Gastro-Intestinal Tract

Esophagus

Mohamed Zaitoun

Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals

EgyptFINR (Fellowship of Interventional

Neuroradiology)-Switzerlandzaitoun82@gmail.com

Knowing as much as possible about your enemy precedes successful battle

and learning about the disease process precedes successful management

-Oblique view of a normal barium swallow shows the normal impressions made by the (A) aortic arch , (B) left mainstem bronchus and (LA) left atrium on the esophagus

Esophagusa) Diverticulumb) Esophageal Ulcerationc) Esophageal Tumorsd) Smooth Esophageal Stricturese) Irregular Esophageal Stricturesf) Motility Disordersg) Hiatus Herniah) Esophageal Atresia & Tracheo-Esophageal

Fistula

a) Pharyngeal / Esophageal Pouches & Diverticula :

-Upper Third-Middle Third-Lower Third

-Upper Third :1-Zenker’s Diverticulum2-Lateral Pharyngeal Pouch & Diverticulum3-Lateral Cervical Esophageal Pouch &

Diverticulum

1-Zenker’s Diverticulum :a) Siteb) Radiographic Features

a) Site :-Pulsion diverticulum originates in the midline of

the posterior wall of the hypopharynx at an anatomic weak point known as Killian's dehiscence (above cricopharyngeus at fiber divergence with inferior pharyngeal constrictor) , during swallowing increased intraluminal pressure forces mucosa to herniate through the wall

b) Radiographic Features :1-Plain Radiography :-Lateral view , air fluid level

An air-fluid level is visible in the upper mediastinum (arrows) , the lateral view shows anterior displacement of the trachea (arrows) by a retrotracheal mass

Air fluid level in the superior mediastinum

2-Barium Swallow :-An (intermittent) outpouching arising from

the midline of the posterior wall of the distal pharynx near the pharyngoesophageal junction

-The pouch is best identified during swallowing and is best seen on the lateral view on which the diverticulum is typically noted at the C5-6 level

2-Lateral Pharyngeal Pouch & Diverticulum :-Through the unsupported thyrohyoid membrane in

the anterolateral wall of the upper hypopharynx-Pouches are common and patients are usually

asymptomatic-Diverticula are uncommon and are seen in

patients with chronically elevated intrapharyngeal pressure (e.g. glass blowers)

3-Lateral Cervical Esophageal Pouch & Diverticulum : (Killian-Jamieson)

-Through the Killian-Jamieson space-Pouches are transient-Diverticula are persistent-Patients are usually asymptomatic -The opening is below the level of

cricopharyngeus

AP view of barium swallow showing a small killian-Jamieson diverticulum (arrow)

Left : Frontal view from a barium swallow shows an outpouching of barium (white arrow) arising laterally from the cervical esophagus

Right : The diverticulum (yellow arrow) is anterior to the normal esophagus

-Middle Third : (TID)1-Traction2-Developmental3-Intramural

1-Traction :-At level of carina-May be related to fibrosis after treatment for

TB-Asymptomatic

2-Developmental :-Failure to complete closure of tracheo-

esophageal communication

3-Intramural (Oesophageal Intramural Pseudodivertoculosis “OIPD”) :

-Rare-Multiple , tiny flask-shaped outpouchings-90% have associated strictures-Mainly in the upper third of the esophagus

-Lower Third :1-Epiphrenic2-Ulcer3-Mucosal Tears4-After Heller's operation

1-Epiphrenic :-Occur less frequently than ZD , comprising

less than 10% of all oesophageal diverticula

Barium swallow shows large epiphrenic diverticulum (arrow)

2-Ulcer :-Peptic or related to steroids / immunosuppression

and radiotherapy

3-Mucosal Tears :-Mallory-Weiss syndrome , postesophagoscopy

4-After Heller's operation

b) Esophageal Ulceration :-Inflammatory-Neoplastic

-Inflammatory :1-Reflux Esophagitis2-Barrett’s Esophagus3-Candida Esophagitis4-Viral5-Caustic Ingestion6-Radiotherapy7-Crohn’s Disease8-Drug Induced9-Behcet’s Disease10-Intramural Diverticulosis

1-Reflux Esophagitis :-With or without hiatus hernia-Signs characteristic of reflux esophagitis :a) A gastric fundal fold crossing the gastro-

esophageal junction b) Erosions , clots or linear streaks of barium

in the distal esophagusc) Ulcers , round or more commonly linear or

serpiginous

Reflux

Air-contrast esophagram shows thick esophageal mucosal folds (arrows) and an ulcer (arrowhead) due to GERD , single contrast esophagram shows stricture (arrow) and sliding hiatus hernia

On the left Irregular stricture (arrowhead) and erosions (arrows) due to GERD

2-Barrett’s Esophagus :-Esophagus is abnormally lined with columnar

acid-secreting gastric mucosa-It is usually due to chronic reflux esophagitis-The diagnosis is strongly suggested by :a) Mid or high esophageal ulcerb) Mid or high esophageal web-like stricturec) Reticular mucosal patternd) Hiatus hernia in 75-90% of patients

Barrett's , Upper GI swallow of patient with Barrett's esophagus , arrow points to new transition point of squamo-columnar junction. , note the irregularities of the mucosa inferior to transition point

Double-contrast esophagography shows a smooth stricture in the midesophagus , multiple ulcerations in the region of the stricture are seen , note the reticular mucosal appearance extending down from the inferior aspect of the stricture

Reticular mucosa and web like stricture (arrow)

3-Candida Esophagitis :-In immunocompromised patients-Discrete plaque-like lesions-Larger plaques may coalesce to produce

"cobblestone" appearance-Ulcers invariably appear only on a background of

diffuse plaque formation , not as isolated findings

-Further coalescence produces (shaggy) contour

Shaggy esophagus associated with Candida infection , image "A" depicts the longitudinally oriented plaque-like lesions visible in Candida esophagitis , image "B" depicts the granular appearance of the esophageal mucosa secondary to edema and inflammation

A double contrast esophagogram demonstrates difuse ulceration , thickened folds and mildly “shagy” borders in the distal esophagus

The esophagus is dilated and has “shagy” borders and difuse ulceration , an area of narowing is present in the proximal third of the esophagus

Double-contrast esophagram shows markedly nodular mucosa with multiple discrete ulcers covering all of esophagus

Numerous fine erosions and small plaques due to Candida albicans in immunocompromised patient

4-Viral :-Herpes and CMV occurring mostly in

immunocompromised patients-May manifest as discrete ulcers , ulcerated

plaques or mimic Candida esophagitis-Discrete ulcers on an otherwise normal

background mucosa are strongly suggestive of a viral etiology

-Herpes Simplex , small ulcers < 5 mm-CMV , large ulcers

Herpes , double-contrast esophagram shows small discrete ulcers (arrows) in the midesophagus on a normal background mucosa , note the radiolucent mounds of edema surrounding the ulcers , in the appropriate clinical setting , this appearance is highly suggestive of herpes esophagitis since ulceration in candidiasis almost always occurs on a background of diffuse plaque formation

Cytomegalovirus esophagitis in a patient with AIDS

Double-contrast esophagram shows a large flat ulcer in profile (large arrows) in the midesophagus with a cluster of small satellite ulcers (small arrows)

AIDS patient with an infectious esophagitis due to Cytomegalovirus. , such giant ulcers can also be due to HIV alone

5-Caustic Ingestion :a) Acute stage :-In the first 10 days from ingestion , acute necrosis

with mucosal blurring and dilated atonic esophagusb) Subacute stage :-10 to 20 days after ingestion and characterized by

esophageal ulcerationc) Chronic stage :-Occurs after 21 days at which esophageal

inflammation healed by fibrosis resulted in stricture

Image "A" and "B" both depict ulcerations of the distal esophageal mucosa secondary to lye ingestion , image "C" depicts irregular narrowing of the esophagus with ulcerations

6-Radiotherapy :-Double contrast studies can demonstrate

superficial esophageal ulceration as shallow irregular collections of barium within 7 to 10 days of radiotherapy

-In severe cases , the esophagus may have an irregular serrated contour due to ulceration and sloughing

-After this acute phase , the most frequent finding on contrast studies is abnormal esophageal motility

7-Crohn’s Disease :- Aphthous ulcers

Aphthous ulcers (arrows) , this is an uncommon manifestation of Crohn's disease , the figure on the right shows the more common colonic aphthous ulcers

8-Drug Induced :-Due to prolonged contact with tetracycline ,

quinidine and potassium supplements

9-Behcet’s Disease

10-Intramural Diverticulosis

-Neoplastic :1-Carcinoma2-Leiomyosarcoma and leiomyoma3-Lymphoma4-Melanoma

c) Esophageal Tumors :-Benign Tumors :1-Leiomyoma , 50%2-Fibrovascular polyp , 25%3-Cysts , 10%4-Papilloma , 3%5-Fibroma , 3%6-Hemangioma , 2%

-Leiomyoma :a) Incidenceb) Radiographic Features

a) Incidence :-Most common benign tumor of the

esophagus-It is most frequently presents in young and

middle age groups 

b) Radiographic Features :1-Barium Swallow2-CT

1-Barium Swallow :-May be seen as a discrete ovoid mass that

is well outlined by barium-Its borders form slightly obtuse angles with

the oesophageal wall

On the left an asymptomatic patient with a leiomyoma , on the chest film an abnormal opacity is seen behind the heart (arrow) , the barium study demonstrates a lobulated mass (arrow) that does not obstruct despite its large size

A calcified esophageal mass is almost always a leiomyoma , on the left a patient with a calcified esophageal lesion (arrows) protrudes into azygoesophageal recess on radiograph , lesion (arrow) on CT and surgical specimen radiograph showing calcification

The ovoid filling defects caused by the leiomyoma , the smooth surface and obtuse angles formed are characteristic of submucosal masses

2-CT :-Ovoid intramural solitary mass with a smooth

surface-The presence of calcification is almost

pathognomonic -Narrowing of esophageal lumen-May displace the esophagus-Moderate diffuse contrast enhancement-No signs of invasion of adjacent tissue

-Malignant :1-Squamous cell carcinoma , 75%2-Adenocarcinoma , 25% , usually in distal

esophagus at GEJ3-Lymphoma4-Leiomyosarcoma5-Metastasis

1-Squamous Cell Carcinoma :a) Incidenceb) Patternsc) Radiographic Features

a) Incidence :-Squamous cell carcinomas are associated with :1-Head and neck cancers2-Smoking3-Alcohol4-Achalasia5-Lye ingestion

b) Patterns :1-Infiltrative2-Polypoid3-Annular stenotic4-Ulcerative5-Varicoid

Infiltrative ulcerated carcinoma , esophageal carcinoma with ulcerations (arrows) and sharp right angle junction with esophageal wall (arrowheads)

Left : Small polypoid carcinoma , right : Large polypoid lesion

Left : long irregular distal stricture due to carcinoma , right : distal narrowing is not tapered and more proximal than achalasia , irregularity (arrow) at narrowed site is subtle but persistent

Varicoid carcinoma , unchanging appearance of filling defects indicate tumor rather than varices , note sharp upper margin of lesion and ulceration (arrows)

(a) AP orthostatic projection shows several filling defects in the middle and distal segments of the esophagus , (b) Left posterior oblique projection shows sharply marginated longitudinal and serpentine lesions that mimic varices and that did not change in size or configuration with respiratory maneuvers or repositioning of the patient ,esophageal peristalsis was normal

c) Radiographic Features :1-Plain Radiography2-Barium Swallow3-CT

1-Plain Radiography :Many indirect signs can be sought on a chest

radiograph and these include :-Widened azygo-oesophageal recess with convexity

toward right lung (in 30% of distal and mid-oesophageal cancers)

-Thickening of posterior tracheal stripe and right paratracheal stripe >4 mm (if tumor located in upper third of esophagus)

-Widened mediastinum-Tracheal deviation

-Posterior tracheal indentation / mass-Retrocardiac mass-Esophageal air-fluid level-Lobulated mass extending into gastric air

bubble-Repeated aspiration pneumonia (with

tracheo-oesophageal fistula)

-The azygo-esophageal recess (AER) is a prevertebral space formed by the interface of the posteromedial right lower lobe of the lung and the azygos vein and esophagus

Normal Widened

-The right paratracheal stripe is a normal finding on the frontal CXR and represents the right tracheal wall , adjacent pleural surfaces and any mediastinal fat between them , it is visible because of the silhouette sign created by air within the trachea medially and air within the lung laterally ,  It normally measures less than 4 mm 

2-Barium Swallow :-Esophageal cancer may appear as an infiltrating , polypoid ,

ulcerative or varicoid lesion-Infiltrating cancers show irregular narrowing of the lumen

with an associated nodular or ulcerated mucosa with well-defined borders

-Polypoid lesions are usually greater than 3.5 cm in diameter and appear as lobulated or fungating intraluminal masses with possible areas of ulceration

-Ulcerative carcinomas appear as well-defined ulcers with a radiolucent rim of tumor surrounding the ulcer

-Varicoid carcinomas mimic esophageal varices and therefore appear as thickened tortuous or serpiginous filling defects because of the submucosal spread of the cancer

Squamous cell carcinoma , A-Polypoid lesion , B-Multiple polypoid tumors , C-Long ulcerative tumor , D-Stenotic, infiltrative tumor

Irregular stricture in the esophagus with ulceration of the esophageal mucosa , also noticed the shouldered margins of the lesions

Carcinoma esophagus , a barium swallow showing irregular narrowing with "shouldered edges" suggestive of a malignant stricture

3-CT :-Eccentric or circumferential wall thickening > 5mm-Peri-esophageal soft tissue and fat stranding-Dilated fluid and debris-filled oesophageal lumen

is proximal to an obstructing lesion-Tracheobronchial invasion appears as

displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the oesophageal tumor

-Aortic invasion

2-Adenocarcinoma :a) Incidenceb) Patternsc) Radiographic Findings

a) Incidence :-Associated with Barrett's esophagus-Less common than SCC-Usually in distal esophagus at GEJ

b) Patterns :-As before

c) Radiographic Features :-As before

Image "A" the red arrows show mucosal invasion with ulceration whereas the yellow arrow points out a stricture at the GE junction , in image "B“ , an irregular filling defect in the distal esophagus associated with adenocarcinoma

Barrett's esophagus with ulcerated (arrow) adenocarcinoma

3-Lymphoma :-Because the esophagus and stomach do

not normally have lymphocytes , primary lymphoma is rare unless present from inflammation

-Secondary metastatic lymphoma is more common

-Radiographic Features : as before

(A) A barium swallow revealed a well-demarcated submucosal mass (arrowheads) of 10×3×3 cm in size in the upper thoracic esophagus without surface ulceration or a stalk , (B) CT showed a sharply demarcated homogeneous mass within the esophagus , note the eccentric location , crescent-shape esophageal lumen (compressed by the mass) and the laterally displaced trachea

4-Leiomyosarcoma :-Polypoidal regular outline filling defect

Barium Swallow showing a smooth filling defect in mid-esophagus

Large lesion distorts esophageal lumen , CT shows lesion distorting but not obstructing esophageal lumen (arrow)

5-Metastasis :-Direct (Thyroid , Lung & Stomach)-Nodal (Lung , breast)-Blood borne (Melanoma)

-Left : normal esophagus , Right : Mediastinal nodes (arrows) displace esophagus to right

-The esophagus (arrow) protrudes under aortic arch into right side of AP window , next to it mediastinal nodes (arrows) that displace the esophagus to right in a patient with bronchogenic carcinoma

d) Smooth Esophageal Strictures :1-Inflammatory2-Neoplastic3-Iatrogenic4-Achalasia

1-Inflammatory :a) Pepticb) Sclerodermac) Corrosives

a) Peptic :-The stricture develops relatively late-Most frequently at the GEJ and associated

with reflux and a hiatus hernia-Less commonly , more proximal in the

esophagus and associated with heterotopic gastric mucosa (Barrett's esophagus) ± Ulceration

b) Scleroderma :1-Incidence2-Associations3-Radiographic Features

1-Incidence :-The esophagus is affected in 80% of

scleroderma cases , symptoms include heartburn and dysphagia

2-Associations : CREST-C : Calcinosis-R : Reynaud's phenomenon-E : Esophageal dysmotility-S : Sclerodactyly-T: Telangiectasia

3-Radiographic Features :-Dilatation of distal 2/3 of the esophagus-Aperistalsis-Free reflux >> stricture

Barium swallow of patient with scleroderma , note the dilated esophagus (arrows)

c) Corrosives :-See before

2-Neoplastic :a) Leiomyomab) Carcinomac) Mediastinal Tumors (carcinoma of the

bronchus and lymph nodes)

3-Iatrogenic :-Prolonged use of a nasogastric tube-Stricture in distal esophagus probably

secondary to reflux

4-Achalasia :-See later

e) Irregular Esophageal Strictures :1-Inflammatory2-Neoplastic3-Iatrogenic

1-Inflammatory :a) Reflux :-Rarely irregular

b) Crohn’s Disease :-Rare

2-Neoplastic :a) Carcinomab) Leiomyosarcomac) Lymphoma

3-Iatrogenic :a) Radiotherapy , rareb) Fundoplication

f) Motility Disorders :1-Tertiary Contractions2-Diffuse Esophageal Spasms (DES)3-Achalasia 4-Chalasia5-Scleroderma6-Chaga’s Disease

1-Tertiary Contractions :-Normally , there is a wave of relaxation

precedes a contractile wave propelling the bolus along the esophagus

-Tertiary contractions , uncoordinated non-propulsive contractions , asymptomatic

-Seen in : elderly , alcoholics , GERD & HH

-Causes of tertiary contractions in the esophagus :1-Reflux esophagitis2-Presbyoesophagus (impaired motor function due to

muscle atrophy in the elderly , occurs in 25% of people > 60 years)

3-Obstruction at the cardia4-Neuropathy :-Early achalasia (before dilatation occurs)-DM-Alcoholism-Malignant infiltration-Chaga’s disease

2-Diffuse Esophageal Spasms (DES) , Cork-Screw , Nutcracker :

-Symptoms include chest pain , dysphagia and gastro-oesophageal regurgitation disease

-Barium swallow shows diffuse oesophageal spasm with simultaneous and uncoordinated contractions

3-Achalasia :a) Etiologyb) Radiographic Features

a) Etiology :-Failure of relaxation of GOJ when the

contractile wave arrives , the esophagus retains much of its contents then dilates progressively

b) Radiographic Features :1-Plain Radiography2-Barium Swallow

1-Plain Radiography :-Dilated esophagus with air-fluid level , characteristic

linear shadow extends along the right side of mediastinum

-Mottled appearance in superior mediastinum (due to mixture of air & retained fluid in the dilated esophagus)

-Superior mediastinum air-fluid level-Small / absent of gastric air bubbles-Anterior displacement and bowing of trachea on the

lateral view-Pneumonia & basal fibrosis

2-Barium Swallow :-Two diagnostic criteria must be met :*Primary and secondary peristalsis absent

throughout esophagus*LES fails to relax in response to swallowing-Tertiary waves-Beaked tapering at GEJ

4-Chalasia :-GOJ is lax and widely patent

5-Scleroderma :-See before

6-Chaga’s Disease :-Megaesophagus , aperistalsis & bird's beak

appearance at GEJ (achalasia look-alike)

g) Hiatus Hernia :1-Definition2-Types

1-Definition :-Occurs where there is herniation

of stomach through the oesophageal hiatus of the diaphragm

2-Types :a) Sliding Herniab) Paraesophageal (Rolling) Herniac) Mixed Type

a) Sliding Hernia :-This is the most common type of hiatus

hernia (95%)-The gastro-esophageal junction (GOJ) is

usually displaced by more than 1cm above the hiatus

-The oesophageal hiatus is often abnormally widened to 3-4cm

b) Paraesophageal (Rolling) Hernia :-The rolling (paraesophageal) hiatus hernia

is much less common than the sliding type-The GOJ remains in its normal location

while a portion of the stomach herniates above the diaphragm

c) Mixed Type :-The mixed or compound hiatal hernia is the most

commonest type of paraesophageal hernia-The GOJ is displaced into the thorax with a large

portion of the stomach which is usually abnormally rotated , in these hernias where large portions of the stomach may be contained within the thoracic cavity , there are significant risks for volvulus , obstruction and ischemia

Sliding Rolling Mixed

1-Normal 2-Sliding 3-Rolling

Sliding Rolling

Sliding Hernia

Sliding Hernia

Sliding Hernia

Rolling Hernia

Rolling Hernia

h) Esophageal Atresia & Tracheo-Esophageal Fistula :

1-Definition2-Incidence3-Types4-Radiographic Features

1-Definition :-Esophageal Atresia :Absence in contiguity of the esophagus due to an

inappropriate division of the primitive foregut into the trachea and esophagus 

-TOF :Congenital pathological communication between

the trachea and esophagus

 

2-Incidence :-Tracheo-oesophageal fistula

and esophageal atresia have a combined incidence of approximately 1 in 3500 liver birth

3-Types :a) Proximal atresia with distal fistula : 85 %b) Isolated oesophageal atresia : 8-9 %c) Isolated fistula (H-type) : 4-6 %d) Double fistula with intervening atresia : 1-

2 %e) Proximal fistula with distal atresia : 1%

4-Radiographic Features :a) Antenatal U/Sb) Plain Radiographyc) Barium Swallow

a) Antenatal U/S :-Antenatal ultrasound may shows

polyhydramnios or even in some cases a distended proximal blind ending esophagus

b) Plain Radiography :-Demonstration of the nasogastric tube curled in

the proximal esophagus in a child where passage of the tube has been unsuccessful is usually sufficient for diagnosis

-The presence of air in the stomach and bowel in the setting of oesophageal atresia implies that there is a distal fistula

-Often the lungs demonstrate areas of consolidation / atelectasis due to recurrent aspiration

Esophageal Atresia with TOF

TOF with lung atelectasis

c) Barium Swallow :-H-type fistulas can be difficult to diagnose

and may require contrast studies , looking for contrast passing into the tracheo-bronchial tree

H-Type