Examination of the oesophagus

13.3. Examination of the oesophagus

13.3.1. Indications of upper GI swallow studies:

 difficulty with swallowing / dysphagia

 painful swallowing / odynophagia

 heartburn / pyrosis

 chest pain

 esophageal foreign body

 esophageal varices

 following endoscopy to exclude perforation Preparation:

The patient needs to be with empty stomach.

13.3.2. Method

The selection whether to use water-soluble iodine based or barium based contrast media depends on the clinically indicated diagnosis.

155 The patient is asked to stand into the fluoroscopy equipment in an anterior oblique position;

this is to make the esophagus project outside the spinal shadow. For a proper study the patient must be examined in both upright and recumbent positions, as sometimes perforations can only be detected from one direction. In order to identify potential alterations in the pharyngeal recesses the pharyngo-esophageal segment should also be examined in the frontal view.

Fig.1.: Normal anatomy of the esophagus

In the double-contrast esophagram the negative contrast is generated by indigestion of CO2 producing crystals. Orientation of the mucosal folds is longitudinal. The luminal diameter is 2-3 cm.

13.3.3. Diseases of the esophagus Achalasia

Clinical presentation: difficulty with swallowing. In severe cases inability to swallow. Upon cold water indigestion the gastric cardia suddenly opens up. Based on this diagnostic test achalasia could be differentiated from esophageal neoplasms. The disease follows a protracted course, symptoms may persist for decades. Clinical symptoms are more reliable in the

assessment of disease status. Weight gain signals improvement.

Fig.2.: Achalasia

Radiographic findings: marked dilatation of the esophageal lumen. Luminal diameter can be seriously widened. In advanced cases the tortuous gullet constitutes the mediastinal interface.

The cardia shows conical narrowing. The esophageal lumen is filled with undigested food.

Opening of the cardia is delayed, emptying is intermittent. The stomach is shrunken. The result is a so called microgaster as the esophagus takes over the stomach’s reservoir function.

Pseudo-diverticulosis, also Bársony-Tessendorf syndrome:

Clinical presentation: difficulty with swallowing, dysphagia. Swallowing may be painful. It presumably has a psychosomatic origin as symptoms worsen during periods of mental stress.

156

Fig.3.: Pseudo-diverticulosis

Radiographic findings: rosary-bead like outpouchings of the esophagus. Static peristaltic waves are seen. These are ineffective in passing forward the esophageal contents.

Esophageal stenosis:

Frequently, it is a complication of esophageal inflammation, which causes narrowing of the esophageal lumen. The degree of narrowing can be so severe that the lumen almost

completely obliterated by scarring. It may also occur due to corrosive effect of acid or alkali indigestion as well as in reflux disease, or precipitated by long term duodenal tube placement.

Irritation of the esophageal mucosa causes inflammation. Alkali indigestion usually results in more severe injury as it causes colliquative necrosis in the deep wall layers, while after acid indigestion the mucosal surface is covered with a fibrotic crust which prevents deeper penetration of the corrosive agent. In addition to the stricture inflammatory diseases are also complicated by esophageal shortening, thus part of the fornix is pulled up into the

mediastinum. Frequently, in patients with reflux esophagitis the stricture only involves the cardia sparing the esophagus; still a shortened esophagus could be detected.

Fig.4.: Esophageal stenosis

Radiographic findings: A long segment, sharp contoured esophageal stricture is detected. Due to stiffness of the fibrotic wall no peristaltic activity can be seen. Differentiation from tumors can be difficult, thus patient history is important. Tumors cause slowly progressing dysphagia, but generally involve shorter segments.

Esophageal diverticula

Esophageal diverticula are classified according to their pathogenesis and anatomic location.

157 Anatomic site:

 pharyngo-esophageal junction

 epibronchial

 epiphrenic

 epicardial

Based on pathomechanism:

 traction diverticula

 pulsion diverticula

Pulsion diverticula are caused by high esophageal pressure due to the increased tone of the lower esophageal sphincter.

Traction diverticula are the result of inflammatory processes adjacent to the esophagus. The inflammation leads to fibrosis and adhesions, and the contracting scar tissue exerts a pulling force on the esophageal wall.

Generally, traction diverticula have a wide opening, and stay asymptomatic. Retained food particles can easily enter and exit the diverticulum. They are often discovered accidentally. As their size increases pulsion diverticula can lead to dysphagia.

Clinical presentation: Presentation depends on the anatomic location. Diverticula located at the pharyngo-esophageal junction, are also called Zenker’s diverticula. In addition to causing dysphagia they can block swallowing completely. The patients complain of food regurgitation when they lean forward. However, they deny feeling sick when they are asked directly.

Regurgitation without nausea is a characteristic symptom of Zenker’s diverticulum. All patients have to be asked about this sign, as it could divert the usual gastric disease centered work up towards an upper GI series which can promptly localize the Zenker’s diverticulum.

Fig.5.: Epiphrenic diveticulum

Radiographic findings: Pulsion type epiphrenic diverticula manifest as rounded contrast retaining objects, with sharp contours. Pulsion diverticula characteristically have a narrow orifice.

Malignant processes in the esophagus are mostly esophageal carcinomas.

Clinical presentation: Carcinomas have a slow and insidious onset. Patients can stay symptom free for months, thus the lesion is rarely detected in an early phase. Most patients fail to contact their physician even after developing the first symptoms. The disease primarily affects alcoholic men who smoke and who are often in a deteriorated physical condition. The earliest

158

symptom is dysphagia, which gets worse by time. Frequently, the diagnosis is delayed till the patient can consume only liquids. By this time the disease is usually in an advanced stage and curative surgical resection is not possible.

Fig.6.: Esophageal tumor.

Radiographic findings: Relatively short segment esophageal stenosis with markedly irregular contours. The esophageal wall is stiffened at the tumor site.

Fig.7.: The CT scan shows prominent wall thickening in the narrowed esophageal segment.