The esophagus (American English) or oesophagus (British English) () is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about long in adult humans, that travels behind the trachea and heart, passes through the diaphragm, and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word esophagus is from Ancient Greek οἰσοφάγος (oisophágos), from οἴσω (oísō), future form of φέρω (phérō, "I carry") + ἔφαγον (éphagon, "I ate").
The wall of the esophagus from the lumen outwards consists of mucosa, submucosa (connective tissue), layers of muscle fibers between layers of fibrous tissue, and an outer layer of connective tissue. The mucosa is a stratified squamous epithelium of around three layers of squamous cells, which contrasts to the single layer of columnar cells of the stomach. The transition between these two types of epithelium is visible as a zig-zag line. Most of the muscle is smooth muscle although striated muscle predominates in its upper third. It has two muscular rings or sphincters in its wall, one at the top and one at the bottom. The lower sphincter helps to prevent reflux of acidic stomach content. The esophagus has a rich blood supply and venous drainage. Its smooth muscle is innervated by involuntary nerves (sympathetic nerves via the sympathetic trunk and parasympathetic nerves via the vagus nerve) and in addition voluntary nerves (lower motor neurons) which are carried in the vagus nerve to innervate its striated muscle.
The esophagus may be affected by gastric reflux, cancer, prominent dilated blood vessels called varices that can bleed heavily, tears, constrictions, and disorders of motility. Diseases may cause difficulty swallowing (dysphagia), painful swallowing (odynophagia), chest pain, or cause no symptoms at all. Clinical investigations include X-rays when swallowing barium sulfate, endoscopy, and CT scans. Surgically,
the esophagus is difficult to access in part due to its position between critical organs and directly between the sternum and spinal column.
Structure
The esophagus is one of the upper parts of the digestive system. There are taste buds on its upper part. It begins at the back of the mouth, passing downward through the rear part of the mediastinum, through the diaphragm, and into the stomach. In humans, the esophagus generally starts around the level of the sixth cervical vertebra behind the cricoid cartilage of the trachea, enters the diaphragm at about the level of the tenth thoracic vertebra, and ends at the cardia of the stomach, at the level of the eleventh thoracic vertebra. The esophagus is usually about 25 cm (10 in) in length, with only around one centimeter of esophagus lying in the abdominal cavity.
Many blood vessels serve the esophagus, with blood supply varying along its course. The upper parts of the esophagus and the upper esophageal sphincter receive blood from the inferior thyroid artery, the parts of the esophagus in the thorax from the bronchial arteries and branches directly from the thoracic aorta, and the lower parts of the esophagus and the lower esophageal sphincter receive blood from the left gastric artery and the left inferior phrenic artery. The venous drainage also differs along the course of the esophagus. The upper and middle parts of the esophagus drain into the azygos and hemiazygos veins, and blood from the lower part drains into the left gastric vein. All these veins drain into the superior vena cava, with the exception of the left gastric vein, which is a branch of the portal vein.
- At the start of the esophagus, where the laryngopharynx joins the esophagus, behind the cricoid cartilage
- Where it is crossed on the front by the aortic arch in the superior mediastinum
- Where the esophagus is compressed by the left main bronchus in the posterior mediastinum
- The esophageal hiatus, where it passes through the diaphragm in the posterior mediastinum
===Sphincters===<!-- Other articles link here -->
<!-- Redirects to here include:
esophageal sphincter,
esophageal sphincter, upper,
esophageal sphincter, lower,
upper esophageal sphincter,
lower esophageal sphincter, and
cardiac sphincter.
-->
The esophagus is surrounded at the top and bottom by two muscular rings, known respectively as the upper esophageal sphincter and the lower esophageal sphincter.
The lower esophageal sphincter, or gastroesophageal sphincter, surrounds the lower part of the esophagus at the gastroesophageal junction between the esophagus and the stomach.
Nerve supply
The esophagus is innervated by the vagus nerve and the cervical and thoracic sympathetic trunk. The sympathetic trunk has a sympathetic function. It may enhance the function of the vagus nerve, increasing peristalsis and glandular activity, and causing sphincter contraction. In addition, sympathetic activation may relax the muscle wall and cause blood vessel constriction. The pink color of the esophageal mucosa contrasts to the deeper red of the gastric mucosa, and the mucosal transition can be seen as an irregular zig-zag line, which is often called the z-line. Histological examination reveals abrupt transition between the stratified squamous epithelium of the esophagus and the simple columnar epithelium of the stomach. Normally, the cardia of the stomach is immediately distal to the z-line and the z-line coincides with the upper limit of the gastric folds of the cardia; however, when the anatomy of the mucosa is distorted in Barrett's esophagus the true gastroesophageal junction can be identified by the upper limit of the gastric folds rather than the mucosal transition. The functional location of the lower oesophageal sphincter is generally situated about below the z-line.
Microanatomy
The human esophagus has a mucous membrane consisting of a tough stratified squamous epithelium without keratin, a smooth lamina propria, and a muscularis mucosae.
The muscular layer of the esophagus has two types of muscle. The upper third of the esophagus contains striated muscle, the lower third contains smooth muscle, and the middle third contains a mixture of both. The mucus from the glands gives a good protection to the lining. The submucosa also contains the submucosal plexus, a network of nerve cells that is part of the enteric nervous system. During the second week of embryological development, as the embryo grows, it begins to surround parts of the sac. The enveloped portions form the basis for the adult gastrointestinal tract. The esophagus develops as a tube, lined with smooth muscle but continues development craniocaudally into different proportions of striated muscle. Both types of muscle have been demonstrated to be of different precursor cells. The innervation of the esophagus develops from the pharyngeal arches. When food is being swallowed, the epiglottis moves backward to cover the larynx, preventing food from entering the trachea. At the same time, the upper esophageal sphincter relaxes, allowing a food bolus to enter. Peristaltic contractions of the esophageal muscle push the food down the esophagus. These rhythmic contractions occur both as a reflex response to food that is in the mouth, and also as a response to the sensation of food within the esophagus itself. Along with peristalsis, the lower esophageal sphincter relaxes. Constriction of the lower esophageal sphincter protects the esophageal mucosa by preventing reflux, the backflow of acid and gastric contents into the esophagus. The acute angle of His and the lower crura of the diaphragm also help this sphincteric action.
Gene and protein expression
About 20,000 protein-coding genes are expressed in human cells and nearly 70% of these genes are expressed in the normal esophagus. Some 250 of these genes are more specifically expressed in the esophagus with less than 50 genes being highly specific. The corresponding esophagus-specific proteins are mainly involved in squamous differentiation such as keratins KRT13, KRT4 and KRT6C. Other specific proteins that help lubricate the inner surface of esophagus are mucins such as MUC21 and MUC22. Many genes with elevated expression are also shared with skin and other organs that are composed of squamous epithelia.
Clinical significance
The main conditions affecting the esophagus are described here. For a more complete list, see esophageal disease.
Inflammation
Inflammation of the esophagus is known as esophagitis. Reflux of gastric acids from the stomach, infection, substances ingested (for example, corrosives), some medications (such as bisphosphonates), and food allergies can all lead to esophagitis. Esophageal candidiasis is an infection of the yeast Candida albicans that may occur when a person is immunocompromised. the causes of some forms of esophagitis, such as eosinophilic esophagitis, are not well-characterized, but may include Th2-mediated atopies or genetic factors. There appear to be correlations between eosinophilic esophagitis, asthma (itself with an eosinophilic component), eczema, and allergic rhinitis, though it is not clear whether these conditions contribute to eosinophilic esophagitis or vice versa, or if they are symptoms of mutual underlying factors. Esophagitis can cause painful swallowing and is usually treated by managing the cause of the esophagitis - such as managing reflux or treating infection. These blood vessels are engorged more than normal, and in the worst cases may partially obstruct the esophagus. These blood vessels develop as part of a collateral circulation that occurs to drain blood from the abdomen as a result of portal hypertension, usually as a result of liver diseases such as cirrhosis. Sclerosis of the esophagus, such as with systemic sclerosis or in CREST syndrome may cause hardening of the walls of the esophagus and interfere with peristalsis. Both of these conditions usually occur together. Half of these cases may be part of a syndrome where other abnormalities are also present, particularly of the heart or limbs. The other cases occur singly.
Imaging
thumbnail|A mass seen during an [[endoscopy and an ultrasound of the mass conducted during the endoscopy session]]
An X-ray of swallowed barium may be used to reveal the size and shape of the esophagus, and the presence of any masses. The esophagus may also be imaged using a flexible camera inserted into the esophagus, in a procedure called an endoscopy. If an endoscopy is used on the stomach, the camera will also have to pass through the esophagus. During an endoscopy, a biopsy may be taken. If cancer of the esophagus is being investigated, other methods, including a CT scan, may also be used. The use of the word esophagus, has been documented in anatomical literature since at least the time of Hippocrates, who noted that "the oesophagus ... receives the greatest amount of what we consume." Its existence in other animals and its relationship with the stomach was documented by the Roman naturalist Pliny the Elder (AD23–AD79), and the peristaltic contractions of the esophagus have been documented since at least the time of Galen.
The first attempt at surgery on the esophagus focused in the neck, and was conducted in dogs by Theodore Billroth in 1871. In 1877 Czerny carried out surgery in people. By 1908, an operation had been performed by Voeckler to remove the esophagus, and in 1933 the first surgical removal of parts of the lower esophagus, (to control esophageal cancer), had been conducted.
The Nissen fundoplication, in which the stomach is wrapped around the lower esophageal sphincter to stimulate its function and control reflux, was first conducted by Rudolph Nissen in 1955. In ruminants, animals with four chambered stomachs, a groove called the sulcus reticuli is often found in the esophagus, allowing milk to drain directly into the hind stomach, the abomasum. In the horse the esophagus is about in length, and carries food to the stomach. A muscular ring, called the cardiac sphincter, connects the stomach to the esophagus. This sphincter is very well developed in horses. This and the oblique angle at which the esophagus connects to the stomach explains why horses cannot vomit. The esophagus is also the area of the digestive tract where horses may have the condition known as choke.
The esophagus of snakes is remarkable for the distension it undergoes when swallowing prey.
In most fish, the esophagus is extremely short, primarily due to the length of the pharynx (which is associated with the gills). However, some fish, including lampreys, chimaeras, and lungfish, have no true stomach, so that the esophagus effectively runs from the pharynx directly to the intestine, and is therefore somewhat longer.
In many vertebrates, the esophagus is lined by stratified squamous epithelium without glands. In fish, the esophagus is often lined with columnar epithelium, an adult human body would not be able to pass through the esophagus of a whale, which generally measures less than in diameter, although in larger baleen whales it may be up to when fully distended.
Invertebrates
A structure with the same name is often found in invertebrates, including molluscs and arthropods, connecting the oral cavity with the stomach. In terms of the digestive system of snails and slugs, the mouth opens into an esophagus, which connects to the stomach. Because of torsion, which is the rotation of the main body of the animal during larval development, the esophagus usually passes around the stomach, and opens into its back, furthest from the mouth. In species that have undergone de-torsion, however, the esophagus may open into the anterior of the stomach, which is the reverse of the usual gastropod arrangement. There is an extensive rostrum at the front of the esophagus in all carnivorous snails and slugs. In the freshwater snail species Tarebia granifera, the brood pouch is above the esophagus.
In the cephalopods, the brain often surrounds the esophagus.