Dorsal

Figure 1-11 Wall structure at the esophagogastric junction. The tunica muscularls Is composed of both a longitudinal and a circular layer, (a = muscularls mucosae, b = lamina propria, c = epithelium, G1 = esophage;

il glands, G2 = gastric glands, Ly = lymph vessels, N1 = myenteric plexus, N2 = submucous nerve plexus.)

Figure 1-13 Structures at the pharyngoesophageal junction viewed from a posterior aspect. These are shown (A) in a human dried-fiber specimen (by Liebermann-Meffert), (B) in a schematic drawing of an anteriorly opened and unfolded specimen (by Killian), and (C) in a simplified diagram of the muscle organization. The muscular arrangement of the inferior constrictor of the pharynx (1) confirms Killian's observation of the tile-shaped arrangement of the bundles of the inferior constrictor muscle (Killian, G.: Z. Ohrenheilk, £5:1, 1908.). With respect to the junction, two features should be emphasized: the change of one muscle layer at the pharynx (1) into two at the esophagus (2) just below the oropharyngeal muscle (3) (UES), the oropharyngeal muscle being part of the pharynx by position and anatomic characteristics. Residual tissue from the removed thyroid gland (4). (From Liebermann-Meffert, D: In Fuchs, K.-H., Stein, H.J., Thiede, A. [eds.]: Gastrointestinale Funktionsstörungen, Berlin, Springer, 1997, with permission.)

Figure 1-13 Structures at the pharyngoesophageal junction viewed from a posterior aspect. These are shown (A) in a human dried-fiber specimen (by Liebermann-Meffert), (B) in a schematic drawing of an anteriorly opened and unfolded specimen (by Killian), and (C) in a simplified diagram of the muscle organization. The muscular arrangement of the inferior constrictor of the pharynx (1) confirms Killian's observation of the tile-shaped arrangement of the bundles of the inferior constrictor muscle (Killian, G.: Z. Ohrenheilk, £5:1, 1908.). With respect to the junction, two features should be emphasized: the change of one muscle layer at the pharynx (1) into two at the esophagus (2) just below the oropharyngeal muscle (3) (UES), the oropharyngeal muscle being part of the pharynx by position and anatomic characteristics. Residual tissue from the removed thyroid gland (4). (From Liebermann-Meffert, D: In Fuchs, K.-H., Stein, H.J., Thiede, A. [eds.]: Gastrointestinale Funktionsstörungen, Berlin, Springer, 1997, with permission.)

Figure 1-14 Schematic drawing of the structures at the pharyngoesophageal junction seen from the posterior aspect. The location of Killian's and Laimer's triangles is indicated; Zenker's diverticula develop cranial to the cricopharyngeal muscle, the upper esophageal sphincter is located at the V-shaped area of Killian.

Simple Diagram Zenker Diverticulum

Figure 1-15 Schematic drawing showing the correlation between radial muscle thickness (left) and three-dimensional manometric pressure image (right) at the gastroesophageal junction. Muscle thickness across the gastroesophageal junction at the posterior gastric wall (PW), greater curvature (GC), anterior gastric wall (AW), and lesser curvature (LC) is shown in mm. Radial pressures at the gastroesophageal junction (in mmHg) are plotted around an axis representing atmospheric pressure. Note the marked radial and axial asymmetry of both the muscular thickness and the manometric pressure profile.

Figure 1-16 Histologic specimens of the human esophagus taken in the transverse (A) and the longitudinal (B) sections 4 cm above the tracheal bifurcation at the transition between striated (1) and smooth muscle (2). Individual striated muscle fibers are interspersed among smooth muscle strands (arrows). The diagram shows the distribution of striated and smooth muscle in adult esophagus as evaluated from consecutive serial histologic sections of 13 esophagi. (Specimen and photo courtesy of Liebermann-Meffert, Geissdorfer, and Winter, Munich.)

Figure 1-17 Arterial cast showing the vascular supply to the middle and lower esophagus. Note that the esophageal branch derives from the bronchial artery. In esophageal resections, it should be ligated close to the esophageal wall so as not to jeopardize the blood supply of the left main bronchus. In this context, it should be mentioned that the esophagus shares its blood supply with other organs: the thyroid gland, the trachea, the stomach, and the spleen.

using a specially created resin without particles. The microvascular supply in the esophageal submucosa in the mid-esophagus (A) and in the cardia (B) is displayed. The vessels form a polygonal meshwork overlying the mucosa. (SEMs by Dr. Duggelin, Basel.)

Blood Supply Hypopharynx
Figure 1-19 Extravisceral sources of arterial blood supply to the esophagus, intramural anastomoses (dotted line), and topographic relationship of the azygos vein to the esophagus and tracheal bifurcation. The arrows indicate the direction of flow.

a. Original drawing. (From Elze, C., and Beck, K, Die venosen Wundernetze des Hypopharynx. Z. Ohrenheilk., 77:185, 1918.)

Figure 1-21 Radiograph of the venous circulation at the esophagogastric junction and the esophagus after injection with barium gelatin. This example shows the various zones of different venous architecture, such as the gastric zone (GZ), the palisade zone (PZ), the perforating zone (PfZ), and the truncal zone (TZ), as well as the irregular polygonal network of the proper gastric veins. (From Vianna, A., Hayes, P.C., Moscoso, G, et al.: Normal venous circulation of the gastroesophageal junction: A route of understanding varices. Gastroenterology, 93:876, 1987, with permission.)

Figure 1-22 Initial lymphatics (arrows) between the lower border of the tunica mucosa and the tela sub mucosa seen on a histologic photomicrograph (A) and In a schematic drawing (B). This view Is taken from the gastric wall, but also seems to be of relevance for the esophagus. (From Lehnert etal.: Lymph and blood capillaries ofthe human gastric mucosa. Gastroenterology, 89:939, 1985.)

Figure 1-23 Lymphatic pathways in the esophageal wall. The suggested pattern of lymph flow is shown to explain the possible local and distal spread of tumor cells, including block of distal lymphatics. The embryologic development and the presence and alignment of valves suggest this pattern of lymph flow, although it has never been substantiated experimentally up to now.

Figure 1-24 A knowledge of the direction of lymph flow and the position of major lymph nodes is essential in understanding the potential spread of an esophageal malignancy. Lymph from areas above the tracheal bifurcation drains mostly toward the neck, and that below the tracheal bifurcation flows preferentially toward the celiac axis. Lymph flow at the bifurcation appears to be bidirectional. The dimensions of the lymph nodes are out of scale. In the normal, nonmallgnant condition, esophageal and mediastinal lymph nodes are difficult to discern because of their small diameter of only 3 to 7 mm. Lymph nodes that drain the lung are usually bigger and can be easily visualized by their carbon particle content.

Figure 1-25 The upper thoracic and right lymphatic ducts. (From Warwick R., and Williams RL [eds.]: Gray's Anatomy, 35th ed. Edinburgh, Longman, 1973, p. 727.)

Figure 1-26 Sympathetic and parasympathetic nerve systems. The sympathetic system forms a chain of ganglia from the base of the skull to the coccyx. In the neck, the sympathetic chain is posterior to the carotid sheath. In the chest, it is found anterolateral to the bodies of the vertebrae. Both vagus nerves carry the parasympathetic innervation and travel along the esophagus. The locations of the right and left superior and inferior recurrent laryngeal nerves are shown.

Figure 1-27 Meandering course of the left recurrent laryngeal nerve (3) shown before its dissection from the underlying peritracheal tissues (2). The thyroid gland (6) is still in place. Esophagus (1), aorta (10), left common carotid artery (7).

Figure 1-28 Posterior aspect of the muscular wall of the esophagus (1) and pharynx (11). The right recurrent laryngeal nerve (3) largely removed from its peritracheal tissue bed is pulled down toward lateral behind its turning point (forceps) around the subclavian artery (9). The rami of the recurrent laryngeal nerve enter the lateral wall of the esophagus (1) and trachea (2). The left thyroid gland (6) is in its natural position, the right is displaced toward posterior. Underneath the lower lobe the thyroid artery and its branches encircle the recurrent laryngeal nerves. The turning point of the left recurrent laryngeal nerve is seen under the aortic arch (10). Esophagus (1), common carotid artery (7), brachiocephalic trunk (8). Note the venous network on top of the pharyngeal muscle (11), the upper esophageal sphincter (12), and the

Figure 1-29 The course of the left recurrent laryngeal nerve (3) between the turning point from the vagus nerve (5) and Its entry Into the larynx Is photographed from the lateral aspect after removal from the peritracheal tissues. The attachments of the thyroid gland (6) are removed, and the gland Is shifted posteriorly to display the recurrent laryngeal nerve (3) and the vascular arrangement underneath. Esophagus (1), trachea (2), inferior constrictor muscle of the pharynx wall (11)—that is, the upper esophageal sphincter (12). Note the Zenker's diverticulum on the right (arrow).

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Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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