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Direction Of The EsophagusCategory: PREPARATION OF THE PATIENT FOR PERORAL ENDOSCOPY Source: 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. Next: Preparation Of The Patient For Peroral Endoscopy Previous: The Esophagus
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