Disorders of the Lower Esophagus

Lower esophageal disorders that may require surgery include esophagitis, perforation, Schatzki's ring, and epiphrenic diverticula. Esophageal cancer is discussed in Ch. 113.

Esophagitis

Although acid reflux is by far the most common cause of esophagitis, bile reflux often occurs after total gastrectomy unless bile diversion has been accomplished by a Roux-en-Y anastomosis or enteroenterostomy. Symptoms depend on the amount of reflux. Pain is most common when the patient lies flat but also may occur when the patient is bent over. Conservative therapy, effective in most cases, includes losing weight, elevating the head at night using at least two pillows, restricting food intake after 6 pm, and taking proton pump inhibitors, H₂ blockers, or antacids before bedtime. Many patients require twice the usual dose of H₂ blockers to control reflux symptoms, because acid suppression must be close to 100%, which can only be achieved using higher doses. However, elderly patients are at greater risk of adverse effects from these drugs, especially when high doses are used or if they have some degree of renal impairment. Intractable esophagitis requires surgery. Laparoscopic Nissen fundoplication is an option for the patient who can tolerate a pneumoperitoneum.

Perforation

Iatrogenic injury: Perforation by an endoscope may occur. Perforation is rare with flexible scopes but not with rigid scopes. The perforation is almost always above the diaphragm rather than below it. Overinflation of Sengstaken-Blakemore tubes, balloon dilation for achalasia, and surgery of the upper stomach or esophagus (eg, vagotomy or hiatus hernia repair) may also cause perforation.

Pain and fever are the important clinical findings; if they develop after an esophageal procedure, perforation is the probable cause. A chest x-ray probably shows mediastinal emphysema, and, later, extensive subcutaneous emphysema involving the chest, neck, abdomen, and scrotum may occur. Perforation is an emergency. A diatrizoate meglumine swallow should be performed immediately; it will nearly always show the perforation. The perforation must be surgically closed immediately and the closure reinforced by the stomach (perforation at the gastroesophageal junction can be repaired by gastric fundoplication), a flap of parietal pleura, or a muscle flap from the chest wall.

Emetic injury: Vomiting when the stomach is full can rupture the distal esophagus, leading to rapid contamination of the left pleural cavity (Boerhaave's syndrome) or peritonitis. Subcutaneous emphysema or complaints of severe pain in the left upper quadrant, chest, or shoulder after vomiting mandate the same emergency diagnostic and therapeutic measures as are required for iatrogenic perforation.

Schatzki's Ring

A ring of mucosa and submucosa that causes narrowing at the esophagogastric junction.

Schatzki's rings generally form before old age. However, they tighten with age, occluding passage when the lumen becomes as small as 15 mm. Intermittent dysphagia may occur. When a Schatzki's ring is asymptomatic, dilation with bougies is usually successful. If surgery is necessary, the ring can be broken with a finger inserted into the esophagus, and any associated hernia can be repaired.

Epiphrenic Diverticula

These diverticula develop just above the diaphragm and are associated with hyperactivity of the lower esophageal sphincter and often with a sliding hiatus hernia. Some may become >= 5 cm in diameter. They can retain food and become infected, and cancer may develop in the mucosa. If pain or regurgitation occurs, excision is necessary; if the diverticula are asymptomatic, they probably should be followed up endoscopically. Accompanying distal esophageal spasm is treated with pneumatic dilation.