Swallowing disorders, burping and heartburn are among the typical symptoms of diseases of the esophagus. Chest pain often comes not from the heart, but from the esophagus. An overview of diseases of the slim organ.
The oesophagus is a 20 to 22 cm long muscle tube between the lower throat (hypopharynx) and stomach, which consists of a circular and longitudinal muscle layer and is closed by the upper and lower oesophagus sphincter. The upper third of the esophageal muscles is striated, the lower two thirds are smooth. The orderly transport of food is achieved by timely opening of the upper and lower esophageal sphincters and peristaltic contractions of the tubular esophagus after swallowing.
The esophagus does not have a serosa coating (lining with epithelial cells), but only an adventitia (connective tissue layer). This is one reason for the early spread and lymphogenic metastasis in esophageal carcinoma.
The esophagus is a sensory organ. The vast majority (90 percent) of vagus fibres are afferent: the brain receives much more information than it gives to the oesophagus. In addition, the sensory nerve tracts that send information from the heart and oesophagus to the brain overlap. This is one reason why diseases of the esophagus can lead to heart attack-like pain (non-cardiac chest pain). In addition, diseases such as reflux or spasms can cause coronary spasms due to the close nerve connections to the heart.
The main symptoms of esophageal diseases are dysphagia (difficulty swallowing), regurgitation (stomach contents flowing back into the esophagus and mouth), heartburn, globe (“dumpling in the throat”) and chest pain. Dysphagia is an alarm symptom that must always be clarified endoscopically at an early stage.
Swallowing disorders are differentiated into oropharyngeal dysphagia with swallowing, Allergiefreie Allergiker, coughing and nasal regurgitation and oesophageal dysphagia with/without regurgitation. In the case of persistent complaints, oesophageal duodenoscopy (examination of the oesophagus, stomach and duodenum) is always indicated.
An emergency situation is acute bolus obstruction (“steakhouse syndrome”), in which a large bite of food gets stuck in the patient’s throat and can no longer be coughed out. Here, an endoscopy with removal of the bolus must be performed very quickly. If the patient suffers from a globus sensation, the doctor should search for gastric mucosa heterotopias in the proximal (upper) esophagus (figure) and for a high gastroesophageal reflux.
Non-cardiac thoracic pain (NCCP) is a recurrent angina-pectoris-like pain, in which no coronary heart disease can be proven as a cause by conventional examinations. About 70 percent of people who go to the doctor with chest pain suffer from NCCP. In many cases there are esophageal causes such as gastroesophageal reflux disease (GERD), motility disorders, infections, tablet-induced ulcers, rings and webs (scarring).
In Germany, screening of the esophagus is not recommended. However, it is important that symptoms are clarified at an early stage. This applies especially to the alarm symptom dysphagia. In chest pain, the search for changes in the esophagus is important in order to make a clear diagnosis and initiate therapy. Likewise, the causes must be clarified before a long-term therapy with proton pump inhibitors (PPI) is started if reflux symptoms are suspected.
Functional disorders versus functional diseases
Esophageal dysfunctions are defined motility disorders of the esophagus. These include achalasia, diffuse esophageal spasm, hypercontractile esophagus and hypomotility of the smooth muscle esophagus in scleroderma. They can be characterized and treated by appropriate functional examinations.
Achalasia is characterized by a lack of or insufficient relaxation of the lower esophageal sphincter (UOS) and the loss of tubular esophageal peristalsis. Diffuse esophageal spasm and hypercontractable esophagus result in increased and prolonged contractions with normal sphincter function. The main symptoms are dysphagia, regurgitation of undigested food and chest pain. Less frequently, nocturnal coughing occurs due to aspiration, heartburn, chest pain and weight loss. The risk of developing esophageal cancer is increased. Even today, an average of six years elapses before a diagnosis is made. It is important to differentiate from pseudo-olephthalasia (2 to 4 percent), which is predominantly caused by infiltrating tumours or neoplastic tumours.
Compared to the established operative therapy methods, drugs (nitro preparations, calcium antagonists) and the injection of botulinum toxin are less relevant. In the final stage of achalasia, esophageal resection with gastric elevation can be considered.
Functional esophageal diseases are esophageal complaints for which no organic correlates or defined dysfunction can be detected using conventional methods. They are divided into functional heartburn, dysphagia, globe and thoracic pain according to the Rome consensus conferences (currently: Rome III). Psychosomatic treatment as well as the administration of tricyclic antidepressants and serotonin reuptake inhibitors are established here.
Recent studies have shown that a differentiated examination often reveals organic diseases in the esophagus that can be successfully treated.