Section 9. Digestive Disorders

Chapter 120. Disorders of the Esophagus

Topics: Introduction | Obstruction of the Esophagus | Abnormal Propulsion of Food | Injury to the Esophagus

Injury to the Esophagus

The esophagus is relatively impervious to injury but can be harmed gradually by backflow of acid from the stomach (gastroesophageal reflux) or, more suddenly, by caustic or acidic chemicals, some irritating drugs, a sharp object, or extreme pressure. Extreme pressure can occur during violent vomiting.

The more sudden types of injuries can cause pain, often experienced as sharp pain under the breastbone, and bleeding, which may be vomited up or present in the stool. Fainting may occur, especially if the esophagus ruptures, allowing blood and food contents to spill into the mediastinum (the area of the chest bordered by the sternum in front, the spinal column in back, the entrance to the chest cavity above, and the diaphragm below).

Erosive Esophagitis

Erosive esophagitis is a condition in which areas of the esophageal lining are inflamed and worn away.

The most common cause of erosive esophagitis is chronic acid reflux. Corrosive substances, such as cleaning solutions, can erode the esophagus if they are swallowed accidentally or deliberately, as in a suicide attempt. Some pills (for example, aspirin or other nonsteroidal anti-inflammatory drugs [NSAIDs], alendronate, doxycycline, and certain large iron and potassium tablets) can cause painful erosions if they lodge temporarily in the esophagus.

Diagnosis of erosive esophagitis is made by esophagoscopy. If an erosion results from a pill, the pill usually can be washed down with large quantities of water; the pain often resolves within hours. Rarely, erosions caused by corrosive substances or pills persist, leading to narrowing of the esophagus.

Esophageal Laceration

An esophageal laceration is a tear that does not penetrate the wall of the esophagus.

A laceration of the lower esophagus and the upper part of the stomach during forceful vomiting, retching, or hiccups is called Mallory-Weiss syndrome. The first symptom is usually bleeding from a ruptured blood vessel in the esophagus. Mallory-Weiss syndrome is the cause of about 5% of bleeding episodes in the upper digestive tract.

Diagnosis is made by esophagoscopy or angiography. The laceration cannot be detected on routine x-rays.

Most bleeding episodes stop by themselves, but sometimes a surgeon must tie off the bleeding vessel. Bleeding may also be controlled by injecting vasopressin or epinephrine during arteriography to reduce blood flow into the bleeding vessel.

Esophageal Ruptures and Perforations

Esophageal ruptures and perforations are tears that penetrate the wall of the esophagus; a perforation has defined borders, whereas a rupture does not.

Ruptures of the esophagus are usually caused by violent vomiting. Perforations can occur during endoscopy (examination of the esophagus with a flexible viewing tube (see Section 9, Chapter 119)) or other procedures in which instruments are inserted through the mouth and throat. An esophageal rupture or perforation leads to tissue inflammation in the chest outside the esophagus and allows fluid to enter the space between the membrane layers (pleura) covering the lungs, a condition called pleural effusion (see Section 4, Chapter 52). The risk of death is very high, especially with esophageal ruptures. Surgical repair of the esophagus and drainage of the area surrounding it are performed immediately.