An Attempt to Localize the Normal Esophagogastric Junction

Abstract

Clinical problems concerning the distal esophagus are largely anatomic (4). Regional anatomy of the esophagogastric junction is gradually proving to be far more complicated than once believed, and, now that surgical technics permit easy access to the segment, it becomes necessary to submit to critical review the comfortable classical understanding of local structures and relationships. A pressing problem is that of the exact position of the esophagogastric junction. It is of tremendous practical importance to know whether an abnormality observed in this region represents esophageal or gastric disease. In a provocative paper, Barrett (2) pointed out that many reported instances of esophageal ulcer may actually represent gastric ulcer, in stomachs which have been drawn up by unrecognized esophageal shortening. Similarly, it may be that a large proportion of distal “esophageal” adenocarcinomas arise on the gastric side of the esophagogastric junction. As Barrett so convincingly reasons, whatever external appearances seem to be, any portion of the gullet which is lined by gastric mucosa must be considered stomach because it functions as stomach and because it is heir to the ailments which afflict that organ. Anatomically, the only clear-cut indication of the limits of the distal esophagus is the uneven line marking the abrupt termination of the squamous epithelium. Quantitative changes in the muscularis mucosae and the muscularis propria are not only less striking and far less precipitous, but are also, of course, impossible of clinical demonstration. Unfortunately, for the radiologist in particular, neither the abrupt increase in the digestive tube's diameter at the stomach nor the obliquity of the esophagogastric junctional angle can necessarily be accepted as indications of the actual beginning of the stomach. In autopsy specimens these often appear to be coincident with the zone marking the epithelial change, but the assumption that the same correlation obtains during life is obviously a dangerous one. The fine roentgen-relief studies of Jutras and colleagues (3) on continuity between esophageal and gastric folds suggest that intrinsic local dynamics may from time to time be responsible for significant shiftings of the esophagogastric junction. Method This study was executed in an effort to localize the esophagogastric epithelial junction roentgenographically. Esophagoscopy was carried out in test subjects who had no demonstrable abnormality of the region, and the epithelial junction was located. A silver brain clip was fastened to the line of junction under 4-diameter telescopic magnification by a technic previously described (5). Appropriate fluoroscopic and film studies were then made. Because the early results were unexpected, suggesting perhaps esophagoscopic misinterpretation of the location of the epithelial junction, in most cases a biopsy was taken of the line first, with immediate fixation of the clip to the biopsy site.