A- succinctly Knowing the functional anatomy of the esophagus:
The esophagus is a tubular organ lined with squamous epithelium.
His muscle structure, extrinsic innervation (vagus) and intrinsic (autonomous nerve plexus) allow the propulsion of pharyngeal food to the stomach.
The main element opposing the reflux of gastric contents is the lower esophageal sphincter (LES).
B- Know the schematic organization of the esophageal motility:
In the resting state, the esophagus is animated by no contraction.
It is closed at both ends with the tonic contraction of his sphincters, which protects both the upper airway and lower esophageal reflux.
When swallowing, immediately after the release of the upper esophageal sphincter (SSO), a peristaltic wave travels down the esophagus to the high speed of 3 to 4 cm / sec (primary peristalsis).
WIS relaxes even before the peristaltic wave reaches do.
This relaxation ends with a contraction that extends peristaltic wave.
Control of esophageal motility is complex since it involves a coordinated manner striated muscles (upper part of the esophagus) and smooth muscle to ensure the alternation of phases of opening and closing of sphincters and smooth progression peristaltic contraction.
The peristaltic sequence is under the control of the vagus as well as the intrinsic innervation.
It seems to follow a very complex plant-level programming bulbo-pontine (center of swallowing).
WIS resting tone involved in both specific properties of the muscle fibers of the sphincter and nerve activity exciter mainly cholinergic.
His relaxation is due to the interruption of the activity, the activity of some vagal fibers (not adrenergic, not cholinergic) and the influence of many agents (hormones, chemical mediators, food).
Thus, gastrin increases its tone and cholecystokinin lowers.
C- List the main signs of a call to esophageal disease:
They are: dysphagia, regurgitation (as distinct from vomiting, or rumination of Rumination and phlegm), heartburn often associated with a feeling of bitterness, belching, gastrointestinal bleeding and / or iron-deficiency anemia microcytic, impaired general condition (anorexia, weight loss), a “node” left supraclavicular (Troisier).
There may also be extra-intestinal symptoms such as chest pain of angina type of nocturnal respiratory symptoms or postprandial and various ENT symptoms (dysesthesia oropharyngeal, hoarseness, earache).
D- Define and recognize dysphagia:
Dysphagia is a discomfort or impede swallowing food.
It is different from odynophagia (pain felt during the progression of food through the esophagus) and cervical constriction sensation usually associated with the qualified anxiety “globus hystericus”.
It can be difficult to distinguish anorexia (loss of appetite) especially when electively covers certain foods (meat).
E- List the main elements of the semiotic analysis of dysphagia:
They are: the retro-sternal location of embarrassment, elective for solids (dysphagia organic stenosis) or associated with that of liquids (paradoxical dysphagia capricious of evolution), the start modes (sudden or not) and changes (increase more or less rapid, intermittent) and associated symptoms (weight loss, regurgitation, signs of gastroesophageal reflux, ENT signs and / or respiratory).
F- Know the semiotic value of dysphagia and the first useful diagnostic examinations:
The semiotic value of dysphagia is great.
Once apart ENT and neurological causes in case of high dysphagia, this symptom almost always falls of organic obstruction or motor disorders of the esophagus, gastric damage rarely reaching the cardia.
In all cases, it is important to realize first esophageal endoscopy that will biopsies.
If endoscopy is normal, the barium swallow of the esophagus and esophageal manometry are especially suitable for search engines disorders.
G- Know the most common causes of esophageal dysphagia original:
1- lesions of the esophagus:
– Tumor stenosis: squamous cell carcinoma of the esophagus or rarely esophageal adenocarcinoma, exceptionally other malignant tumors (sarcoma and melanoma) or benign (leiomyoma) and extrinsic tumors (lymph node, lung, mediastinal);
– The non-tumor stenosis mostly due to reflux esophagitis, a caustic, postoperative esophagitis (on nasogastric tube) or radiation, much more rarely to extrinsic compression (lymphadenopathy, aortic arch);
– The non stenotic oesophagitis drug or infectious (especially Candida albicans) in which the predominant symptom is actually odynophagia;
– Esophageal rings: Schatzki ring at the proximal end of a hiatal hernia.
2- The motor abnormalities:
• primitives such as achalasia (synonyms cardiospasm, idiopathic megaesophagus), the disease of diffuse esophageal spasm, the nutcracker esophagus;
• observed during or gastroesophageal reflux, certain connective tissue diseases (scleroderma) and many diseases affecting the innervation or the esophageal muscles.
H- Indicate the methods of morphological exploration of esophagus and their cost:
Endoscopic examination of the esophagus (K40 quotation for simple endoscopy, K50 for endoscopy with biopsies) is the most reliable method.
Especially suitable for the diagnosis of endoluminal tumors and esophagitis, upper endoscopy allows both a detailed study of the mucosa and to biopsy specimens.
In case of gastrointestinal bleeding, the examination should be performed urgently.
The barium swallow of the esophagus (Z30 listing) is practiced as second-line or in cases impossible or incomplete endoscopy (impassable stenosis).
It can also be useful to objectify extrinsic compression or movement disorders, and to clarify the topography and extent of esophageal cancer.
Chest computed tomography (Z90 listing) can be studied by transverse axial slices parietal extension, and mediastinal lymph node neoplastic lesions.
The endoscopic ultrasonography (K40 + K30 listing / 2) even more finely explores the esophageal wall (achievement of various layers) and the atmosphere peri-esophageal.
It differentiates wall intra submucosal lesions extrinsic compressions, appreciates the parietal extension of tumors and detect lymph node metastases. The existence of a stenosis limit performance.
I- Know the indications and the cost of esophageal manometry and pH monitoring:
The esophageal manometry (K40 listing) saves the WIS resting pressure and relaxation during swallowing and peristalsis in the body of the esophagus. This is the key for the diagnosis of motor disorders of the esophagus.
It does not help to establish the diagnosis of gastroesophageal reflux.
The esophageal pH monitoring (K40 listing) is by means of an electrode placed 5 cm above the ORC for a period of 3 or 24 hours.
This method is the only one able to affirm gastroesophageal reflux disease (percentage of time at pH below 4> 5%).
It has no indication when reflux symptoms are typical.
It is very useful to bring against atypical symptoms with a pathological reflux when the endoscopic examination is negative in case of treatment failure and in case of a surgical indication.