New Era Radiology of the Esophagus

Isaac Sanders, MD, Los Angeles, California

In the past the major concern of many radiologic studies was to detect an “abnormal shadow.” Indeed, the ability to differentiate the abnormal from the

normal and the normal variant on radiographs rep- resented one of the early advances in radiologic thinking. Today, sophisticated radiologic effort seeks tc+ explain the shadows in terms of altered morpho-

logic or physiologic characteristics, or both [I]. It uses pharmacologic principles not only for diagnosis but

also for therapeutic intent. Furthermore, because sOme diseases have a similar radiologic appearance, the radiologist recognizes the need to be provided

with the appropriate aspects of the patient’s history, physical examination and laboratory data, not only tc., help tailor the study requested to the patient’s

particular needs, but also to triangulate such infor- mation into the interpretation so as to reach a meaningful conclusion.

The explosive logarithmic growth of radiology is reflected in its many new modalities of investigation a:, well as in the use of diagnostic techniques for t,herapeutic intervention. The use of selective angi- ography for the introduction of pharmacologic agents or the selective embolization of vessels is an example of’ such efforts.

Currently, many methods are used to evaluate the esophagus, such as manometry, endoscopy, brush

technique for cytology, radioimmunoassay and acid perfusion techniques. Radiologic thought and methods of investigation have similarly changed and advanced in response to the need for more informa- t,icm about esophageal disorders and their early de- tection. The following represents current thought regarding radiologic contributions in the evaluation of several esophageal disorders.

From the Radiologic Sciences, White Memorial Medical Center, and the

Department of Radiology. Loma Linda University School of Medicine, Los

Angeles. California.

IReprint requests should be addressed to Isaac Sanders, MD, Department

of Radiology. White Memorial Medical Center, 1720 Brooklyn Avenue, Los

Angeles. California 90033

Presented at the Fifth Annual Lyman A. Brewer Ill Cardiothoracic Sym-

posium. Los Angeles, California, December 6 and 7. 1979.

Esophageal Disorders

Zenker’s diverticula: In the past, most radiologic presentations were a form of “show and tell,” and

without fail, a diverticulum located just above the

upper esophageal sphincter (the cricopharyngeus muscle) was shown. This diverticulum appears in the midline or slightly to the left of the spine. An ac- companying chest roentgenogram often demon- strated aspiration pneumonia.

Today, there is much greater satisfact.ion in de-

tecting failure of the cricopharyngeus muscle to relax during deglutition [2]. This condition is the so-called

hypertensive sphincter, and it is this phenomenon that suggests the potential for developing a Zenker’s diverticulum. Thus, an attempt t,o explain altered physiologic characteristics is an advance over a simple description of roentgenographic shadows.

Malignant tumors of the esophagus: The de-

tection of malignant masses of the esophagus is an area in which several modalities are prepared to make a contribution. The detection of large masses radio- logically has never been a problem, and certainly

endoscopy and biopsy are ideal here. The radiograph,

a form of gross pathologic evaluation, can effectively demonstrate submucosal extension of the tumor, which is of value in determining operability and ra- diation therapy.

Our interest is directed toward detect,ion of the small superficial tumor. All too often these have been detected retrospectively when a second radiographic examination was performed or when endoscopy fol- lowed the x-ray investigation. The radiologist may facilitate detection of occult lesions by advising that any area of the esophagus showing limited distensi- bility be evaluated by endoscopy and biopsy [,‘j,d]. Air contrast techniques may not only aid in detecting areas of the esophagus that lack distensibility, but also demonstrate subtle mucosal alterations that reflect early malignancy [5].

The endoscopist‘must repeat the biopsy if the

Volume 139, June 1980 749

Sanders

microscopic sections of large ulcerated masses in the esophagus are reported as “necrotic or inflammatory tissue.” Most often such ulcerated masses turn out to be malignant tumors.

In evaluating the obstructed distal esophagus, the question often arises as to whether one is dealing with achalasia, a stricture secondary to reflux esophagitis or carcinoma. Although history may be of some as- sistance in this differential diagnosis, and although achalasia may be investigated pharmacologically (to be discussed herein), this area is one in which the radiologist is grateful for the endoscopy and biopsy. Sometimes, distortion of the juxtacardioesophageal area of the stomach provides the clue that the prob- lem is adenocarcinoma of the stomach with superfi- cial extension into the esophagus.

Benign tumors of the esophagus: The general experience is that benign tumors of the esophagus are quite infrequent compared with malignant tumors, are usually well marginated and smoothly elevate the mucosa without destroying it. The latter is a key point. After esophagoscopy and the elimination of carcinoma of the esophagus a benign tumor may be followed by periodic roentgenologic examination. However, if any evidence of contour abnormality exists, malignant degeneration must be suspected and the lesion appropriately investigated [6,7].

Reflux esophagitis: It is generally accepted that esophageal hiatal hernia and ieflux esophagitis are essentially two separate and unrelated phenomena. Although many questions are still unanswered, reflux esophagitis is presumed secondary to lower esopha- geal sphincter insufficiency, which produces gas- troesophageal reflux.

In gastroesophageal reflux, certain radiologic ef- forts may well be the source of some confusion. When, during esophageal study, spontaneous gas- troesophageal reflux reproduces the patient’s symptoms, this is a significant finding. The water siphon test is helpful in detecting gastroesophageal reflux. Water is given after an esophagogram and the reflux of barium from the stomach to the esophagus demonstrates gastroesophageal reflux.

Many radiologists have reached the following conclusions in regard to assessing reflux: (1) The detection of spontaneous reflux with symptoms is a significant finding; however, routine esophageal studies are not sensitive enough to pick up many cases of reflux esophagitis that are later documented by other more sophisticated methods. (2) The water siphon test [B] has led to “overcalling” the presence of reflux esophagitis. There is no doubt that one can “fool the sphincter” with a swallow of water and that a small amount of barium may return from the

stomach during this procedure. This result is ap- parently without significance. The interpretation of the water siphon test has also been hampered by several maneuvers to produce reflux that are not really physiologic. (3) Finally, many patients who demonstrated reflux on a conventional study and a water siphon study were symptom-free and did not have reflux esophagitis.

Esophageal tissue exposed to prolonged gastro- esophageal reflux has been shown to repair itself with both stratified squamous epithelium and columnar epithelium, and the latter may well have parietal cells in a configuration similar to that of the gastric mu- cosa: the so-called Barrett’s esophagus [9]. Many nuclear medicine studies have demonstrated that technetium pertechnetate pickup in the distal esophagus is an indication of reflux esophagitis, an important aid in detecting Barrett’s esophagus

[lOI. Reflux esophagitis secondary to prolonged naso-

gastric intubation can lead to stricture of the distal esophagus. This exchange of one disease for another is unfortunate. Monilial esophagitis is being reported with increasing frequency, parallelling the use of antibiotics, steroids and cytotoxic and immunosup- pressive agents. The debilitated patient is particu- larly susceptible to this condition. Although it has become fashionable to show films in which the esophagus shows mucosal alteration due to deposited excretions, giving the mucosal outline a pitted con- figuration, all too often patients with moniliasis may present with an esophagus that appears rather nor- mal on standard roentgenography, and a negative study does not rule out the presence of this dis- ease.

Achalasia: The characteristic radiographic find- ings in this entity are decreased or absent peristaltic activity in the body of the esophagus, which is usually grossly dilated and contains food, barium and se- cretions [11,12]. A smooth, tapering, funnel-shaped constriction may be seen in the cardioesophageal junction and transit time of esophageal contents between the esophagus and stomach is markedly diminished.

Thanks to the work of pathologists, physiologists and manometrists, two factors now appear to con- tribute to dilatation of the esophagus. The first is essentially a parasympathetic denervation secondary to degeneration of Auerbach’s plexuses in the esophageal wall, as demonstrated by careful patho- logic studies. Failure of the lower esophageal sphincter to relax in response to swallowing con- tributes to esophageal obstruction.

Cannon showed that the destruction of efferent

750 The American Journal of Surgery

Radiology of Esophagus

nl?urons to a portion of the gastrointestinal tract renders it hypersensitive to chemical stimulation.

After subcutaneous injection of parasympathomi- metic substances, such as 7.5 mg of methacholine, diagnostic tetanic cont.ractions occur in the distal

third of t.he esophagus. The presence of diffuse esophageal spasm (also

known as “corkscrew” esophagus, tertiary contrac-

tions (or pseudodiverticulosis) or “curling” of the esophagus may be seen in an early stage of this dis- e;ise. Manomet ric studies show the repetitive, non-

peristalt,ic contractions of the esophagus often as- sociated with dysphagia and substernal pain. Al- t,hough such contractions occasionally occur in el- derly patients in response to the corrosive action of active peptic disease or other ingested chemicals,

they are also seen in achalasia and in Chaga’s disease. The occurrence of’ this contraction may suggest an early stage of’ achalasia and may be evaluated by the use of methacholine. In the medical treatment of achalasia, f’luoroscopy is a great aid in the accurate placement of balloons and dilators.

Barium-air stasis: Barium-air stasis in the esophagus seen in scleroderma and systemic sclerosis is related to smooth muscle atrophy inherent in these disorders. It is also seen in patients with derma-

tomyositis, achalasia and diabetes with disordered esophageal motility and in elderly patients. Diagnosis

oil the cause of‘ this stasis in the esophagus is aided by a,jpropriate clinical data.

Trauma: Esophagitis secondary to the ingestion

0. alkalis. concentrated acid or other corrosive agents is still an all-too-frequent occurrence. Lye ingestion

ir- the major culprit. The immediate necrosis of the nlucosa and submucosa most often results in stricture formation. The esophagus may give the illusion of c&her compromise adjacent to the arch of the aorta or left main stem bronchus or its junction with the sl omach.

Iat rogenic perforation of’ the esophagus by an en-

doscope, balloon or nasogastric tube requires im- mediate intervention, as mortality rates are directly proportional to the delay before appropriate surgical tr,eatment is instituted. An esophagogram should be perf’ormed as soon as a perforation is suspected. Similarly, rupture of’ the esophagus that follows forceful vomiting (Boerhaave’s syndrome) should also be studied by an esophagogram as quickly as pi)sFible.

Superf’icial mucosal tears of the esophagus sec- ondary to vomiting seen in the Mallory-Weiss syn- d rome are almost never identified by esophagogram.

Regional perfusion of esophageal arteries with

vasoconstrictive agents may control massive hem-

orrhage from these mucosal lacerations and from other forms of esophageal hemorrhage such as esophageal varices [13]. In these cases selective catheterization and embolization or perfusion with vasoconstrictors has proved effective in controlling massive upper gastrointestinal bleeding [ I‘$].

Summary

In our modern era, the radiologist is no longer content merely to discern abnormal shadows; he must correlate the radiologic finding with clinical and physiologic findings. With this in mind, the radiol- ogist must be familiar with pertinent data from the

patient’s history, physical examination and labora- tory studies to aid not only in structuring the exam- ination of the patient but also in interpreting the radiologic findings.

References

1. Code CF. Atlas of esophageal motility in health and disease. Springfield, II: Charles C Thomas, 1958.

2. Ellis FH, Schlegel JF, Lynch VP, Payne WS. Cricopharyngeal

myotomy for pharyngo-esophageal diverticulum. Ann Surg 1955;170:340-9.

3. Suzuki H. Kobayashi S, Endo M, Nakayama K. Diagnosis of early esophageal cancer. Surgery 1972;71:99-103.

4. ltai Y. Kogure T, Okuyama Y. Akiyama H. Superficial esopha- geal carcinoma. Radiology 1978; 126:597-601.

5. Skucas J, Schrank WW. The routine air-contrast examination of the esophagus. Radiology 1975; 115482-4.

6. Baker HL. Good CA: Smooth-muscle tumors of the alimentary tract: their roentgen manifestations. Am J Roentgen01 1955;74:246-55.

7. Bernatz PE, Smith JL, Ellis FH, Anderson HA. Benign pedunc-

ulated, intraluminal tumors of the esophagus. J Thorac Surg 1958;35:503-12.

8. Stilson WL, Sanders I, Gardiner GA, Gorman HC, Lodqe DF. Hiatal hernia and gastroesophageal reflux. Radiology 1969;93:1323-7.

9. Bremner CG, Lynch VP, Ellis FH. Barrett’s esophagus: con- genital or acquired? An experimental study of esophageal mucosal regeneration in the dog. Surgery 1970;68:209- 16.

10. Berquist TH, Nolan NG, Stephens DH, Carlson HC. Radioisotope scintigraphy in diagnosis of Barrett’s esophagus. Am J

Roentgen01 1975;123:401-11. 11. Ellis FH. Code CF, Olsen AM. Long esophagomyotomy for dif-

fuse spasm of the esophagus and hypertensive gastro- esophageal sphincter. Surgery 1960;48:155-69.

12. Ellis FH, Olsen AM. Achalasia of the esophagus. Philadelphia: WB Saunders, 1969:109-14.

13. Clark RA. Intraarterial vasopressin infusion for treatment of Mallory-Weiss tears of the esophagogastric junction. Am J

Roentgen01 1979; 133:449-51. 14. Carson GM, Casarella WJ, Spiegel RM. Transcatheter embol-

ization for treatment of Mallory-Weiss tears of the esopha- gogastric junction. Radiology 1978; 128:309- 13.

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