Tog-line at the level of the diaphragm esophageal hole. Normal anatomy, esophagus physiology

Date: 04.03.2020

The esophagus is a hollow muscle, lined with an inside with a mucous membrane, a tube connecting the throat with a stomach.
It is an average length of 25-30 cm in men and 23-24 cm in women
It begins at the lower edge of the handberry cartilage, which corresponds to C vi, and ends at the level of TH XI with the transition to the cardiac part of the stomach
The wall of the esophagus consists of three shells: mucous (Tunica Mucosa), muscular (Tunica Muscularis), connecting shell (Tunicaadventicia)
The abdominal part of the esophagus is covered with a serous shell, which is a visceral leaflet of peritoneum.
In its go, it is fixed to the surrounding organs with connecting hills containing muscle fibers and vessels. Has several bends in the sagital and frontal planes

the cervical - from the lower edge of the pisteward cartilage at the C vi level to the tier cut at the level of the TH I- II. Its length is 5-6 cm;
the thoracic dilution of the jugular cutting to the place of passage of the esophagus through the feed-aqueous hole of the diaphragm at the level of the TH x xi, its length is 15-18 cm;
abdominal department from the esophageal hole of the diaphragm to the place of transition of the esophagus in the stomach. Length of its 1-3 cm.

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

tracheal (8-9 cm);
retropericardial (3 - 4 cm);
aortic (2.5 - 3 cm);
nadadiaphragmal (3 - 4 cm);
bronchial (1 - 1.5 cm);
intraphragmal (1.5 - 2 cm);
aortic-bronchial (1 - 1.5 cm);
abdominal (2 - 4 cm).
podbronchial (4 - 5 cm);

Anatomical esophageal narrowings:

Pharingeal - in the field of transition of the pharynx in the esophagus at the level of VI-VII cervical vertebrae
Bronchial - in the field of contact of the esophagus with the rear surface of the left bronchus at the level of IV-V breast vertebrae
The diaphragmal - at the site of the passage of the esophagus through the diaphragm

Physiological esophageal narrowings:

Aortic - in the area where the esophagus goes to the arc of the aorta at the level of TH IV
Cardual - when moving the esophagus to the cardiac part of the stomach

The endoscopic sign of the esophageal-gastric transition is the Z-line, which is located at the rate at the level of the esophageal hole of the diaphragm. The line is the transition of the epithelium of the esophagus in the gastric epithelium. The mucule of the esophagus is covered with a multilayer flat epithelium, the stomach mucosa is covered with single-layer cylindrical epithelium.

Figure shows an endoscopic pictureZ-lines

The blood supply to the esophagus in the cervical department is carried out by branches of the lower thyroid arteries, the left upper thyroid artery, connectible arteries. Verkhnegruda Division is branched by branches of lower thyroid artery, connectible arteries, right paral-free trunk, right vertebral artery, the right intrathless artery. The average breeding department feeds bronchial arteries, esophageal branches of the chest aorta, 1 and 2 intercostal arteries. The blood supply to the Nizhneggudinal Department is provided by the esophageal branches of the chest aorta, its own esophageal, departing from the aorta (TH7-TH9), branches of the right intercostal arteries. The nutrition of the abdominal diet of the esophagus is carried out by the esophageal-frame branches of the left gastric, esophageal (from the chest aorta), the left lower diaphragmal.

The esophagus has 2 venous plexuses: the central in the sublifted layer and surface parasepal phasezophageal. Blood outflow from the cervical esophagus is carried out through the lower thyroid, bronchial, 1-2 intercostal veins into the Unnamed and the upper hollow vein. Blood outflow from the chest department occurs on the esophageal and intercostal branches in the unpaired and semi-head veins, then into the upper hollow vein. From the lower third of the esophagus - through the branches of the left gastric vein, the upper branches of the spleen vein in the portal vein. Part of the left lower diaphragmal veins in the lower hollow vein.

Fig. Venous system of esophageal

The lymphotok from the cervical esophageal is carried out in the paratroheal and deep cervical l / y. From the Uppergrochny Department - to the paratrahelny, deep cervical, tracheobronchial, paravertebral, bifurcational / y. The outflow of lymphs from the average moral department of the esophagus is carried out to the bifurcation, tracheobrocheial, rear media, inter-phaseortopic and paravertebral / y. From the lower third of the esophagus - to the near-cardial, upper diaphragmal, left gastric, gastrointestinal, curious and hepatic l / y.

Fig. Lymph nodes of the esophagus

Sources of the innervation of the esophagus are wandering nerves and border trunks of sympathetic nerves, the main role belongs to the parasympathetic nervous system. Preggangional neurons of the efferent branches of wandering nerves are in the dorsal motors of the brain stem. Efferent fibers form the front and rear esophages of the plexus and penetrate the organ of the organ, connecting with the intramural of ganglia. Auerbakhovo plexus is formed between the longitudinal and circular muscle layers of the esophagus, and in the sublifted layer - the nervous plexus of Maissener, in the ganglia of which are peripheral (postgangngling) neurons. They have a certain stand-alone function, and a short nervous arc can be closed at their level. The cervical and uppergrochny departments of the esophagus are innervated by the branches of returning nerves forming powerful plexuses, innervating the heart and trachea. In the average germ, the esophagus in the front and rear nerve plexuses also includes branches of the border sympathetic barrel and large ventricular nerves. In the Nizhnegrudny Department of the esophagus of plexuses, trunks are remedied - right (rear) and left (front) wandering nerves. In the nadiaphragmal segment of the esophagus, the wandering trunks are closely adjacent to the wall of the esophagus and, having a spiral stroke, branch: left - on the front, and the right - on the rear 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 THV-VIII level. The role of the sympathetic nervous system in the physiology of the esophagus is finally not found out. The mucous membrane of the esophagus has thermal, pain and tactile sensitivity, and the most sensitive zones of the pharyngeal and esophageal and gastric transition are the most sensitive.

Fig. Innervation of the esophagus

Fig. The diagram of the internal nerves of the esophagus

Functions of the esophagus include: Motor-evacuation, secretory, locking. The cardi function is regulated by the central way (pharyngeal reflex), autonomous centers laid out in the cardia itself and the distal esophagus, and also with the help of a complex humoral mechanism in which numerous gastrointestinal hormones are involved (Gastrin, Cholecystokinin-Pancreatin, Somatostatin, etc., are involved. ) Normally, the lower esophageal sphincter is usually in a state of constant reduction. Swallowing causes the occurrence of a peristaltic wave, which leads to short-term relaxation of the lower esophageal sphincter. Signals, initiating the peristaltics of the esophagus, are generated in the dorsal motor nuclei of the wandering nerve, are then carried out through long preggaeer neurons of the wandering nerve to short postganglyonary brake neurons located in the field of the lower esophageal sphincter. The brake neurons during stimulation are isolated a vasoactive intestinal peptide (VIP) and / or approach Nitrogen, which cause relaxation of the smooth muscles of the lower esophageal sphincter using intracellular mechanisms with the participation of cyclic adenosine monophosphate.

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Studies with long-term monitoring pH have shown that even in healthy people, short-term episodes of gastroesophageal reflux (GER) arise, as a rule, after excess food intake.

Over the past 30 years, many experimental works were conducted in the field of Pathophysiology Reflux Ezophagitis. These studies have proven polyethology and multi-factority of this disease. It is known that the basis of the pathogenesis of reflux-esophagitis is the insufficiency of the cardia and the violation of its zombie-valve function. Most often, the destruction of the antireflury cardia mechanism occurs with the sliding hernia of the esophageal hole of the diaphragm (GPO), especially with a short esophagus - in this case, reflux-esophagitis is expressed to the greatest extent. The ulcerative stenosis of the gatekeeper, especially in combination with the cardiac hernia under, largely contributes to the development of reflux-esophagitis. Recreation of the stomach and gastroenterostomy lead to a bile in the stomach, in such cases the so-called "alkaline reflux-esophagite" can develop. Ezophagitis easily arises in some cases during severe vomiting (for example, after various operations, with the toxicosis of pregnant women). Often, heavy reflux-esophagitis occurs as a result of long-term probe drainage of the stomach, since the standing probe actually causes cardia deficiency. Reflux-esophagitis develops after preceding cards on cardia, destroying its zomper-valve mechanism.

According to gravity distinguish:

Easy Ezophagitwhich is macroscopically characterized by hyperemia and an edema mucous membrane.

For essophagitis of average degree These changes are exacerbated, erosion appears on the mucous membrane.

Heavy esophagitis It is characterized by rude changes in the form of a fibrin coated with fibrin on the background of a sharply inflamed easily bleeding mucous membrane, which in the distal esophagus can be completely destroyed or substituted with a cylindrical epithelium metaplazated in the intestinal type - so-called. Barrett's esophagus. For the same stage, the development of the peptic ("round") ulcer of the esophagus is also characteristic. Heavy reflux-esophagitis often ends with the formation of the scar peptic stricture of the esophagus. Peptic strictures are localized, as a rule, in the lower third of the esophagus. This area is most exposed to an aggressive gastric juice. The inflammatory process usually affects all layers of the esophagus wall, but most of all pathological changes are expressed in its mucous membrane and the sublifted layer.

Peptic strictures are separated by short (less than 3 cm) and extended (most often from 3.5 to 6-7 cm long).

Long-term flowing inflammation leads to the shortening of the esophagus, while the cardiac stomach is even more drawn into the rear media (therefore the sliding hernia becomes fixed), and the cardiya antirefluxic mechanism is increasingly destroyed - the vicious circle is closed when the inflammation in the esophagus contributes to its shortening, and short The esophagus supports reflux.

Barrett's esophagus or Barrett syndrome is the pathological replacement of the flat-milk epithelium of the lower third of the esophagus specialized (metaplazated in intestinal type) with cylindrical epithelium. With an endoscopic study, the foci of the Barrett's epithelium look like the lines of the bright red epithelium (z-line) lines (visually not distinguvenched from the epithelium of the cardiac stomach).

Figure - Endoscopic Pattern of Food Barrett

Normally, Z-line tongues can rise by 2-3 cm up above the main level of esophageal-gastric transition, therefore, the clinical significance has so-called. Long segment of the barrett (longer than 3 cm). A special role is played by the identification of incomplete intestinal metaplasia and heavy dysplasia in the epithelium of Barrett, which is currently considered as a bond preference. The probability of the development of adenocarcinoma in the Barrett esophagus increases almost 10 times in the event of foci of heavy dysplasia in Barrett's epithelium.

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The esophagus is an extended muscular organ, represented in the form of a tube with saving, in calm condition, walls. The formation of the organ begins on the 4th week of intrauterine development, by the time of birth, all characteristic structural features take care.

Where is the esophagus in humans (photo)
Features of the structure
Functions of the esophagus
Length organ
Departments
Anatomical and physiological narrowings
Z-line
Blood supply
Innervation
X-rayanatomy
Bend
Structure of the wall
Epithelium of the esophala

Where is the esophagus

The esophagus is a binder chain between the rotoglot and the body of the stomach. The anatomy of the organ is quite complicated. It has its own innerware and a network of feed vessels, the cavity opens glands that generate a secret. The wall is multi-layered, all the lengths there are natural bends and.

Topography places it between 6 cervical and 11 breast vertebra, behind the trachea. The upper segment adjacent to the fractions of the thyroid gland, the lower, passing through the hole in the diaphragm, is connected to the stomach in its proximal part. The rear of the esophagus is adjacent to the spinal pole, the front is adjacent to the aorta and the wandering nerve.

You can consider where the esophagus is located in a person, the photo gives a schematic representation.

The structure of the esophagus of man

In the structure of the esophagus, three departments are distinguished:

the cervical is located behind the larynx, the average length of 5 cm is the most mobile part of the organ;
thoracic, with a length of about 18 cm, at the entrance to the diaphragm hole is hidden by pleural sheets;
the abdominal with a length of no more than 4 cm is located in the subadiaphragmal region and connects with the cardia.

The organ is equipped with two sphincters: the top limits the refund of the food into the throat, the lower blocks the cast of gastric acid and the food mass back.

Feature of the organ - Anatomical narrowings:

sip
diaphragmal;
bronchial;
aortic;
gastric.

Muscular layer - the base of the organ wall is arranged in such a way that allows fibers to significantly expand and narrow, transporting the food com. Outside, muscle fibers are covered with a connective tissue. From the inside the organ is littered with the mucous epithelium, which opens the lumens of secretory ducts. Such a structure allows several important functions in the digestion process.

Functions of the esophagus

In the human esophagus, the structure and functions are closely connected, and the role of the coordinator performs the central nervous system.

Several main tasks allocate:

Motor - Movement of food and transporting it in the stomach. Motor activity is provided by the work of skeletal muscles, which make up the basis of the upper third of the wall of the esophagus. The phased reduction in muscle fibers causes a wave-like movement - peristaltic.
Secretoric due to the work of the special glands. During the passage of food comes is abundantly wetted by enzymatic liquid, which makes it easier to transport and launches the digestion process.
The barrier, performed by the work of the esophageal sphincters, prevents from entering the food particles back to the Rothoglotka and the respiratory tract.
Protective is ensured by the production of immunoglobulin of the mucous membrane of the esophagus, which adversely affects the pathogenic microflora's accidentally swallowed by man.

Methods of studying the esophagus and the diagnosis of its pathology are based on the characteristics of the structure and operation. The organ is an initial link in digestion, and the violation of his activity causes a failure in the entire GTS system.

Food length

The size of the body is individual and depends on age, growth, physique and individual characteristics. On average, the length of the esophagus in an adult is 28-35 cm. Its weight depends on the total body weight and on average equal to 30-35 g.

The diameter varies depending on the department under consideration. The smallest lumen is marked in the cervical segment - about 1.7-2 cm. The largest diameter reaches in the subadiaphragmal part - 2.8-3 cm. Such data is installed in a calm (saving condition).

Departments of the Food Food

In the generally accepted classification, 3 people of the esophagus of a person are distinguished:

Cervical. Upper border - 6th cervical vertebra, lower boundary - 1-2 breast vertebra. Its length ranges from 5-7 cm. The segment is adjacent to the larynx and the upper part of the trachea, two sides are the lobes of the thyroid gland and the trunks of the return nerves.
Chest. This is the most extelligent part of the esophagus, in an adult, it is about 17 cm. In addition, it is the most complex topographic area, since there are: arcs aorta, the zone of the nervous plexus and the branch of the wandering nerve, dividing the trachea to bronchi.
Cardial, called otherwise distal. The shortest segment, length of no more than 4 cm. It is it that is subject to the formation of hernia bags when moving through a diaphragm.

Some sources distinguish 5 departments of the esophagus:

top, corresponding to the cervical;
chest;
nizhnegorudnaya;
abdominal;
the lower corresponding to the cardiac segment.

In the topographic classification, there is a division into segments on brombaru, where 9 zones are distinguished.

The narrowings are the sections of the smallest diameter, differ in anatomical and physiological. In total, 5 natural essences are distinguished. These are the places of increased risk, since it is here that obstruction occurs when the foreign object is hit or the food cluster during dysfagia (a functional breakdown of food).

Anatomical narrowings are defined both in the body of a living person and with a pathological analytical study. Distinguish 3 such sites:

cervical department at the lower edge of the throat;
in the thoracic segment - the place of contact with the left bronchial tree;
switch to the distal department when crossing the diaphragmal window.

Physiological narrowings of the esophagus are due to the spastic effect of muscle fibers. You can detect these areas only when a person's life is aortic and cardiac segments.

Flying line of the esophagus

The Z-line of the esophagus is the boundary, determined by the endoscopic method, is located at the transition site of the esophagus in the stomach. Normally, the inner layer of the organ is a multilayer epithelium, having a pale pinkish color. The gastric mucosa represented by a cylindrical epithelium is distinguished by a bright red color. A line is formed on the place of the joint, which resembles teeth is the distinction between the epithelial layer and the inner environment of the organs.

The outer boundary of the toothed line is the gastric cardia - the place of flow of the esophagus. The external and inner boundary may not coincide. Often the toothed line is located between the cardia and the diaphragm.

Blood supply of esophagus

The blood supply to the esophagus depends on the common circulatory system of the segment.

In the cervical circulation, the circulation provides a thyroid artery and vein.
The chest department is bustling at the expense of aortic, bronchial branches and unpaired veins.
Abdominal part feed the diaphragm aorta and gastric vein.

Lymphotok is carried out towards the following large nodes:

cervical and tracheal;
bronchial and ocolopotes;
large abdominal lymphosus.

Innervation

Ensuring the functionality of the organ occurs due to the work of both types of nervous regulation: sympathetic and parasympathetic. Connections of nerve fibers form a plexus on the front and rear surface of the esophagus. Breast and abdominal department are more dependent on the work of the wandering nerve. The innervation of the esophagus in the cervical department is provided by the trunks of recurrent nerves.

The nervous system regulates the motor's motor function. The greatest answer gives a pharyngeal and gastric zone. This is the location of the sphincter.

The hernia of the esophageal hole of the diaphragm is a pathological condition due to intimate damage to the muscular substrate of the diaphragm and accompanied by a transient or constant displacement of the part of the stomach into the mediastinum.

For the first time, the French surgeon Ambroaz Parre was described in 1679 and the Italian Anata Morgani in 1769 in Russia Ilyshinsky N.S. In 1841 he came to the conclusion about the possibility of a lifetime diagnosis of the disease. By the beginning of the XX century, only 6 cases were described, and from 1926 to 1938. Their detection increased 32 times, and the disease occupied 2 place after peptic ulcer. Currently, the hernia of the esophageal hole of the diaphragm y is detected with a radiographic study of more than 40% of the population.

Causes of the formation of hernia of the teaching hole of the diaphragm

Main reasons.

Systemic lesion of muscle tissue. The esophageal hole is formed by the legs of the diaphragm, they cover the esophagus, over and under them is a connective tissue plate, it connects with the adventitia of the esophagus, forming the esophageal-diaphragmal membrane. Normally, the diameter of the hole is 3.0-2.5 cm. In the elderly, adipose tissue accumulates here. The diaphragm esophageal hole is expanding, the membranes are stretched, muscle diefragm dystrophy develops.
Increased intra-abdominal pressure. This contributes to the stomach propagation in the esophagus (during constipation, pregnancy, wearing weights).

Nezernaya reasons.

Shorting of the esophagus. The primary shortening of the esophagus in violation of the cardi function leads to reflux-esophagitis, which leads to the peptic stricture of the esophagus, and this, in turn, causes the shortening of the esophagus, etc. - The hernia of the esophageal hole of the diaphragm progresses.
Longitudinal disfigurations of the esophagus: can cause an excitation of a wandering nerve, which in turn leads to strengthening the longitudinal contraction of the muscles of the esophagus, the disclosure of the cardia - the hernia of the esophageal hole of the diaphragm is formed.

The main classification of the hernia of the diaphragm of the diaphragm is the classification of Akerlund (1926). It allocates 3 main types of hernia:

Sliding hernia.
Parasezophageal hernia.
Short esophagus.

The sliding (axial) hernia is found almost 90% of patients with the hernias of the esophageal hole. In this case, the Cardial Division of the stomach is shifted to the mediastinum.

Parasezophageal hernia is observed in approximately 5% of patients. It is characterized by the fact that the cardia does not change its position, and the bottom and large curvature of the stomach come through the extended hole. The hernia can also contain other organs, for example, a cross-hazelnaya intestine.

Short esophagus as an independent disease is rare. It is an anomaly of development and many specialists as hernia of the diaphragm's esophageal hole is currently not considered.

Endoscopic signs of diaphragmal hernia

Reducing the distance from the front cutters to the cardia.
Cardia's gaping or incomplete closure.
Prolapse of the gastric mucosa in the esophagus.
The presence of a "second entry" in the stomach.
The presence of a hernia cavity.
Gastroesophage reflux of gastric content.
Signs of reflux-esophagitis and gastritis.

Reducing the distance from the front cutters to the cardia. Normally, this distance is 40 cm. Cardia's socket is normally closed, in 2-3 cm above it is a gear line (Z-line). With axial hernias of the esophageal hole of the diaphragm, the Z-line is determined in the breast of the esophagus above the diaphragmal hole. The distance to her from the cutters is shortened. A diagnostic error is often allowed with a short esophagus. It is necessary to know that only the gear line is shifted, and the cardia is in place. Often the rosette of the cardia shifts with hernias to the side.

Cardia's gaping or incomplete closure. It is also observed in axial hernias. Norma Cardia is closed. Cardia's gaping with hernias of the diaphragm esophageal opening is observed in 10-80% of cases. The esophagus, when inspection at the entrance, should be examined carefully, and when approaching the cardia, it is necessary to stop the air supply, otherwise there will be errors. When the endoscope passes through the cardia there is no resistance, and in the norm there is a minor resistance.

The prolapse of the gastric mucosa in the esophagus is a characteristic endoscopic sign of axial hernia. Typical dome-shaped outlet of the gastric mucosa over the diaphragm hole is best determined with a deep breath. The gastric mucosa is mobile, while the esophagus is fixed. Inspect at the entrance in calm condition, because When an apparatus is removed, a vomit reflex and the mucosa prolapse may be normal. The height may increase to 10 cm.

The presence of a "second entry" in the stomach. Characteristic for parasephageal hernia. The first entrance in the area of \u200b\u200bthe gastric mucosa, the second - in the field of the esophageal hole of the diaphragm. With deep breathing, the legs of the diaphragm converge and the diagnosis is simplified.

The presence of a hernia is a characteristic feature of parasephageal hernia. Determined only when inspection from the cavity of the stomach. Located next to the esophageal opening.

Gastroesophageal reflux of gastric content is well visible on the left side.