ESOPHAGUS

PHYSIOLOGY
The esophagus is a simple muscular tube composed of two layers :
1. Outer longitudinal layer
2. Inner circular muscle layer
The Esophagus connects the pharynx to the gaster. Striated (voluntary) muscle in the
upper portion gradually changes to smooth muscle in the lower part and then becomes
continous with the muscle layer of the gaster. The lining of the esophagus also changes
from a stratified squamous epithelium to columnar epithelium at the gastroesofageal
junction.

Upper Esophageal Sphincter

Located at the upper end of the esophagus, the upper esophageal sphincter (UES) is
composed of striated muscle condensation covering 2 to 3 cm, reinforced by the
transverse fibers of the cricopharyngeus muscle (Figure 1.2). The UES remains closed
except during swallowing, when it relaxes in response to pharyngeal contraction. In the
resting state, the UES maintains a pressure of approximately 40mmHg. This pressure is
essential to prevent aspiration of esophageal contents during gastroesophageal reflux or

when swallowed food empties poorly. Failure of the UES to relax in response to
swallowing may result in upper esophageal dysphagia and aspiration
Body of Esophagus
The muscular coat of the upper third of the body of the esophagus (i.e., the cervical
esophagus) is composed of striated muscle, while that of the lower two thirds is smooth
muscle. The smooth-muscle coat consists of an inner circular and an outer longitudinal
layer. The esophagus has no serosal layer.
The mean resting pressure in the body of the esophagus varies from -8 to +5mmHg,
depending on the respiratory cycle. In response to swallowing, however, a coordinated
peristalsis sweeps from the upper to the lower end of the esophagus. The mean amplitude
of contractions during esophageal peristalsis is 60 + 5 mm Hg. When the lumen of the
esophagus is acidified, strong peristaltic waves are initiated that serve to rid the
esophagus of acid. This "esophageal pump" mechanism is important in the overall health
of the gastrointestinal system.
Lower Esophageal Sphincter
The lower esophageal sphincter (LES) is located at the terminal end of the esophagus and
represents the distal 3 to 5cm of the organ (see Figure 1.2).
Most of the LES lies within the abdominal cavity, but a short segment often extends
above the diaphragm. A small condensation of circular smooth-muscle fibers resides in
this region, too indefinite to constitute an anatomical sphincter. The specialized nature
and unique innervation of the smooth muscle of the terminal esophagus provide the
basis for a physiological sphincter. These specialized smooth-muscled fibers contain
receptors for a number of peptide (e.g., vasoactive intestinal peptide, substance P) and
non-peptide neurotransmitters that are released locally from peptidergic and
nonpeptidergic neurons.

The LES is a high-pressure zone interposed between the body of the esophagus and the
cardia of the stomach (Figure 1.3). Normally, a mean pressure of 20 + 5mmHg is
maintained at all times except during swallowing, when the pressure falls to OmmHg,
allowing esophageal peristalsis to empty the swallowed food into the stomach. In its
resting state, therefore, the high pressure of the LES prevents reflux of gastric
contents into the esophagus.

The LES contracts and increases its pressure in response to sudden increase in abdominal
pressure an to alkalinization of the gastric lumen. As mentioned above, the LES relaxes in
response to swallowing, a function mediated by local release from neurons in the LES
musculature of vasoactive intestinal peptide (VIP) and nitric oxide (NO). Other factors
contributing to the lowering of LES pressure are nicotine, gastric acidification, ingestion
of fats and release of cholecystokinin (CCK). Essential features of LES anatomy are
summarized in Table 1.2.

Swallowing Mechanism
When food or fluid enter the pharynx, pharyngeal contractions are initiated. At the very
beginning of swallowing , both UES and LES relax. Pharyngeal contractions deliver the
food into the upper esophagus, initiating a coordinated contraction of the body of the
esophagus and carrying the food past the LES which remains in a state relaxation- into
the stomach. The LES then contracts in sequence with esophageal peristaltis. By the time
the bolus reaches it, the gaster is in the state of receptive relaxation brought about by
esophagogastric vagal reflexes and activated by increases in luminal pressure due to
esophageal contraction. This process of gastric relaxation is mediated by release VIP and
NO from nerve terminals within the fundus and body of the gaster. This normal
swallowing mechanism is depicted in Figure 1.4.

Figure 1.4. Normal swallowing mechanism : At the initiation of swallowing,

the pharynx contracts and the UES relaxes.
At the same time, the LES relaxes and stays relaxes
until the peristaltic wave of contraction sweeps down the esophagus
and arrives at the LES. The LES then contracts in sequence with the peristaltis,
by which time the swallowed bolus has entered the gaster.

Preventing regurgitation of the stomach contents back in to the oesophagus is dependent on:
1. Gravity.
2. LOS pressure.
3. The oblique course of the gastro-oesophageal junction.
4. The diaphragmatic crura wrapped around the oesophagus.
5. The physiological emptying of the stomach contents into the duodenum through the
pylorus.