Oesophagus

and Ian A. D. Bouchier²

(1)

Bishop Auckland, UK

(2)

Edinburgh, Midlothian, UK

The major symptoms of oesophageal disease are dysphagia, heartburn, postural dyspepsia and waterbrash. There are many tests of oesophageal function, though their interpretation depends on the definition of oesophageal disease.

4.1 Oesophageal Acid Perfusion Test

This traditional investigation is useful where more sophisticated tests are not available.

Pain of oesophageal origin may be identical to that of cardiac origin. The perfusion of 0.1 mol/l hydrochloric acid into the oesophagus is an easy and reasonably consistent way of reproducing the pain that arises from the gullet.

4.1.1 Method

The patient is seated in a high backed chair and the oesophagus is intubated so that the distal end of the tube lies 30 cm from the teeth. Any convenient tube may be used, and its position can be checked radiologically. The infusions to be used are suspended on a drip stand behind the patient who is unaware of which solution is being used and when the bottles are changed. Solutions of isotonic sodium chloride and 0.1 mol/l hydrochloric acid are made up in bottles and these are connected in turn to the oesophageal tube.

Initially the isotonic sodium chloride is perfused at a rate of 10 ml/min for 10 min, followed by 20 ml/min for 5 min. Without the patient’s knowledge the infusate is changed to 0.1 mol/l hydrochloric acid, initially 10 ml/min for 15 min followed by 20 ml/min for 15 min. If pain occurs the infusion is stopped and a solution of 0.05 mol/l sodium bicarbonate is infused. Perfusion of acid can be repeated to confirm that a response is genuine. A standard 12-lead electrocardiogram is obtained during any induced pain.

4.1.2 Interpretation

A positive response is pain produced by the acid but not by the saline solution: this signifies pain of oesophageal origin but not necessarily oesophagitis. The test may be positive in normal subjects who have never suffered from pain and who have no evidence of oesophagitis. However, pain generally develops earlier (during the first 10 min of acid perfusion) in patients with oesophagitis.

Patients with angina pectoris who have a positive response can usually distinguish the induced pain from that of angina pectoris.

A negative test is no pain being experienced during the perfusion, but this result does not completely eliminate oesophageal disease as the cause of chest pain. Pain of similar severity induced both by saline and acid perfusion is also regarded as a negative test. Patients with angina pectoris usually have a negative response.

The procedure may induce an attack of angina pectoris (even with the infusion of saline) and abnormalities of the electrocardiogram may then be seen. This usually occurs in patients with severe ischaemic heart disease.

Some patients with a negative test respond with pain to infusion of foodstuffs which are suspected of causing symptoms.

4.2 Oesophagoscopy

Most disorders of the oesophagus affect the lower portion, which is conveniently inspected with a flexible pan-endoscope. If a patient has severe dysphagia a barium swallow examination is sometimes useful. The frequent coexistence of upper digestive abnormalities makes oesophagogastroduodenoscopy an important investigation. The upper oesophagus is often not well seen with the flexible endoscope, and if a thorough examination of the post-cricoid region is required rigid oesophagoscopy under general anaesthetic is best. This technique also permits larger biopsy samples to be obtained.

4.3 Histology

At endoscopy it is important to take biopsies with forceps, and also to take cytology brushings if cancer is suspected. The usefulness of histology in benign oesophagitis is more contentious, but in dysphagia it may reveal eosinophilic oeophagitis. The distal 2.5 cm usually shows changes compatible with oesophagitis even in normal individuals, and it is not uncommon to find changes in health above this level. Probably the best site for biopsy is from 5 cm above the apparent gastro-oesophageal junction. In gastric metaplasia (Barrett’s mucosa) it is recommended to take four quadrant biopsies at 2 cm intervals throughout its length, but bleeding from previous biopsy sites may make this policy difficult to practice rigorously. The findings in oesophagitis include cellular infiltrates, increase in length of the dermal papillae and basal cell hyperplasia. Histology does not correlate well with symptoms, nor with macroscopic appearances at endoscopy.

4.4 Radiology (Figs. 4.1, 4.2, 4.3, 4.4 and 4.5)

A variety of techniques of barium swallow has been described and each radiologist has his favourite, particularly when it comes to the diagnosis of hiatus hernia and gastro-oesophageal reflux.

Fig. 4.1

Barium swallow. Typical ‘shouldering’ due to carcinoma of the lower two-thirds of the oesophagus

Fig. 4.2

Barium swallow showing long peptic stricture

Fig. 4.3

Barium swallow showing an oesophageal web

Fig. 4.4

(a) Barium swallow and meal showing achalasia. (b) Chest radiograph in achalasia showing no air in the gastric fundus

Fig. 4.5

(a) Isotope bone scan showing destruction of pelvic bone by metastasis in carcinoma of the lower two-thirds of the oesophagus. (b) Radiograph of bone metastasis in (a); note irrelevant gas in caecum and terminal ileum top left

The oesophagus should be examined both during and between swallows and in the upright and lying position. The patient is frequently tilted in the head-down position to demonstrate gastro-oesophageal reflux. When examining a patient for dysphagia the examination does not stop at failure to demonstrate an obstruction.

Careful attention to oesophageal motility is essential. Various manoeuvres can be used to bring out diffuse oesophageal spasm, oesophageal rings and other motor disturbances of the oesophagus. The use of thick barium is one; even more informative is a ‘bread bolus’ in which a mouthful of bread is partially chewed and then swallowed with a mouthful of barium solution. The patient must report any pain or discomfort during the act of swallowing and at such time particular attention is paid to oesophageal contractions.

Cineradiology has the advantage that both the radiologist and the clinician together can review and discuss the motility and function of the oesophagus at some time after the radiological examination.

MRI scanning and endosonography are challenging CT scanning in the evaluation of extent of oesophageal carcinoma. Both are reported to give superior results.

4.5 Manometry

Pressure recording from the oesophagus is increasingly being used in clinical medicine. Oesophageal motility studies are particularly valuable in the early diagnosis of achalasia of the cardia and in various motor disorders. The apparatus consists of a multichannel pressure recorder and a series of tubes to conduct the oesophageal pressure. Scrupulous attention to detail is necessary to obtain interpretable results.

4.5.1 Method

Intraluminal pressures can be recorded by water-filled polyethylene tubes with lateral orifices. Tubes are sealed together and the lateral orifices are set at intervals so that simultaneous recordings can be made from eight or more multiple sites. A Dent sleeve is used to avoid missing achalasia and outflow obstruction. Pressure changes are transmitted via transducers to a multichannel direct recorder (any recorder used for cardiopulmonary studies can be used). Swallowing and respiratory movements are recorded. Pressure recordings are taken in the stomach, at the gastrooesophageal region and in the oesophagus both during and between swallowing.

The patient can be studied while drinking 10 ml of water or during a ‘dry’ swallow. Recordings are made with the tube fixed at different levels throughout the oesophagus (‘station’ method). There is controversy over whether a rapid pull-through technique is superior; it certainly gives different results from the standard station method. Ambulatory 24-h manometry of the oesophagus may be the most sensitive test of motility disorders, but few centres are equipped for it.

4.5.2 High Resolution Manometry (HRM)

This uses water perfusion in 20–24 channels with a 1 cm separation at the gastrooesophageal junction and 2 cm elsewhere, or solid state recorders with 36 channels at a 1 cm separation. It allows easier identification of landmarks and clearly shows movement of the lower oesophageal sphincter and diaphragm during swallowing, avoiding spurious results when the catheter drops into the stomach. This technique permits subclassification of hiatus hernias and achalasia when used with algorithms.

A manometry catheter with impedance channels has been developed , but is not yet well established and validated.

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