Direction Of The Esophagus

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The esophagus enters the chest in a

decidedly backward as well as downward direction, parallel to that of

the trachea, following the curves of the cervical and upper dorsal

spine. Below the left bronchus the esophagus turns forward, passing

through the hiatus in the diaphragm anterior to and to the left of the

aorta. The lower third of the esophagus in addition to its anterior

curvature turns strongly to the left, so that an esophagoscope

inserted from the right angle of the mouth, when introduced into the

stomach, points in the direction of the anterior superior spine of the

left ileum.

It is necessary to keep this general course constantly in mind in all

cases of esophagoscopy, but particularly in those cases in which there

is marked dilatation of the esophagus following spasm at the diaphragm

level. In such cases the aid of this knowledge of direction will

greatly simplify the finding of the hiatus esophageus in the floor of

the dilatation.

The extrinsic or transmitted movements of the esophagus are

respiratory and pulsatory, and to a slight extent, bechic. The

respiratory movements consist in a dilatation or opening up of the

thoracic esophageal lumen during inspiration, due to the negative

intrathoracic pressure. The normal pulsatory movements are due to the

pulsatile pressure of the aorta, found at the 4th thoracic vertebra

(24 cm. from the upper teeth in the adult), and of the heart itself,

most markedly felt at the level of the 7th and 8th thoracic vertebrae

(about 30 cm. from the upper teeth in adults). As the distances of all

the narrowings vary with age, it is useful to frame and hang up for

reference a copy of the chart (Fig. 46).

The intrinsic movements of the esophagus are involuntary muscular

contractions, as in deglutition and regurgitation; spasmodic, the

latter usually having some pathologic cause; and tonic, as the normal

hiatal closure, in the author's opinion may be considered. Swallowing

may be involuntary or voluntary. The constrictors are anatomically not

considered part of esophagus proper. When the constrictors voluntarily

deliver the bolus past the cricopharyngeal fold, the involuntary or

peristaltic contractions of the esophageal mural musculature carry the

bolus on downward. There is no sphincter at the cardiac end of the

esophagus. The site of spasmodic stenosis in the lower third, the

so-called cardiospasm, was first demonstrated by the author to be

located at the hiatus esophageus and the spasmodic contractions are of

the specialized muscle fibers there encircling the esophagus, and

might be termed phrenospasm, or hiatal esophagismus. Regurgitation

of food from the stomach is normally prevented by the hiatal muscular

diaphragmatic closure (called by the author the diaphragmatic

pinchcock) plus the kinking of the abdominal esophagus.

In the author's opinion there is no spasm in the disease called

cardiospasm. It is simply the failure of the diaphragmatic pinchcock

to open normally in the deglutitory cycle. A better name is functional

hiatal stenosis.

At retrograde esophagoscopy the cardia and abdominal esophagus do not

seem to exist. The top of the stomach seems to be closed by the

diaphragmatic pinchcock in the same way that the top of a bag is

closed by a puckering string.