Venous outflow from the thoracic esophagus is carried out. Esophagus in endoscopic image

It is generally accepted that the abdominal esophagus is covered on all sides by the peritoneum, but recent evidence suggests that the posterior wall of the esophagus, adjacent to the diaphragm, is often devoid of peritoneal cover. Anteriorly, the esophagus is covered by the left lobe of the liver.

Stomach

The stomach (ventriculus, s.gaster) can be divided into two large sections by an oblique line passing through the notch on the lesser curvature (incisura angularis) and the groove on the greater curvature corresponding to the left border of the expansion of the stomach (see below). To the left of this line lies a larger section - cardiac (occupies approximately 2/3 of the stomach), to the right - a smaller section - pyloric. The cardial section, in turn, consists of the body and the bottom, and the bottom, or arch, is the wide part of the stomach, lying to the left of the cardia and upward from the horizontal line, drawn through the cardiac notch (incisura cardiaca). In the pyloric section, the left extended part is distinguished - the vestibule (vestibulum pyloricum), otherwise - the sinus (sinus ventriculi), and the right narrow part - the antrum (antrum pyloricum), passing into the duodenum.

The inlet and lesser curvature retain their position even with significant filling of the stomach, which is associated with the fixation of the final section of the esophagus in a special aperture of the diaphragm; on the contrary, the pylorus and greater curvature can be displaced quite strongly. The position of the organ also depends on the ligamentous apparatus, the position and functional state of neighboring organs and the elasticity of the abdominal muscles.

The stomach is located almost entirely in the left half of the abdominal cavity, with the greater part (cardia, bottom, body part) in the left hypochondrium (under the left dome of the diaphragm) and the smaller part (body part, pyloric region) in the epigastric region proper.

The large curvature of a moderately filled stomach in a living person with a vertical position of the body is located slightly above the level of the navel.

The anterior wall of the stomach on the right is covered by the liver, on the left - by the costal part of the diaphragm: part of the body and the pyloric part of the stomach adjoins directly to the anterior abdominal wall. Adjacent to the posterior wall of the stomach are organs separated from it by a stuffing bag (pancreas, diaphragmatic pedicles, left adrenal gland, upper pole of the left kidney), as well as the spleen. The lesser curvature of the stomach is covered by the left lobe of the liver. The greater curvature borders on the transverse colon.

The cardial part of the stomach and its bottom are connected with the diaphragm by means of lig.phrenicogastricum dextrum and sinistrum. Between the lesser curvature and the gates of the liver stretched lig.hepatogastricum. The fundus of the stomach is connected to the spleen through lig.gastrolienale. The greater curvature of the stomach is connected with the transverse colon through the initial section of the greater omentum (lig.gastrocolicum).

The blood supply of the stomach is carried out by the truncus coeliacus system (a.coeliaca - BNA). The stomach has two arterial arches: one along the lesser curvature, the other along the greater one. On the lesser curvature, aa.gastrica sinistra (from truncus coeliacus) and dextra (from a.hepatica) are connected to each other, passing between the leaves of the lesser omentum. On the greater curvature, they anastomose, and often connect with each other aa.gastroepicloica sinistra (from a.lienalis) and dextra (from a.gastroduodenalis).

Both arteries pass between the sheets of the greater omentum: the right one first goes behind the upper part of the duodenum, and the left one goes between the sheets of the lig.gastrolienale. In addition, several aa.gastricae breves go to the bottom of the stomach in the thickness of the lig.gastrolienale. These arteries give off branches that anastomose with each other and supply blood to all parts of the stomach.

Veins, like arteries, run along the lesser and greater curvatures. V.coronaria ventriculi passes along the lesser curvature, v.gastroepiploica dextra (v.mesenterica superior tributary) and v.gastroepiploica sinistra (v.lienalis tributary) pass along the greater curvature; both veins anastomose with each other. Vv.gastricae breves flow into v.lienalis.

Along the pylorus, almost parallel to the midline, v.prepulorica passes, which quite accurately corresponds to the place where the stomach passes into the duodenum and is usually a tributary of the right gastric vein.

In the circumference of the inlet of the stomach, the vein is anastomosed with the veins of the esophagus, and thus a connection is made between the systems of the portal and superior vena cava. If the outflow in the portal vein system is disturbed, these anastomoses can expand varicosely, which often leads to bleeding.

The stomach is innervated by sympathetic and parasympathetic fibers. The first go as part of the branches that depart from the solar plexus and accompany the vessels arising from the celiac artery. Wandering trunks, giving parasympathetic fibers, branch on the anterior and posterior walls of the stomach: anterior - on the anterior wall, posterior - on the posterior. The most sensitive zones of the stomach to reflex influences are the pylorus and a significant part of the lesser curvature.

The regional nodes of the first stage for the outlet lymphatic vessels of the stomach are:

1) a chain of nodes located along the left gastric artery (they receive lymph from the right two-thirds of the bottom and body of the stomach);

2) nodes in the region of the gate of the spleen, the tail and the part of the body of the pancreas closest to it (they receive lymph from the left third of the fundus and body of the stomach to the middle of the greater curvature);

3) nodes located on a.gastroepiploica dextra and under the pylorus (take lymph from the territory of the stomach adjacent to the right half of the greater curvature).

The regional nodes of the second stage for most of the efferent lymphatic vessels of the stomach are the celiac nodes adjacent to the trunk of the celiac artery. Numerous connections are formed between the lymphatic vessels of the stomach and neighboring organs, which are of great importance in the pathology of the abdominal organs.

Esophagus- part of the gastrointestinal tract between the pharynx and stomach, which is a hollow tubular muscular canal, starting at the level of the lower edge of the VI cervical vertebra and ending with the transition to the cardial part of the stomach at the level of the XI thoracic vertebra.

The wall of the esophagus consists of several layers, namely: from the mucous membrane, submucosal layer, muscular membrane and adventitia, sometimes the abdominal part of the esophagus is covered with a serous membrane. The muscular layer consists of two layers: outer longitudinal and inner circular.

In an adult, the length of the esophagus is on average 25 cm. It is customary to divide the esophagus into three sections: cervical, thoracic, abdominal (abdominal).

cervical esophagus has a length of 5-6 cm, it begins at the level of the VII cervical vertebra behind the cricoid cartilage of the larynx and, being behind the trachea and in front of the spine, stretches to the level of the upper aperture of the chest. To the right and left of the esophagus are the lobes of the thyroid gland.

Thoracic esophagus has a length of 17-19 cm, is located in the posterior mediastinum, first between the trachea and the spine, and then between the heart and the thoracic part of the aorta, which pushes it a little to the left.

Abdominal located at the level of the XI-XII thoracic vertebrae. Its length ranges from 2 to 4 cm. In the zone of the esophageal-gastric junction (transition to the cardial part of the stomach), the lumen of the esophagus is normally closed and opens only when food passes.

There are three narrowings of its lumen throughout the esophagus. The first narrowing is associated with pressure from the cricoid cartilage and the lower pharyngeal constrictor, the second is due to pressure from the aortic arch, which presses the esophagus against the left main bronchus. This narrowing is located at the level of the IV thoracic vertebra. The third narrowing is at the level of the esophageal opening of the diaphragm.

The blood supply of the esophagus in the cervical region is carried out by branches of the inferior thyroid artery, in the thoracic region - by 4-5 esophageal branches of the thoracic aorta (own esophageal arteries), in the lower (abdominal) region - by the ascending branch of the left gastric artery and inferior phrenic artery. The outflow of blood from the esophagus is carried out into the unpaired and semi-unpaired veins. The main collector of venous blood is the submucosal plexus.

The lymphatic system of the esophagus is represented by a network of capillaries and vessels that are located in all layers of the esophageal wall: the mucous membrane, submucosal layer, muscular membrane, and also in the adventitia.

A feature of the lymphatic system of the esophagus are longitudinal, rather large lymphatic collector vessels located in the submucosal layer of the wall along the entire length of the esophagus, connecting the lymphatic networks of all its layers.

The efferent lymphatic vessels exit both on the anterior and posterior surfaces of the esophagus and have ascending, descending, and transverse directions.

Very important is the topography of the regional lymph nodes of the esophagus. From the cervical esophagus, the efferent vessels go to the deep cervical lower and paratracheal lymph nodes.

Deep cervical lower lymph nodes are located along the main vascular bundle of the neck on both sides, along the internal jugular vein. The efferent lymphatic vessels flow into the subclavian and jugular lymphatic trunks, into the thoracic lymphatic duct, and also directly into the subclavian and jugular veins.

Lymphatic vessels from the cervical and upper thoracic esophagus also drain into the paratracheal lymph nodes. They are located in a chain on both sides of the trachea in the groove between the esophagus and trachea, accompanying the recurrent nerves. The efferent lymphatic vessels from them go to the deep cervical lymph nodes, mediastinal, and can also flow into the jugular lymphatic trunks, the thoracic lymphatic duct, the right lymphatic duct. The lowest of the group of right paratracheal lymph nodes is the lymph node of the arch of the unpaired vein. It is located under the arch of the unpaired vein. From it, the lymph flows into the broncho-pulmonary and tracheobronchial lymph nodes.

From the upper esophagus, lymph also flows into the upper and lower tracheobronchial lymph nodes. The superior tracheobronchial lymph nodes are located between the trachea and the main bronchus. They also drain lymph from the lower tracheobronchial and bronchopulmonary lymph nodes. The outflow of lymph through the efferent lymphatic vessels is carried out to the deep cervical lymph nodes, the thoracic lymphatic duct and the right lymphatic duct. The lower tracheobronchial (bifurcation) lymph nodes are located under the bifurcation of the trachea. They also receive lymph from the middle sections of the esophagus, as well as from the bronchopulmonary lymph nodes. The outflow of lymph occurs in the upper tracheobronchial, paratracheal, posterior mediastinal lymph nodes, as well as directly into the thoracic lymphatic duct.

Bronchopulmonary lymph nodes are located along the main bronchus and its branches. They drain lymph from the nearest parts of the esophagus. Further, the lymph flows into the anterior mediastinal, upper and lower tracheobronchial lymph nodes, as well as into the thoracic lymphatic duct on the right and the lymphatic duct on the left.

From the middle sections of the esophagus, lymph also flows into the posterior mediastinal lymph nodes, which are located near the esophagus in the posterior mediastinum. From them, the lymph flows through the outlet vessels to the tracheobronchial lymph nodes, which can also flow directly into the thoracic lymphatic duct.

The prevertebral lymph nodes are located along the anterior surface of the thoracic spine. They receive lymph from the thoracic esophagus. From them, the outflow of lymph occurs in the thoracic duct.

Lymph flows from the lower esophagus in two directions. Through short efferent vessels, it is directed to the lateral pericardial lymph nodes located behind the pericardium at the place where the phrenic nerve enters the diaphragm, the upper phrenic lymph nodes located above the diaphragm behind the xiphoid process of the sternum in the mediastinum, the paraesophageal, bronchopulmonary and lower tracheobronchial lymph nodes. Along the long efferent vessels that descend into the abdominal cavity along the right and left vagus nerves, the lymph flows into the chain of left gastric lymph nodes located near the lesser curvature of the stomach along the left gastric artery and paracardial lymph nodes located in the tissue near the esophageal-gastric junction in the abdominal cavity. The lowest of the group of left gastric lymph nodes are the lymph nodes of the fork of the celiac trunk.

Two features of the esophageal lymphatic system should be noted.

First- large lymphatic collectors are located longitudinally along the entire esophagus in the submucosal layer.

Second- often the abducting lymphatic vessels, bypassing the regional lymph nodes, flow into the left gastric or paracardial lymph nodes, or directly into the thoracic lymphatic duct.

The thoracic lymphatic duct begins in the retroperitoneal space in the form of a cistern located at the level of the I lumbar -XII thoracic vertebrae, runs along the right wall of the aorta into the chest cavity, into the posterior mediastinum, located between the aorta and the azygos vein. Above the thoracic duct is located in the midline on the prevertebral fascia to the left of the aorta and is partially covered by the esophagus. Rising above the thoracic duct, being further connected with the esophagus, it passes to the neck and forms an arc at this level. The latter bends around the dome of the pleura from back to front and flows into the left venous angle. At the confluence of the thoracic lymphatic duct is a large number of lymph nodes. Often the thoracic duct is represented by not one, but several trunks.

Most often, during resection of the thoracic esophagus, the surgeon is forced to contact the thoracic duct, which is associated with the risk of injuring both the main trunk and the branches flowing into it. This requires ligation of the duct above and below the injury site.

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Esophagus, represents a narrow and long active tube inserted between the pharynx and the stomach and promotes the movement of food into the stomach. It begins at the level of the VI cervical vertebra, which corresponds to the lower edge of the cricoid cartilage of the larynx, and ends at the level of the XI thoracic vertebra.

Since the esophagus, starting in the neck, passes further into the chest cavity and, piercing the diaphragm, enters the abdominal cavity, parts are distinguished in it. The length of the esophagus is 23-25 cm. The total length of the path from the front teeth, including the oral cavity, pharynx and esophagus, is 40-42 cm (at this distance from the teeth, adding 3.5 cm, it is necessary to move the gastric rubber tube into the esophagus for taking gastric juice for examination).

Topography of the esophagus. The cervical part of the esophagus is projected in the range from the VI cervical to the II thoracic vertebra. The trachea lies in front of it, the recurrent nerves and common carotid arteries pass to the side.

The syntopy of the thoracic esophagus is different at different levels: the upper third of the thoracic esophagus lies behind and to the left of the trachea, the left recurrent nerve and left a are adjacent to it in front, the spinal column is behind it, and the mediastinal pleura is on the right. In the middle third, the aortic arch is adjacent to the esophagus in front and on the left at the level of the IV thoracic vertebra, slightly lower (V thoracic vertebra) - the bifurcation of the trachea and the left bronchus; behind the esophagus lies the thoracic duct; on the left and somewhat posteriorly, the descending part of the aorta adjoins the esophagus, on the right - the right vagus nerve, on the right and behind. In the lower third of the thoracic esophagus, behind and to the right of it lies the aorta, anteriorly - the pericardium and the left vagus nerve, on the right - the right vagus nerve, which is shifted to the posterior surface below; lies somewhat behind; left - left mediastinal pleura.

The abdominal part of the esophagus is covered in front and sides by the peritoneum; in front and on the right, the left lobe of the liver is adjacent to it, on the left - the upper pole of the spleen, at the place where the esophagus passes into the stomach there is a group of lymph nodes.

Structure. On a transverse section, the lumen of the esophagus appears as a transverse slit in the cervical part (due to pressure from the trachea), while in the thoracic part, the lumen has a roundish or stellate shape.

The wall of the esophagus consists of the following layers: the innermost - the mucous membrane, the middle and outer - of a connective tissue nature, contains mucous glands, which facilitate the sliding of food during swallowing with their secret. In addition to the mucous glands, there are also small glands in the lower and, more rarely, in the upper part of the esophagus, similar in structure to the cardiac glands of the stomach. When unstretched, the mucosa is collected in longitudinal folds. Longitudinal folding is a functional adaptation of the esophagus, which promotes the movement of fluids along the esophagus along the grooves between the folds and the stretching of the esophagus during the passage of dense lumps of food. This is facilitated by loose, due to which the mucous membrane acquires greater mobility, and its folds easily either appear or smooth out. The layer of unstriated fibers of the mucosa itself also participates in the formation of these folds.

In the submucosa there are lymphatic follicles, corresponding to the tubular shape of the esophagus, which, when performing its function of carrying food, must expand and contract, is located in two layers - the outer, longitudinal (expanding esophagus), and the inner, circular (narrowing). In the upper third of the esophagus, both layers are composed of striated fibers, below they are gradually replaced by non-striated myocytes, so that the muscle layers of the lower half of the esophagus consist almost exclusively of involuntary muscles.

Surrounding the esophagus from the outside, consists of loose connective tissue, with the help of which the esophagus is connected to the surrounding organs. The friability of this membrane allows the esophagus to change the value of its transverse diameter during the passage of food.

X-ray examination of the digestive tube is performed using the method of creating artificial contrasts, since without the use of contrast media it is not visible. For this, the subject is given a "contrast food" - a suspension of a substance with a large atomic mass, best of all, insoluble barium sulfate. This contrasting food delays X-rays and gives a shadow on the film or screen, corresponding to the cavity of the organ filled with it. By observing the movement of such contrasting food masses using fluoroscopy or radiography, it is possible to study the x-ray picture of the entire digestive canal. With complete or, as they say, "tight" filling of the stomach and intestines with a contrasting mass, the x-ray picture of these organs has the character of a silhouette or, as it were, a cast of them; with a small filling, the contrast mass is distributed between the folds of the mucous membrane and gives an image of its relief.

X-ray anatomy of the esophagus. The esophagus is examined in oblique positions - in the right nipple or left scapular. On x-ray examination, the esophagus containing a contrast mass has the form of an intense longitudinal shadow, clearly visible against a light background of the lung field located between the heart and the spinal column. This shadow is like a silhouette of the esophagus. If the bulk of the contrast food passes into the stomach, and swallowed air remains in the esophagus, then in these cases one can see the contours of the walls of the esophagus, enlightenment at the site of its cavity, and the relief of the longitudinal folds of the mucous membrane. On the basis of X-ray data, it can be seen that the esophagus of a living person differs from the esophagus of a corpse in a number of features due to the presence of a living muscle tone in a living person. This primarily concerns the position of the esophagus. On the corpse, it forms bends: in the cervical part, the esophagus first goes along the midline, then slightly deviates from it to the left, at the level of the V thoracic vertebra, it returns to the midline, and below it again deviates to the left and forward to the diaphragm. On the living, the curves of the esophagus in the cervical and thoracic regions are less pronounced.

The lumen of the esophagus has a number of constrictions and expansions that are important in the diagnosis of pathological processes:

pharyngeal (at the beginning of the esophagus)
bronchial (at the level of the bifurcation of the trachea)
diaphragmatic (when the esophagus passes through the diaphragm).

These are anatomical narrowings that remain on the corpse. But there are two more narrowings - aortic (at the beginning of the aorta) and cardiac (at the transition of the esophagus to the stomach), which are expressed only in a living person. There are two extensions above and below the diaphragmatic constriction. The lower expansion can be considered as a kind of vestibule of the stomach. Fluoroscopy of the esophagus of a living person and serial images taken at intervals of 0.5-1 s make it possible to examine the act of swallowing and peristalsis of the esophagus.

Endoscopy of the esophagus. When esophagoscopy (i.e., when examining the esophagus of a sick person using a special device - an esophagoscope), the mucous membrane is smooth, velvety, moist. Longitudinal folds are soft, plastic. Along them are longitudinal vessels with branches.

The esophagus is fed from several sources, and the arteries that feed it form abundant anastomoses of the esophagus from several branches. Venous outflow from the cervical part of the esophagus occurs from the thoracic region, from the abdominal region - into the tributaries of the portal vein. From the cervical and upper third of the thoracic esophagus, lymphatic vessels go to the deep cervical nodes, pretracheal and paratracheal, tracheobronchial and posterior mediastinal nodes. From the middle third of the thoracic region, the ascending vessels reach the named nodes of the chest and neck, and the descending vessels reach the nodes of the abdominal cavity: gastric, pyloric and pancreatoduodenal. Vessels extending from the rest of the esophagus (supradiaphragmatic and abdominal sections) flow into these nodes.

The esophagus is innervated. A feeling of pain is transmitted along the branches; sympathetic innervation reduces the peristalsis of the esophagus. Parasympathetic innervation enhances peristalsis and secretion of glands.

Doctors for the examination of the Esophagus:

Gastroenterologist

Diseases associated with the esophagus:

Benign tumors and cysts of the esophagus

Esophageal sarcoma

Esophageal carcinoma

Congenital malformations of the esophagus

Esophageal injury

Foreign bodies of the esophagus

Chemical burns and cicatricial narrowing of the esophagus

Achalasia cardia (cardiospasm) of the esophagus

Chalazia (insufficiency) of the cardia of the esophagus

Reflux esophagitis (peptic esophagitis)

Esophageal diverticula

Esophageal ulcer

What tests and diagnostics need to be done for the Esophagus:

Methods for examining the esophagus

X-ray of the esophagus

CT scan of the esophagus

MRI of the esophagus

The esophagus is one of the most important organs of the digestive system; it is a natural continuation of the pharynx, connecting it with the stomach. It is a smooth, stretchable fibromuscular mucosal tube, flattened in an anterior-posterior direction. The esophagus begins behind the cricoid cartilage at its lower edge, which corresponds to the level of the VI-VII cervical vertebrae and ends at the cardia of the stomach at the level of the XI thoracic vertebra. The length of the esophagus depends on age, sex and constitution, averaging 23-25 cm in an adult.

For most of its path, the esophagus is located posterior to the trachea and anterior to the spine in the deep cervical and thoracic mediastinum. Behind the esophagus, between the fourth sheet of fascia enveloping the esophagus and the fifth sheet (prevertebral fascia), there is a retrovisceral space filled with loose fiber.

This space, which allows the esophagus to expand freely during the passage of food, is clinically very important, because. is a natural way for the rapid spread of infection when the esophagus is damaged.

In its course, the esophagus deviates from a straight line, bending around the aorta in the form of a gentle spiral. On the neck, located behind the trachea, it protrudes somewhat to the left from behind it and in this place is most accessible for surgical intervention. At the border of the IV and V thoracic vertebrae, the esophagus crosses with the left bronchus, passing behind it, then deviates somewhat to the right and, before perforating the diaphragm, again lies to the left of the median plane. In this place, the thoracic aorta is located much to the right and posterior to it.

Three sections are distinguished in the esophagus: cervical, thoracic and abdominal (Fig. 5.1). The border between the cervical and thoracic esophagus passes at the level of the jugular notch of the sternum in front and the gap between the VII cervical and I thoracic vertebrae posteriorly. The thoracic, the longest section of the esophagus, has a lower border of the diaphragm, and the abdominal is located between the diaphragm and the cardia of the stomach. The length of individual parts of the esophagus in adults is: cervical - 4.5-5 cm, thoracic - 16-17 cm, abdominal - 1.5-4.5 cm.

In the esophagus, there are three anatomical and two physiological constrictions (Tonkov VN, 1953). However, in clinical terms, the three most pronounced constrictions are important, the origin of which is associated with a number of anatomical formations, as well as the distances to these constrictions, which are favorite places for retaining foreign bodies, from the edge of the upper incisors (Fig. 5.2).

The first, most important for clinical practice, narrowing corresponds to the beginning of the esophagus. It is due to the presence of a powerful muscle pulp that performs the function of a sphincter. One of the first esophagoscopists, Killian, called it "the mouth of the esophagus." The first narrowing is located at a distance of 15 cm from the edge of the upper incisors. The origin of the second narrowing is associated with pressure on the esophagus of the left main bronchus, located in front and the aorta, lying on the left and behind. It is located at the level of the bifurcation of the trachea and the fourth thoracic vertebra. The distance from the edge of the upper incisors to the second narrowing is 23-25 cm. The third narrowing of the esophagus is located at a distance of 38-40 cm from the edge of the incisors and is caused by the passage of the esophagus through the diaphragm and into the stomach (gastroesophageal junction).

The listed narrowing of the esophagus, especially the first one, which makes it difficult to pass the tube of the esophagoscope and other endoscopic instruments, may be the site of their instrumental damage.

In the cervical and abdominal sections, the lumen of the esophagus is in a collapsed state, and in the thoracic section it gapes due to negative pressure in the chest cavity.

Three layers are distinguished in the wall of the esophagus, which is about 4 mm thick. The muscle layer is formed by external longitudinal and internal circular fibers. In the upper parts of the esophagus, the muscular layer is similar to the muscular layer of the pharynx, and is a continuation of its striated muscle fibers. In the middle section of the esophagus, striated fibers are gradually replaced by smooth ones, and in the lower section, the muscle layer is represented only by smooth fibers. Morphological studies of F.F. Saksa et al. (1987) showed that the inner ends of the longitudinal muscle fibers of the outer layer go deep into the wall, where they, as if wrapping the esophagus, form a circular layer. As a result of a combination of circular and longitudinal muscles in the area of the transition of the esophagus to the stomach, a sphincter of the cardia is formed.

The submucosal layer is represented by a well-developed loose connective tissue, in which numerous mucous glands are located. The mucous membrane is covered with stratified (20 - 25 layers) squamous epithelium. Due to the pronounced submucosal layer, loosely associated with the muscular layer, the mucous membrane of the esophagus can fold, giving it a stellate appearance in transverse sections.

With the passage of food and the endoscope (esophagoscope), the folds straighten out. The absence of folds in a separate section of the esophagus may indicate the presence of a pathological process (tumor) in the wall.

Outside, the esophagus is surrounded by adventitia, which consists of loose fibrous connective tissue that envelops the muscular layer of the esophagus. Some authors consider it as the fourth (adventitial) layer of the esophagus. Adventitia without clear boundaries passes into the tissue of the mediastinum.

Blood supply. The blood supply to the esophagus comes from several sources. In this case, all the esophageal arteries form numerous anastomoses among themselves. In the cervical region, the esophageal arteries are branches of the inferior thyroid artery, in the thoracic region, they are branches extending directly from the thoracic aorta, and in the abdominal region, from the phrenic and left gastric arteries. The esophageal veins drain blood: from the cervical region into the inferior thyroid veins, from the thoracic region into the unpaired and semi-azygous veins, from the abdominal region into the coronary vein of the stomach, which communicates with the portal vein system. Compared to other parts of the gastrointestinal tract, the esophagus has a very developed venous plexus, which, in some pathological conditions (portal hypertension), is a source of massive and dangerous bleeding.

Lymphatic system. The lymphatic system of the esophagus is represented by a superficial and deep network. The superficial network originates in the thickness of the muscular wall, and the deep network is located in the mucous membrane and submucosal layer. The outflow of lymph in the cervical esophagus goes to the upper paratracheal and deep cervical nodes. In the thoracic and abdominal regions, the lymph is directed to the lymph nodes of the cardial part of the stomach, as well as to the paratracheal and parabronchial nodes (Zhdanov D.A., 1948).

Innervation of the esophagus. The esophagus is innervated by branches of the vagus and sympathetic nerves. The main motor nerves of the esophagus are considered to be parasympathetic branches emanating from both sides of the vagus nerves. At the level of the bifurcation of the trachea, the vagus nerves form the anterior and posterior periesophageal plexuses, which are connected by numerous branches with other plexuses of the chest organs, especially the heart and lungs.

The sympathetic innervation of the esophagus is provided by branches from the cervical and thoracic nodes of the border trunks, as well as by the celiac nerves. There are numerous anastomoses between the branches of the sympathetic and parasympathetic nerves that innervate the esophagus.

In the nervous apparatus of the esophagus, three closely related plexuses are distinguished: superficial (adventitial), intermuscular (Auerbach's), located between the longitudinal and circular muscle layers, and submucosal (Meissner's).

The mucous membrane of the esophagus has thermal, pain and tactile sensitivity. All this indicates that the esophagus is a well-developed reflexogenic zone.

The esophagus is a hollow muscular tube lined from the inside with a mucous membrane that connects the pharynx with the stomach.
Its length is on average 25-30 cm in men and 23-24 cm in women.
It starts at the lower edge of the cricoid cartilage, which corresponds to C VI, and ends at the level of Th XI with a transition to the cardial part of the stomach
The wall of the esophagus consists of three membranes: mucous (tunica mucosa), muscular (tunica muscularis), connective tissue membrane (tunica adventicia)
The abdominal part of the esophagus is covered on the outside with a serous membrane, which is the visceral sheet of the peritoneum.
In its course, it is fixed to the surrounding organs by connecting cords containing muscle fibers and blood vessels. Has several bends in the sagittal and frontal planes

cervical - from the lower edge of the cricoid cartilage at the level of C VI to the jugular notch at the level of Th I-II. Its length is 5-6 cm;
the thoracic region from the jugular notch to the passage of the esophagus through the esophageal opening of the diaphragm at the level of Th X-XI, its length is 15-18 cm;
abdominal region from the esophageal opening of the diaphragm to the point of transition of the esophagus into the stomach. Its length is 1-3 cm.

According to the classification of Brombart (1956), 9 segments of the esophagus are distinguished:

tracheal (8-9 cm);
retropericardial (3 - 4 cm);
aortic (2.5 - 3 cm);
supradiaphragmatic (3 - 4 cm);
bronchial (1 - 1.5 cm);
intradiaphragmatic (1.5 - 2 cm);
aortic-bronchial (1 - 1.5 cm);
abdominal (2 - 4 cm).
subbronchial (4 - 5 cm);

Anatomical narrowing of the esophagus:

Pharyngeal - in the area of the transition of the pharynx into the esophagus at the level of VI-VII cervical vertebrae
Bronchial - in the area of contact of the esophagus with the posterior surface of the left bronchus at the level of IV-V thoracic vertebrae
Diaphragmatic - where the esophagus passes through the diaphragm

Physiological narrowing of the esophagus:

Aortic - in the area where the esophagus is adjacent to the aortic arch at the level of Th IV
Cardiac - when the esophagus passes into the cardial part of the stomach

The endoscopic sign of the esophageal-gastric junction is the Z-line, which is normally located at the level of the esophageal opening of the diaphragm. The Z-line represents the junction of the esophageal epithelium into the gastric epithelium. The mucous membrane of the esophagus is covered with stratified squamous epithelium, the gastric mucosa is covered with a single-layer cylindrical epithelium.

The figure shows the endoscopic pictureZ-lines

The blood supply of the esophagus in the cervical region is carried out by branches of the lower thyroid arteries, the left upper thyroid artery, and the subclavian arteries. The upper thoracic region is supplied with blood by branches of the inferior thyroid artery, subclavian arteries, the right thyroid trunk, the right vertebral artery, and the right intrathoracic artery. The mid-thoracic region is fed by bronchial arteries, esophageal branches of the thoracic aorta, 1st and 2nd intercostal arteries. The blood supply of the lower thoracic region is provided by the esophageal branches of the thoracic aorta, the proper esophageal branch from the aorta (Th7-Th9), and the branches of the right intercostal arteries. The abdominal esophagus is fed by the esophagocardial branches of the left gastric, esophageal (from the thoracic aorta), and the left lower diaphragmatic.

The esophagus has 2 venous plexuses: central in the submucosal layer and superficial paraesophageal. The outflow of blood from the cervical esophagus is carried out through the lower thyroid, bronchial, 1-2 intercostal veins into the innominate and superior vena cava. The outflow of blood from the thoracic region occurs along the esophageal and intercostal branches into the unpaired and semipaired veins, then into the superior vena cava. From the lower third of the esophagus - through the branches of the left gastric vein, the upper branches of the splenic vein into the portal vein. Portion from the left inferior phrenic vein into the inferior vena cava.

Rice. Venous system of the esophagus

Lymph outflow from the cervical esophagus is carried out into the paratracheal and deep cervical lymph nodes. From the upper thoracic region - to the paratracheal, deep cervical, tracheobronchial, paravertebral, bifurcational. The outflow of lymph from the mid-thoracic esophagus is carried out to the bifurcation, tracheobronchial, posterior mediastinal, interaortoesophageal and paravertebral lymph nodes. From the lower third of the esophagus - to the pericardial, upper diaphragmatic, left gastric, gastro-pancreatic, celiac and hepatic l / y.

Rice. Lymph nodes of the esophagus

The sources of innervation of the esophagus are the vagus nerves and the border trunks of the sympathetic nerves, the main role belongs to the parasympathetic nervous system. The preganglionic neurons of the efferent branches of the vagus nerves are located in the dorsal motor nuclei of the brainstem. Efferent fibers form the anterior and posterior esophageal plexuses and penetrate the wall of the organ, connecting with the intramural ganglia. Between the longitudinal and circular muscle layers of the esophagus, the Auerbach plexus is formed, and in the submucosal layer, the Meissner nerve plexus, in the ganglia of which peripheral (postganglionic) neurons are located. They have a certain autonomous function, and a short neural arch can close at their level. The cervical and upper thoracic esophagus are innervated by branches of the recurrent nerves, which form powerful plexuses that also innervate the heart and trachea. In the midthoracic esophagus, the anterior and posterior nerve plexuses also include branches of the borderline sympathetic trunk and large celiac nerves. In the lower thoracic esophagus, trunks are again formed from the plexuses - the right (posterior) and left (anterior) vagus nerves. In the supradiaphragmatic segment of the esophagus, the vagus trunks are closely adjacent to the wall of the esophagus and, having a spiral course, branch out: the left one is on the anterior, and the right one is on the posterior surface of the stomach. The parasympathetic nervous system regulates the motor function of the esophagus reflexively. Afferent nerve fibers from the esophagus enter the spinal cord at the level of Thv-viii. The role of the sympathetic nervous system in the physiology of the esophagus has not been fully elucidated. The mucous membrane of the esophagus has thermal, pain and tactile sensitivity, with the most sensitive being the zones of the pharyngeal-esophageal and esophageal-gastric junction.

Rice. Innervation of the esophagus

Rice. Diagram of the internal nerves of the esophagus

The functions of the esophagus include: motor-evacuation, secretory, obturator. The function of the cardia is regulated by the central pathway (pharyngeal-cardiac reflex), by autonomous centers located in the cardia itself and the distal esophagus, as well as by a complex humoral mechanism that involves numerous gastrointestinal hormones (gastrin, cholecystokinin-pancreozymin, somatostatin, etc.). ) Normally, the lower esophageal sphincter is usually in a state of constant contraction. Swallowing causes a peristaltic wave, which leads to a short-term relaxation of the lower esophageal sphincter. Signals that initiate esophageal peristalsis are generated in the dorsal motor nuclei of the vagus nerve, then passed through the long preganglionic neurons of the vagus nerve to short postganglionic inhibitory neurons located in the region of the lower esophageal sphincter. Inhibitory neurons, when stimulated, release vasoactive intestinal peptide (VIP) and / or oxide nitrogen, which cause relaxation of the smooth muscles of the lower esophageal sphincter using intracellular mechanisms involving cyclic adenosine monophosphate.

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