Diseases of the Esophagus

Checklist:

Diseases of the Esophagus

Does the patient choke or cough while eating or drinking?

Does food get stuck when the patients is eating?

Has a foreign body been swallowed?

Does the patient complain about a lump in the throat, regurgitation of undigested food, or bad breath?

Is swallowing painful for the patient?

Has the patient had heartburn for extended periods?

and his grandchildren have been complaining about grandpa's bad breath. He has brought one of them with him to help out with the test. Paul is just getting his first instructions on the art of fluoroscopy, the realtime x-ray examination of the intestinal tract. Dr. Llewellyn, a dyed-in-the-wool, old-school specialist in gastrointestinal imaging, watches him carefully while he sets out to do the examination. The clinical information given by Wiggle's general practitioner and the conversation with Mr. Wiggle as well as the young man who accompanies him have not provided any definite clues as to what is going on.

The Steak Won't Go Down Easy

Jack Wiggle (86) comes to the radiology department for an examination because he has problems swallowing. He chokes quite often and feels a lump in the throat, f If a functional swallowing disorder were suspected, dei dicated videofluoroscopy of the swallowing act would be the examination of choice. Videofluoroscopy documents the different phases of the highly complex swallowing act in multiple video frames (Fig. 9.9). If, for example, the disturbance is due to the nonrelaxation of

I Normal Swallowing

Functional Esophageal DisordersNormal Swallowing Process

Fig. 9.9 This is what normal swallowing looks like. a The contrast bolus is held and formed between the tongue and the soft palate. b The tongue and the soft palate elevate to present the bolus to the oropharynx. In the process the soft palate seals the communication to the nasopharynx to prevent regurgitation. c The bolus moves dorsally and downward while the epiglottis seals the laryngeal introitus. d The soft palate descends even further and the cricopharyngeus muscle relaxes, permitting the passage of the bolus. e As the bolus has passed the cricopharyngeus muscle, the tongue base and the soft palate rise again. f As the bolus reaches the thoracic esophagus, the tongue base moves forward, the epiglottis flips up, and the larynx returns to its resting position. (From Richard M. Gore, Marc S. Levine, Igor Laufer, eds. Textbook of Gastrointestinal Radiology. Philadelphia: WB Saunders, 1994.)

Fig. 9.9 This is what normal swallowing looks like. a The contrast bolus is held and formed between the tongue and the soft palate. b The tongue and the soft palate elevate to present the bolus to the oropharynx. In the process the soft palate seals the communication to the nasopharynx to prevent regurgitation. c The bolus moves dorsally and downward while the epiglottis seals the laryngeal introitus. d The soft palate descends even further and the cricopharyngeus muscle relaxes, permitting the passage of the bolus. e As the bolus has passed the cricopharyngeus muscle, the tongue base and the soft palate rise again. f As the bolus reaches the thoracic esophagus, the tongue base moves forward, the epiglottis flips up, and the larynx returns to its resting position. (From Richard M. Gore, Marc S. Levine, Igor Laufer, eds. Textbook of Gastrointestinal Radiology. Philadelphia: WB Saunders, 1994.)

I The Case of Jack Wiggle the cricopharyngeal muscle, an injection of botulinum toxin may be considered. Specific other findings, such as weak stripping motion of the tongue, weakness of the soft palate, or food getting stuck in the valleculae or piriform sinus, can aid the speech pathologist in figuring out a new swallowing technique for the patient affected by these abnormalities.

Paul studies a frontal radiograph of the chest and upper abdomen that was obtained prior to the examination on Mr. Wiggle, which demonstrates no obvious abnormality To get oriented a bit, he has Mr. Wiggle take a little sip of a barium suspension and watches the barium pass through his esophagus under fluoroscopy. Subsequently he asks the patient to drink some more and obtains radiographs of the whole esophagus in two projections, both fully distended with the barium column and in double contrast technique to assess the mucosal lining of the esophagus. When he sees a narrow segment of esophagus, he hesitates and obtains some enlarged collimated views of this suspicious segment (Fig. 9.10).

• What is your diagnosis?

Esophageal diverticula: These are circumscribed mucosal and submucosal outpouchings of the esophagus with little or absent muscular coverage. They are divided into traction and pulsion diverticula. Pulsion diverticula tend to

Abnormal Barium Swallow Images
Fig. 9.10 Here you see the diagnostic film of the barium swallow of Jack Wiggle. Is there anything abnormal?

I Diverticulum

I Diverticulum

Pyriform Sinus Diverticula

Fig. 9.11 a This lateral view of the swallowing act shows the appearance after passage of the barium bolus into the esophagus. The soft palate is pressed against the dorsal pharyngeal wall (black arrow), thus preventing the regurgitation of food into the nasal cavity. The tongue base (large white arrow) has moved upward and backward; the epiglottis (small white arrows) seals off the laryngeal entrance. The bolus has entered the proximal esophagus. There is a diverticulum in the area of the epiglottic

Fig. 9.11 a This lateral view of the swallowing act shows the appearance after passage of the barium bolus into the esophagus. The soft palate is pressed against the dorsal pharyngeal wall (black arrow), thus preventing the regurgitation of food into the nasal cavity. The tongue base (large white arrow) has moved upward and backward; the epiglottis (small white arrows) seals off the laryngeal entrance. The bolus has entered the proximal esophagus. There is a diverticulum in the area of the epiglottic fold (star). It extends laterally from the tongue base. b In a Zenker diverticulum the depiction of the width of the diverticular neck (large arrow) is of particular importance to the surgeon. The esophagus and the trachea (small arrows) are displaced ventrally. c Another typical location of a pulsion diverticulum is the distal esophagus. d Traction diverticula tend to occur at the level of the pulmonary hila and are usually the consequence of inflammatory lymphadenitis in the mediastinum.

I Achalasia

I Achalasia

Cricopharyngeal Achalasia

Fig. 9.12 a The distended esophagus filled with remnants of food and air in this patient with achalasia is prominent up to the upper mediastinum. b The lateral projection of the chest displays the food impaction in the esophagus and the anteriorly displaced trachea with even greater clarity. c After the administration of oral contrast medium, the grossly dilated proximal esophagus and the narrowed ganglion depleted segment are outlined. This finding is also called the "bird's beak." d A little imagination helps, of course.

Birds Beak Esophagus

Fig. 9.12 a The distended esophagus filled with remnants of food and air in this patient with achalasia is prominent up to the upper mediastinum. b The lateral projection of the chest displays the food impaction in the esophagus and the anteriorly displaced trachea with even greater clarity. c After the administration of oral contrast medium, the grossly dilated proximal esophagus and the narrowed ganglion depleted segment are outlined. This finding is also called the "bird's beak." d A little imagination helps, of course.

be cervical (Fig. 9.11a) and epiphrenic (Fig. 9.11c) and usually occur proximal to a relative point of obstruction such as the upper or lower esophageal sphincter or when a weak spot in the muscular wall of the esophagus gives way to the pressure. Traction diverticula due to pulling inflammatory processes (often in the mediastinum) occur almost exclusively at the level of the tracheal bifurcation (Fig. 9.11d).

The Zenker diverticulum is a pulsion diverticulum always located left of the pharyngoesophageal transition zone

(Fig. 9.11b). It may become extremely large and it can retain undigested food and can compress the esophagus. The food remnants give rise to the frequent symptom of halitosis (synonym for bad breath).

f Esophageal diverticula can be overlooked during endo-i scopy, especially if they have a narrow neck, while wide-necked diverticula may be mistaken for the esophageal lumen and be perforated when the endoscopist tries to advance the scope during the procedure.

Disturbances of the esophageal peristalsis:

Achalasia: In this neurogenic disorder those ganglion cells of the muscle layers of the distal esophagus that normally inhibit the contraction of the lower esophageal sphincter are decreased. It is rare in children and can occur throughout adult life. The disorder is characterized by a combination of absent peristalsis and a hypertensive lower esophageal sphincter, resulting in a functional obstruction at or close to the esophagogastric junction. Over time this can lead to a dilated esophagus, often filled with secretions and undigested food. The chronic irritation of the mucous membranes induces a chronic inflammation of the esophagus and is associated with a 10-fold higher risk of developing esophageal carcinoma. The diagnosis of acha-lasia may be suggested on a simple chest radiograph (Fig. 9.12a, b). The final confirmation is achieved by performing a barium swallow (Fig. 9.12c, d). Diffuse esophageal spasm (DES): DES is due to a local neuro-degenerative process and it shows a completely different appearance: so-called "tertiary" (uncoordinated) contractions occur that may give the esophagus a "corkscrew" configuration; this kind of uncoordinated peristalsis is more frequent in the elderly (Fig. 9.13). Scleroderma: Peristalsis of the esophagus is weakened or completely absent in scleroderma (Fig. 9.14). Delayed radiographs after a barium swallow may show residual contrast in the esophagus.

| Diffuse Esophageal Spasm (DES)_

Des Barium Swallow

Fig. 9.13 In elderly patients the peristalsis of the esophagus may become disorganized, losing its propulsive force. After barium has been given, the esophagus may look like a corkscrew in DES. This entity is not associated with alcohol abuse, however.

I Scleroderma

Elderly Esophageal
Fig. 9.14 In extreme cases of scleroderma the rigid and dilated esophagus (thick arrows) may appear as a second air column behind the trachea (thin arrows)—the "double-barrel sign."

f Peristaltic disturbances are best diagnosed by a barium i swallow examination.

Esophageal tumors: If the appearance on barium swallow suggests the possibility of an esophageal tumor, it must be considered to be malignant until proven otherwise. If the lesion is located in the very proximal esophagus, it is most likely a squamous cell carcinoma of the hypopharynx (Fig. 9.15) or of the esophagus (Fig. 9.16a); further distal the frequency of adenocarcinomas increases (Fig. 9.16b). These are particularly frequent if precursor diseases of the esophagogastric transition zone such as reflux eso-phagitis (Fig. 9.17a) or a Barrett esophagus (Fig. 9.17b) have been present.

Esophageal varices: Venous varices of the esophageal wall may develop as a consequence of portal hypertension due to liver cirrhosis (Fig. 9.18) or portal vein occlusion. The veins around the esophagus have connections to the portal system in the upper abdomen around the esophagogastric junction and drain into the azygos and hemiazygos venous systems in the posterior mediastinum, which are part of the systemic circulation. This pathway may be used by the body to decompress the portal venous system in the aforementioned conditions. Severe acute hemorrhage is the greatest risk associated with this condition.

I Hypopharyngeal Carcinoma

I Esophageal Carcinoma

I Hypopharyngeal Carcinoma

Hypopharyngeal Carcinoma Barium Swallow

I Esophageal Carcinoma

Rare Esophageal Tumor

Fig. 9.16a This esophageal carcinoma presents as an abnormal appearance of the esophageal wall contour (arrows), frequently with ulcerations. Submucosal lesions are also detectable in a barium swallow because they change the peristalsis of the esophageal wall; that is a real advantage in comparison to fiberoptic endoscopy. b A carcinoma of the distal esophagus like this one tends to involve the gastric cardia as well. Note the irregular proximal contour (arrow) and the distal margin of the stenosis.

Fig. 9.15 This polypoid growing hypopharyngeal carcinoma (arrows) is located in the left piriform recess, directly proximal to the entrance into the esophagus and directly distal to the epiglottis, which is nicely outlined by contrast medium. (Where was your anatomy book again?)

Fig. 9.15 This polypoid growing hypopharyngeal carcinoma (arrows) is located in the left piriform recess, directly proximal to the entrance into the esophagus and directly distal to the epiglottis, which is nicely outlined by contrast medium. (Where was your anatomy book again?)

Fig. 9.16a This esophageal carcinoma presents as an abnormal appearance of the esophageal wall contour (arrows), frequently with ulcerations. Submucosal lesions are also detectable in a barium swallow because they change the peristalsis of the esophageal wall; that is a real advantage in comparison to fiberoptic endoscopy. b A carcinoma of the distal esophagus like this one tends to involve the gastric cardia as well. Note the irregular proximal contour (arrow) and the distal margin of the stenosis.

I Esophageal Carcinoma: Precursor Diseases

I Esophageal Carcinoma: Precursor Diseases

Esophageal Varices Abnormalities Xray

I Esophageal Varices

I Esophagitis in Crohn Disease

I Esophageal Varices

I Esophagitis in Crohn Disease

Esophageal Perforation

Fig. 9.19 Small contrast tracks and depots are visible in the wall of the esophagus. These correspond to ulcerations and fistula formations such as are also found in the bowel wall in Crohn disease.

Fig. 9.18 The wormlike contrast defects in the esophageal lumen in this barium swallow are due to dilated veins in the wall. This patient suffered from severe portal hypertension with recurrent variceal bleeds.

Fig. 9.18 The wormlike contrast defects in the esophageal lumen in this barium swallow are due to dilated veins in the wall. This patient suffered from severe portal hypertension with recurrent variceal bleeds.

Fig. 9.19 Small contrast tracks and depots are visible in the wall of the esophagus. These correspond to ulcerations and fistula formations such as are also found in the bowel wall in Crohn disease.

Esophagitis: Inflammatory changes of the esophageal mucosa may be due to gastroesophageal reflux, caustic injury, candidiasis, or viral infection in immunocompromised patients. Sometimes Crohn disease can affect the esophagus in the child and adolescent (Fig. 9.19).

Foreign body: This is of particular importance in psychiatric patients (Fig. 9.20b). Potential foreign bodies in the esophagus include dental fixtures, toothbrushes, coins, etc. If a fine and delicate structure like a fishbone is suspected, the patient should be asked to swallow cotton pads soaked in iodinated water-soluble contrast medium that will get stuck to the fishbone. However, the examination should be performed only if endoscopy is either not available or ambiguous.

I Foreign Body in the Esophagus

Xray Retained Foreign Body Cotton Wool

Fig. 9.20 a While baking that delicious plum cake with its mother, this child suddenly developed swallowing problems. The contrast medium marks the margins and the surface structure of the plum pit impacted in the proximal esophagus. b This patient from a psychiatric institution was sent for the examination because the danger of self inflicted injury was known and the toothbrush—here nicely outlined in the stomach—was missing.

Fig. 9.20 a While baking that delicious plum cake with its mother, this child suddenly developed swallowing problems. The contrast medium marks the margins and the surface structure of the plum pit impacted in the proximal esophagus. b This patient from a psychiatric institution was sent for the examination because the danger of self inflicted injury was known and the toothbrush—here nicely outlined in the stomach—was missing.

I Compression of the Esophagus a Arteria lusoria b Osteochondrosis of the cervical spine

Fig. 9.21 a When the right subclavian artery runs posterior to the esophagus toward the right it may impinge on the esophageal lumen, which is termed arteria lusoria. On this anteroposterior view it is characterized by a smooth oblique defect of the luminal contrast filling just above the aortic knob (arrows). b Degenerative disk disease of the cervical spine with formation of anterior osteophytes may encroach on the esophagus and cause swallowing problems.

a Arteria lusoria b Osteochondrosis of the cervical spine

Arteria Lusoria Oesophagus

If there is a risk of esophageal perforation, only water-soluble iodinated contrast medium should be used initially. Barium formulations are contraindicated if a perforation is present. If there is none, one may switch to barium for a much more accurate diagnosis. The postoperative patient should always receive thin barium suspension because of the better diagnostic yield and the high chance of aspiration.

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