Diseases of the Esophagus

895 Pages·1974·29.046 MB·English

by  Gaston R. Vantrappen M.D., Agg. H.O., Jan J. Hellemans M.D., Agg. H.O. (auth.)

Handbuch
der inneren Medizin
Begriindet yon L. Mohr und R. Staehelin
Herausgegeben yon
H. Schwiegk
Dritter Band: Verdauungsorgane
Fiinfte, Yollig neu bearbeitete und erweiterte Auflage
Teil1 Esophagus
Springer-Verlag Berlin Heidelberg New York 1974
Diseases
of the Esophagus
By
G. Vantrappen and J. Hellemans
With Contributions of
C. Debray' W. Deloof· V.J. Desmet· D.A.W. Edwards' J. Fevery
G. Fransen' K. Geboes . J. De Groote' E. Hafter . A. Haney
P. Heitmann' P. Housset . J. Janssens' A. Lacquet
H.P. Lazar' B. T. Le Roux . H. Monges . J. G. Pearson' W. Pelemans
E. Ponette . J. Pringot . J. A. Rinaldo' J. De Schryver
E. C. Texter' G. N. Tytgat . P. Valembois . F. ViI ardell . B. S. Wolf
With 358 partly coloured Figures
Springer-Verlag Berlin Heidelberg New York 1974
GASTON R. VANTRAPPEN, M.D., Agg. H.D. Professor of Medicine
JAN J. HELLEMANs, M.D., Agg. H.D. Professor of Medicine
Department of Medical Research and Department of Medicine,
Akademisch Ziekenhuis St. RafaeI, University of Leuven, B·3000 Leuven
A special US edition is available under the title
G. VANTRAPPEN J. HELLEMANS, Diseases of the Esophagus
ISBN 978-3-642-86431-5 ISBN 978-3-642-86429-2 (eBook)
DOI 10.1007/978-3-642-86429-2
Library of Congress Cataloging in Publication Data
Diseases of the Esophagus
(Verdauungsorgane. T. 1) (Handbuch der inneren Medizin, Bd. 3. T. 1)
Bibliography: p.
Esophagus-Diseases. II. V ANTRAPPEN, G., ed. III. HELLEMANS, J., ed. IV. Series: Handbuch der inneren Medizin.
Bd. 3. T. 1.
RC41.H342 Bd. 3, T. 1 [RC815.7] 616'.026 74-13240
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Softcover reprint ofthe hardcover 1s t edition 1974
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List of Contributors
DEBRAY, c., M.D., Professeur, Medecin des Hopitaux, Chef du Service de Gastro
enterologie, Hopital Bichat, Paris, France
DELOOF, W., M.D., Department of Medicine, Akademisch Ziekenhuis St. Rafael,
University of Leuven, 3000 Leuven, Belgium
DESMET, V. J., M.D., Professor of Pathology, Department of Medical Research
and Department of Pathology, Akademisch Ziekenhuis St. Rafael, University
of Leuven, 3000 Leuven, Belgium
EDWARDS, D. A. W., M.D., F.R.C.P., MRC Department of Clinical Research,
University College, Hospital Medical School, University Street London
WC1E 6JJ, Great Britain
FEVERY, J., M.D., Associate Professor of Medicine, Department of Medical
Research and Department of Medicine, Akademisch Ziekenhuis St. Rafael,
University of Leuven, 3000 Leuven, Belgium
FRANSEN, G., M.D., Department of Surgery, Akademisch Ziekenhuis St. Rafael,
University of Leuven, 3000 Leuven, Belgium
GEBOES, K., M.D., Department of Medical Research and Department of Medicine,
Akademisch Ziekenhuis St. Rafael, University of Leuven, 3000 Leuven, Bel
gium
GROOTE, De, J., M.D., Professor of Medicine, Department of Medical Research
and Department of Medicine, Akademisch Ziekenhuis St. Rafael, University
of Leuven, 3000 Leuven, Belgium
HAFTER, E., M.D., Spezialarzt fUr innere Medizin F.M.H., Magen-Darmkrank
heiten, T6distrasse 36, CH-8002 Zurich, Switzerland
HANCY, A., M.D., 27, Bd. d'Athenes, F-1300 Marseille, France
HEITMANN, P., M. D., Krankenanstalten Duren, Abteilung fUrinnere Krankheiten,
516 Duren, Germany
HELLEMANS, J., M.D. Agg. H.O., Professor of Medicine, Department of Medical
Research, University of Leuven, Leuven, Belgium; Chief Geriatric Unit, De
partment of Medicine, Akademisch Ziekenhuis St. Rafael, 3000 Leuven, Bel
gium
HOUSSET, P., M.D., Attache de consultation it L'Hopital Bichat, Membre de la
Societe Nationale Francaise de Gastro-Enterologie, Paris, France
JANSSENS, J., M.D., Aangesteld Navorser NFWO, Department of Medical
Research and Department of Medicine, Akademisch Ziekenhuis St. Rafael,
University of Leuven, 3000 Leuven, Belgium
LACQUET, A., M.D., Professor of Surgery, Department of Surgery and Department
of Surgical Pathology, Akademisch Ziekenhuis St. Rafael, University of
Leuven, 3000 Leuven, Belgium
VI List of Contributors
LAZAR, H. P., M.D., 700 North Michigan, Chicago, Ill, 60611, USA
LE Roux, B. T., Ch.M., F.R.C.S.E., Professor of Thoracic Surgery, Thoracic
Unit, Department of Surgery, Wentworth Hospital, P. B. Jacobs, Durban,
Natal, South Africa
MONGES, H., M.D., Professeur, Medecin des Hopitaux, Clinique des maladies
de l'appareil digestif et de la nutrition, Hopital Nord, Marseille 15, France
PEARSON, J. G., M.D., Director of Radiotherapy, Provincial Cancer Hospitals
Board, Dr. W. W. Cross Cancer Institute, 11560 University avenue, Edmonton,
Alberta, T6G 1Z2, Canada
PELEMANS, W., M.D., Research Fellow, Department of Medical Research and
Department of Medicine, Akademisch Ziekenhuis St. Rafael, University of
Leuven, 3000 Leuven, Belgium
PONETTE, E., M.D., Assistant Professor of Radiology, Department of Radiology,
Akademisch Ziekenhuis St. Rafael, University of Leuven, 3000 Leuven, Bel
gium
PRINGOT, J., M.D., Assistant Professor of Radiology, Department of Radiology,
Cliniques Universitaires, U.C.L., 3000 Leuven, Belgium
RINALDO, J. A., Jr., M.D., Medical Director, Providence Hospital, 16001 W. Nine
Mile Rd., Southfield, Michigan 48075, USA
SCHRYVER, DE, J., M.D., Wilhelmina Kinderziekenhuis, Nieuwe Gracht 137,
Utrecht, The Netherlands
TEXTER, E. C., Jr., M.D., Professor of Medicine, Physiology and Biophysics,
School of Medicine, Assistant Dean, School of Health, Related Professions,
Associate Chief of Staff for Education, 300 E Roosevelt Rd., Little Rock,
AR 72206, USA
TYTGAT, G. N., M.D., Lektor in Gastroenterologie, Akademisch Ziekenhuis bij
de Universiteit van Amsterdam, Wilhelmina Gasthuis, Amsterdam, The
Netherlands
V ALEMBOIS, P., M.D., Aangesteld Navorser N.F.W.O., Consultant in Surgery,
Department of Medical Research and Department of Surgery, Akademisch
Ziekenhuis St. Rafael, University of Leuven, 3000 Leuven, Belgium
V ANTRAPPEN, G., M.D. Agg. H.O., Professor and Chairman, Department of Medi
cal Research, University of Leuven, Leuven, Belgium; Chief Gastrointestinal
Unit, Department of Medicine, Akademisch Ziekenhuis St. Rafael, 3000 Leu
yen, Belgium
VILARDELL,F., M.D.,D. Sc.Med., Director, School of Gastroenterology, Universidad
Autonoma de Barcelona, Hospital Santa Cruz y San Pablo, Barcelona 13,
Spain
WOLF, B. S., M.D., Chairman and Professor of Radiology, The Mount Sinai
School of Medicine, 11 East 100th street, New York 10029, USA
Preface
This book aims to be a synthesis of our current knowledge about the normal
and pathological esophagus. Although a number of excellent monographs on
limited aspects of esophageal pathology are available, a recent handbook treating
the whole of esophageal physiology and pathology is lacking. We attempted to
present the collected material in such a way that even the neophyte in the field
would not get lost in the wealth of data. For this reason we have included a
number of illustrations such as classical radiological and endoscopic images,
manometric tracings and uncomplicated graphs, which may seem superfluous for
specialists but will be helpful to the reader who wants to be initiated in the subject.
At the same time we tried to be fairly complete so as to make available to the
esophageal specialist a book of references, to which he can readily turn when
faced with rare diseases or unusual physiological or pathophysiological pheno
mena. In order to achieve both aims the authors often give their own point of
view when faced with controversal topics, while classical as well as more recent
features and concepts are mentioned and diverging opinions discussed.
Our knowledge about the structure and function of the normal and the patho
logical esophagus has increased considerably during the last few years. Our
insight into the local and central innervation of the esophagus has improved; the
behavior of the gastroesophageal sphincter has greatly been clarified and different
types of esophageal motor responses have been recognized which, each in its own
way, may be influenced pharmacologically. Therefore we thought it useful to
thoroughly discuss the basic data, i.e. anatomy, histology, electron microscopy
and physiology. Many diseases cause disturbances of esophageal mechanisms.
The section on physiology was written to elucidate these mechanisms, starting
from the normal motility. The examination of the esophagus has been improved
by the refinement of the traditional methods, such as radiology, endoscopy and
by the recent introduction of new techniques, such as electromyography, the
acid infusion test and pH- and PD-measurements. Although the clinical and
diagnostic value of these procedures has not yet been fully established, clinical
correlations are discussed. In the chapter on diagnotic procedures, however, the
stress is laid on procedures rather than on diagnosis, in order to minimize overlap
with the chapters in which the diseases themselves are discussed.
There are many esophageal diseases in which the disorders or lesions of the
esophagus are but a component of a more general condition. Motor disturbances
may be found in collagen diseases, anatomical anomalies in various congenital
malformations, mucosal lesions in several cutaneous diseases, esophageal varices
in a series of extraesophageal conditions, etc. It is obviously unnecessary to give
a detailed description of all these larger entities; for instance, we deemed it
superfluous to elaborate on causes, symptoms and treatment of acute and chronic
alcoholic intoxication because it may produce motility disturbances. Other
conditions, such as systemic sclerosis, Chagas' disease and portal hypertension
are discussed more thoroughly since their cause, evolution or treatment are
important for the understanding of the esophageal component. In this discussion
special prominence has been given to involvement of other parts of the gastroin
testinal tract.
VIn Preface
The necessity of subdividing the text in chapters and sections sometimes
entails artificial classifications. For instance, hiatal hernia with gastroesophageal
reflux, reflux esophagitis and peptic stenosis of the gullet are treated in three
different sections, although they may be considered one coherent entity, which
might equally well have been discussed under a single heading.
This book does not offer detailed descriptions of surgical interventions but
surgery is treated to the extent that it may interest the non-surgeon.
We wish to express our gratitude to all those who have helped us so much in
the preparation of this book. First of all we wish to mention the contributors,
especially those not belonging to the Leuven group. Their competence and personal
experience have greatly enhanced the value of this work. These, and the authors
of our university, who have shown so much forbearance, will forgive us for the
strict demands we imposed on them.
Our thanks are due also to our collegues of the Sint-Rafael and Saint-Pierre
University Hospitals, who have allowed us to draw on the work of their depart
ments: at Sint-Rafael Prof. J. VANDENBROUCKE, head of the department of
internal medicine, Prof. A. BAERT, head of the department of radiology, Prof.
H. DEGREEF, head of the department of dermatology, and Dr. L. BROECKAERT
of the section of gastroenterology; at Saint-Pierre, Prof. P. BODART, head of the
department of radiology, Prof. P. J. KESTENS, head of the department of surgery
and Prof. C. DIVE and Dr. R. FIASSE of the section of gastroenterology.
Dr. G. Tops (UFSIA) has ably assisted us in the translation of many texts
into English.
Mr. RUMMENS carried out the photographic work on the pictures provided by
the Leuven group. We also gratefully acknowledge the help of the Gevaert
Company, Mortsel. We are particularly grateful for the secretarial assistance of
Mrs. M. VANDERVEKEN, R. VERBIST and M. RUMBAUT, who have done a great
job in the preparation of the manuscript. And last but not least our thanks are
due to the Springer Verlag. The spirit of cooperation and the courtesy of Mr.
BERGSTEDT has been a great help throughout the preparation of this book.
Leuven, October 1974 G. VA NTRAPPEN
J. HELLEMANs
Contents
Chapter 1
Basic Data
Anatomy and Embryology. By G. FRANSEN and P. VA LEMBOIS. With 6 Figures 1
1. Anatomy ..... . 1
1.1. Topographic Anatomy 1
1.1.1. The Cervical Esophagus 1
1.1.2. The Thoracic Esophagus 3
1.1.3. The Abdominal Esophagus 3
1.2. The Musculature of the Esophagus Proper 4
1.3. The Pharyngoesophageal Junction 6
1.4. The Esophagogastric Junction . 6
1.4.1. The Gastroesophageal Sphincter 6
1.4.2. The Phrenoesophageal Membrane 7
1.4.3. The Diaphragmatic Hiatus 7
1.5. Arterial Blood Supply 9
1.6. Venous Drainage . . 9
1.6.1. Intrinsic Veins . . . 10
1.6.2. Extrinsic Veins 10
1.7. Lymphatic Drainage 11
1.8. Nerve Supply (Innervation) 12
1.8.1. Parasympathetic Innervation 12
1.8.2. Sympathetic Innervation 13
2. Embryology 13
References 15
Histology and Electron Microscopy. By V. J. DESMET and G. N. TYTGAT. With 8 Figures 17
1. Mucous Membrane (Tunica Mucosa) 17
1.1. Epithelium. . . . . 17
1.1.1. Squamous Epithelium 17
1.1.1.1. Histology..... 17
1.1.1.2. Cell Kinetics 19
1.1.1.3. Histochemistry 19
1.1.1.4. Electron Microscopy 21
1.1.2. Non.squamous Epithelial Structures, Cardia-type Glands 24
1.1.2.1. Histology..... 24
1.1.2.2. Electron Microscopy 27
1.2. Lamina Propria 27
1.3. Muscularis Mucosae 29
2. Tunica Submucosa 29
3. Tunica Muscularis 30
4. Angio-architecture 35
5. Innervation . . . 35
6. Adventitia, Elastic-muscular System, Serosa 37
References . . . . . . . . . . . . . . . . . . . . 38
Physiology. By J. HELLEMANS and G. VANTRAPPEN. With 20 Figures 40
1. The Functions of the Esophagus . 40
2. The Esophagus at Rest . . . . . . . . . . . . . . . 40
2.1. The Pharyngoesophageal Sphincter . . . . . . . . . . 40
2.1.1. Location..................... 40
2.1.2. The Pressure Profile of the Pharyngoesophageal Sphincter 41
2.1.3. Manometric Measurements of the Resting Pressure in the Pharyngoesophageal
Sphincter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
x
Contents
2.1.4. Respiratory Pressure Variations 43
2.1.5. Elasticity or Tonic Contraction 43
2.2. The Esophagus Proper 45
2.2.1. The Resting Pressure . . . . . 45
2.3. The Lower Esophageal Sphincter (L.E.S.) (Gastroesophageal Sphincter) 45
2.3.1. The Position of the Sphincter in Relation to the Squamocolumnar Junction 46
2.3.2. The Pressure Profile of the Sphincter. The Pressure Inversion Point (P.I.P.) 46
2.3.3. Manometric Measurements of the Resting Pressure in the Lower Esophageal
Sphincter . . . . . . . . . . . . . . . 48
2.3.4. Other Measurements of Sphincter Strength 50
2.3.5. Variations of the Sphincteric Pressure 51
2.3.5.1. The Intrinsic Sphincteric Properties 51
2.3.5.2. Hormonal Control of the Sphincter Strength 53
2.3.5.3. The Response of the Lower Esophageal Sphincter to Increased Intragastric
Pressure ....................... 56
2.3.5.4. Nervous Control of the Lower Esophageal Sphincter Pressure 57
3. Bolus Transport. Primary Peristalsis 59
3.1. Mechanical Activity 59
3.1.1. Oral Transport . . . . . . . . . . 59
3.1.2. Pharyngeal Transport. . . . . . . 62
3.1.3. Electromyographic Studies of Deglutition 63
3.1.3.1. Leading Complex . . . . . . . 63
3.1.3.2. Constrictor Musculature . . . . 64
3.1.3.3. Variations in Ancillary Activity 65
3.1.4. Esophageal Transport . . . . . 65
3.1.4.1. The Peristaltic Progression 65
3.1.4.2. Longitudinal and Circular Musculature 65
3.1.4.3. Striated and Smooth Muscles 67
3.1.5. Transport through the Gastroesophageal Sphincter 68
3.2. Intraluminal Pressure Variations . . . . . . . . 69
3.2.1. The Deglutition Complex in the Pharynx and in the Pharyngoesophageal
Sphincter . . . . . . . . . . . . 69
3.2.1.1. Relaxion of the High Pressure Zone 69
3.2.1.2. The e-(Elevation) Wave . . . . . . 71
3.2.1.3. The t-(Tongue) Wave . . . . . . . 71
3.2.1.4. The p-(Peristaltic) Wave ..... 71
3.2.2. The Deglutition Complex in the Esophagus 71
3.2.2.1. The Initial Negative Deflexion 72
3.2.2.2. The First Positive Wave 72
3.2.2.3. The Second Positive Wave 73
3.2.2.4. The Peristaltic Contraction 73
3.2.3. The Deglutition Complex in the Gastroesophageal Sphincter 74
3.3. Innervation . . . . . . . . . . . . . . . . 75
3.3.1. Innervation of Oropharyngeal Phase . . . . . 75
3.3.1.1. The Deglutition Center in the Rhombencephalon 75
3.3.1.1.1. The Existence of a Deglutition Center 75
3.3.1.1.2. Localization of the Deglutition Center 75
3.3.1.2. The Peripheral Afferent System 76
3.3.1.3. Elementary Reflexes Versus Swallowing 77
3.3.1.4. The Central Afferent System ..... 78
3.3.1.5. The Cortical Control of the Deglutition Center 78
3.3.1.6. Interference with Other Centers 80
3.3.1.7. Efferent Pathways. Motoneurons . . 81
3.3.2. Innervation of the Esophageal Phase 82
3.3.2.1. Central Nervous Centers 82
3.3.2.2. Afferent Pathways . . . . . . 82
3.3.2.3. Efferent Pathways . . . . . . 84
3.3.2.4. The Intramural Nervous System 85
3.3.2.4.1. The Motor Neurons. . . . . . 85
3.3.2.4.2. Local Nerve Fibers . . . . . . 85
4. Reflex Responses of the Esophagus 86
4.1. Secondary Peristalsis . . . . . . . 86
4.2. Esophageal Propulsive Force (E.P.F.) 87
4.3. On- and off-Response; Duration Response 87
4.3.1. The "On" Response (Circular Muscle) 87
Contents XI
4.3.2. The "Off" Response (Circular Muscle) 88
4.3.3. The Duration Response (Longitudinal Muscle) 89
4.4. Inhibition . . . . . . . . . . . . . . . 89
4.4.1. Deglutitive Inhibition ........ . 89
4.4.2. Inhibition by Distension ....... . 91
4.5. Relaxion of the Gastroesophageal Sphincter 91
4.6. Other Reflexes . . . . 91
5. Retrograde Transport . 92
5.1. Rumination-Eructation 92
5.2. Retching and Vomiting 92
5.3. Belching 93
References . . . . . . . . . . . 93
Chapter 2
Diagnostic Procedures
History and Symptoms of Esophageal Disease. By D. A. W. EDWARDS. With 5 Figures 103
1. Symptoms and Syndromes 103
1.1. Symptoms and their Significance 104
1.1.1. The Sensation of Obstruction 104
1.1.1.1. The Site of the Obstruction 104
1.1.1.2. The Site of the Receptors . 105
1.1.1.3. The Sensation of "Choking" 105
1.1.2. Regurgitation . . . . . . 105
1.1.2.1. The Volume of Regurgitate 105
1.1.2.2. The Taste ....... . 106
1.1.2.3. The Content . . . . . . . 106
1.1.2.4. The Timing ...... . 106
1.1.2.5. The Association with Position 106
1.1.3. Pain ..... 107
1.1.3.1. The Distribution 107
1.1.3.2. The Character . . . . . . . 107
1.1.3.3. The Timing ....... . 107
1.2. Syndromes ....... . 108
1.2.1. "Spill-Over" and "Spill-Into" Disease 108
1.2.2. Obstruction Syndromes . . . . . . . 109
1.2.2.1. The Stricture Syndrome ..... . 109
1.2.2.2. The Achalasia Syndrome . . . . . . 110
1.2.3. The So-Called "Functional" Dysphagias 111
2. History ..... . 112
2.1. Pharyngeal Problems 113
2.1.1. Pouch ..... . 113
2.1.2. Stricture or Web .. 114
2.1.3. Muscular and Neural 114
2.2. Esophageal Problems 114
Radiological Examination of the Esophagus. By J. PRINGOT and E. PONETTE. With
72 Figures ............ 119
1. The Radiological Technique . . 119
1.1. Equipment. . . . . . . . . 119
1.1.1. The Standard Diagnostic X-Ray Unit 119
1.1.2. The Image Intensifier . . . . . . . . 122
1.1.3. Television Fluoroscopy . . . . . . . 125
1.1.4. Spot Filming ........... 126
1.2. The Recording Techniques Used with Image Intensifiers 127
1.2.1. Photofluorography............. 127
1.2.2. Cinefluorography . . . . . . . . . . . . . . 128
1.3. Techniques of Recording the Television Images 131
1.3.1. Cinefluorography . . . . . 131
1.3.2. Video Recording . . . . . 131
2. Contrast Materials . . . . 133
2.1. Positive Contrast Materials 133
2.1.1. Barium Sulfate ..... 133
2.1.2. Iodinated Contrast Materials . 135