the inferior thyroid artery, a branch of the thyrocervical trunk

• Esophageal branches of the descending thoracic aorta

• Branches from the bronchial arteries. The right bronchial artery takes origin from the right third posterior intercostal artery, a branch of the descending thoracic aorta, whereas the left bronchial arteries issue directly from the descending thoracic aorta.

• Left gastric artery, a branch from the celiac trunk

• Left inferior phrenic artery, the first branch, along with its fellow, of the abdominal aorta


WHAT IS THE VENOUS DRAINAGE OF THE ESOPHAGUS?


The veins of the esophagus drain into the following:


• Inferior thyroid veins

• Azygos, hemiazygos, and accessory hemiazygos veins

• Left gastric vein


WHAT IS THE INNERVATION OF THE ESOPHAGUS?


The nerve supply to the esophagus is from the:


• Recurrent laryngeal nerves, branches of the vagi, provide motor innervation to the upper esophageal sphincter (cricopharyngeus muscle) and to the cervical segment of the esophagus. Injury to this nerve may result in dysfunction of the upper esophageal sphincter.

• Anterior and posterior vagal trunks

• Thoracic parts of the sympathetic trunk

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Jun 16, 2016 | Posted by in ANATOMY | Comments Off on 5

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