STEPTRACKERGASTROINTESTINAL | PATHOLOGY + PHYSIOLOGY | HIGH-YIELD REVIEW

Esophagus I — Structural & Motility

When food can't get down or the wall gives way: motility disorders, rings and pouches, tears, ruptures, varices and hernias.

FOCUS ON
The dysphagia pattern localizes the problem. Solids and liquids from the start = motility disorder (achalasia: "bird's beak", lost myenteric inhibitory neurons). Solids only and progressive = mechanical. Then separate the vomiting injuries: Mallory-Weiss (mucosal tear, bleeding) vs Boerhaave (full-thickness rupture, crepitus).
DISORDER
MECHANISM
FEATURES
CLUE · TREATMENT
Achalasia
Loss of inhibitory (NO/VIP) neurons of the myenteric plexus → LES can't relax + aperistalsis; idiopathic, Chagas, or tumor (pseudoachalasia)
Dysphagia to solids and liquids from onset, regurgitation, weight loss
Manometry: high LES pressure, no relaxation · barium bird's beak · ↑ SCC risk · dilation, myotomy, POEM
Diffuse esophageal spasm
Uncoordinated simultaneous contractions
Chest pain + dysphagia, mimics angina
Corkscrew esophagus on barium
Scleroderma esophagus
Smooth muscle atrophy and fibrosis
↓ LES pressure + weak distal peristalsis → severe GERD, strictures, Barrett
CREST "E"
Esophageal web
Thin mucosal fold in the upper esophagus
Dysphagia to solids
Plummer-Vinson: web + iron deficiency + glossitis → SCC risk
Schatzki ring
Mucosal ring at the squamocolumnar junction
Intermittent solid-food dysphagia ("steakhouse")
Dilation
Zenker diverticulum
False diverticulum (mucosa + submucosa) through Killian triangle above the cricopharyngeus
Elderly: halitosis, regurgitation of old food, gurgling neck mass, aspiration
Cricopharyngeal dysfunction
Mallory-Weiss tear
Longitudinal mucosal laceration at the GE junction from forceful retching
Painless hematemesis
Alcohol binge, bulimia
Boerhaave syndrome
Transmural rupture of the distal esophagus (left posterolateral)
Severe chest pain, subcutaneous emphysema, pneumomediastinum (Hamman crunch), left effusion with high amylase
Surgical emergency
Esophageal varices
Portal hypertension → left gastric vein → dilated submucosal veins in the distal esophagus
Painless, massive hematemesis
Banding + octreotide; nonselective β-blocker prophylaxis; TIPS
Hiatal hernia
Sliding: GE junction above diaphragm (most common, GERD) · paraesophageal: fundus beside a normally placed GE junction
Sliding: "hourglass" stomach
Paraesophageal → strangulation risk
Esophageal atresia + TE fistula
Most often proximal atresia with distal tracheoesophageal fistula
Polyhydramnios; drooling, choking, cyanosis with first feeds; NG tube coils; gas in stomach
VACTERL association

Mechanism — the swallowing path

OropharynxStroke, myasthenia
→
UES (cricopharyngeus)Zenker
→
Esophageal bodySpasm, scleroderma, webs, rings
→
LESAchalasia (won't open) · GERD (won't close)

LES relaxation needs nitric oxide and VIP from inhibitory myenteric neurons — exactly what achalasia destroys.

Reading the dysphagia

PATTERN
THINK
Solids → then liquids, progressive, weight loss
Carcinoma, peptic stricture
Solids, intermittent
Schatzki ring, web, eosinophilic esophagitis
Solids + liquids from onset
Motility: achalasia, scleroderma, spasm
Trouble starting a swallow, coughing
Oropharyngeal: stroke, MG, ALS, Zenker
Painful swallowing
Infectious or pill esophagitis

How it's tested

COMMON CONFUSIONMallory-Weiss is a mucosal tear that bleeds. Boerhaave is a full-thickness rupture that leaks air and fluid into the mediastinum.
THE TRAPAn older smoker with an achalasia picture and rapid weight loss may have a cancer at the cardia (pseudoachalasia). Endoscopy before any dilation.
YOUR APPROACHDysphagia type → level → test (barium for anatomy, manometry for motility, endoscopy for mucosa and tumor).

If you see… think…

Dysphagia to solids and liquids, regurgitation, bird's beak → achalasia
Achalasia in a Latin American immigrant → Chagas disease
Halitosis + regurgitated old food + gurgling neck pouch → Zenker diverticulum
Painless hematemesis after a night of vomiting → Mallory-Weiss tear
Severe chest pain + neck crepitus after violent vomiting → Boerhaave rupture
Cirrhosis with massive painless hematemesis → varices — band + octreotide
Food sticks occasionally with steak → Schatzki ring
Iron deficiency + upper web + glossitis → Plummer-Vinson
Chest pain + corkscrew esophagus → diffuse esophageal spasm
Newborn chokes on first feed, NG tube coils, gas in stomach → atresia + distal TEF