Barium studies in esophageal cicatricial pemphigoid

Background: Cicatricial pemphigoid (CP) (benign mucous membrane pemphigoid) is a rare, blistering disease of skin and mucous membrane. The disease rarely extends to involve the esophagus, and there are only a few cases reported in the radiological literature. The aims of this study were to document the frequency of esophageal involvement and to describe the findings on upper GI barium studies. Methods: A total of 197 patients with CP were seen at our institution from 1981 to 1991. The clinical and radiological findings of these patients were reviewed and compared with findings reported in the literature. Results: Esophageal involvement was documented in seven patients. Cervical esophageal webs were found in five of the seven patients. Two patients had single esophageal webs while three had multiple webs. Frank strictures of the esophagus were also seen in five patients. These were most common in the cervical esophagus, but strictures were also found in the mid and lower esophagus. Two of the strictures resulted in significant dysphagia and required multiple endoscopic dilatations. One of the dilatations was complicated by mucosal injury, and follow-up barium examination showed dissection of the esophageal mucosa from the cervical esophagus to the esophagogastric junction. One patient demonstrated intramural pseudodiverticulosis in the cervical esophagus. Functional disturbances demonstrated on barium studies included tracheal aspiration in two patients and nasopharyngeal reflux in three. Conclusions: CP involves the esophagus in approximately 5% of cases. The hypopharynx and cervical esophagus are most commonly involved, but any portion of the esophagus may be involved, and multiple levels of involvement may be seen. Cervical esophageal webs, often multiple or complex, are the most common appearance on barium studies, but frank strictures are also found. Secondary manifestations of esophageal involvement include nasopharyngeal reflux, tracheal aspiration, and intramural pseudodiverticulosis.     

Videofluoroscopy of the pharynx and esophagus in chronic graft-versus-host disease

Successful allogeneic bone marrow transplantation (BMT) for hematologic disorders may be complicated by graft-versus-host-disease (GVHD). Chronic GVHD is a systemic disease, involving, among other organs, the skin, mouth, liver, and esophagus. Esophageal involvement results in mucosal inflammation, leading to submucosal fibrosis and, occasionally, formation of webs and strictures. We investigated 25 allogeneic BMT recipients (17 with and eight without chronic GVHD). All patients had a videofluoroscopic study of the pharynx and esophagus to determine the radiographic abnormalities characteristic of chronic GVHD. Oropharyngeal abnormalities (poor bolus control, pharyngeal retention, or excessive mucous secretions) were found in five patients with and three patients without GVHD. Only one patient with GVHD had a pharyngo-esophageal stricture. There was no significant difference between the two groups with regard to pharyngo-esophageal radiographic abnormalities and esophageal symptoms. Radiographic evidence of esophageal motility disorder is not specific for GVHD involvement. In the absence of specific radiographic features, endoscopy is the most accurate method for the diagnosis of esophageal involvement by GVHD.This work was supported by the Ludwig Boltzmann Institute for Radiologic Tumor Diagnosis, Vienna, Austria.     

Radiologic demonstration of multiple foci of malignancy in the esophagus

Three patients, each with two synchronous esophageal carcinomas demonstrated radiologically, are presented. The importance of complete esophageal evaluation in patients with one obvious tumor of the esophagus is emphasized. Assessment of the full extent of disease in such cases directly affects treatment planning.     

Infiltrating carcinoma simulating achalasia

Three cases of carcinoma infiltrating the esophagus and simulating achalasia are presented and the differential diagnostic problems discussed. The radiologic distinction between achalasia and carcinoma can be extremely difficult. Any rigidity, irregularity, nodularity, or ulceration of the distal-most esophagus or gastric fundus or symptoms of short duration in older patients should alert the radiologist to the possibility of carcinoma. It is suggested that all patients with suspected achalasia undergo esophageal and gastric endoscopy with biopsy and esophageal manometry to confirm the diagnosis, expecially if pneumatic dilatation is contemplated.     

Radiation therapy of esophageal carcinoma: Correlation of clinical and radiographic findings

Seventeen patients with esophageal carcinoma treated by radiation therapy (RT) at our hospital between 1981 and 1984 had initial diagnostic esophagrams and 1 or more repeat esophagrams after completing RT. Total regression of the tumor was observed radiographically in 10 patients (59%) with a normal esophagus (24%) or benign-appearing residual stricture (35%) at the site of the previous lesion. Partial regression was observed in 4 patients, and progression of the tumor in 3. No correlation was found between the size, stage, or morphology of the lesion and its response to therapy. Although local recurrences were relatively uncommon, patient survival was often limited by the development of distant metastases. Fourteen of 15 patients with clinical followup initially had significant relief from dysphagia as the tumor regressed. However, 9 of those patients had recurrent or increased dysphagia over a subsequent 3–9-month period. Exacerbation of symptoms did not necessarily indicate recurrent carcinoma; it also resulted from benign radiation strictures, opportunistic esophagitis, or other complications of RT detected on esophagography.     

Cervical esophageal web associated with a patch of heterotopic gastric mucosa

Cervical esophageal webs are a relatively common finding on esophograms. We report a web resulting from the squamocolumnar junction produced by heterotopic gastric mucosa. The clinical significance of this lesion is discussed and the importance of differentiating it from Barrett's esophagus is stressed.     

Radiologic manifestations of iatrogenic changes of the esophagus

The review of the roentgen manifestations of iatrogenic changes in the esophagus permits their grouping into two major categories of intentional and nonintentional alterations. In the first group, iatrogenic changes are encountered following reconstructive or other types of surgery, radiotherapy, and their respective complications. Nonintentional changes of the esophagus include injuries induced during diagnostic procedures, life-saving measures, and drug therapy. The knowledge of the spectra of possible iatrogenic alterations is important for accurate radiologic evaluation of the patients and the recognition of complications.     

Esophageal squamous cell carcinoma: MRI evaluation of mediastinum

Thirty-two patients with esophageal spinocellular (squamous cell) carcinoma were studied with superconductive magnet in order to evaluate local and extraluminal extent, as well as mediastinal lymph node spread of the disease. In the absence of adenopathy, the localized tumors were considered susceptible to surgical treatment. All patients were operated on within 21 days. The resectability criteria were correctly evaluated in 75% of cases; sensitivity and specificity were 86 and 67%, respectively. Unsatisfactory results were obtained in the evaluation of mediastinal adenopathies. We conclude that magnetic resonance imaging (MRI) is useful in the preoperative evaluation of resectability criteria in patients with esophageal squamous cell carcinoma.     

Premature contraction of the cricopharyngeus: a new sign of gastroesophageal reflux disease

Background: A cricopharyngeal bar seen on barium fluoroscopy has been shown to be related to the presence of gastroesophageal reflux (GER). We investigated premature contraction of the cricopharyngeus (PCC) muscle, which may be a precursor of a fixed cricopharyngeal bar, to assess its significance in GER. Methods: The prevalence of PCC on barium swallow was recorded in three groups: (1) 83 patients with noncardiac chest pain who were investigated for possible GER; (2) 21 patients with severe GER undergoing fundoplication; and (3) 25 normal controls. Results: Group 1: PCC was observed in 42 of 77 with documented GER (54.5%), and in two of six patients without GER. Group 2: PCC was present in 11 of 21 fundoplication subjects. Group 3: PCC was seen in five of 25 normal controls. The incidence of PCC in patients with GER was statistically significantly higher than in normal subjects (p = 0.002). The sensitivity of the presence of PCC as a predictor of GER is only 0.54, but the specificity is 0.774, with a positive predictive value of 0.883. Conclusion: We conclude that observing premature cricopharyngeal contraction during the first swallows of an upper gastrointestinal (GI) study should direct attention to the possibility of GER.     

Stridor in infants and children due to esophageal inflammatory disease

Esophageal inflammatory disease is an unusual cause of stridor in infants and children. Pediatric patients with upper respiratory tract obstructive symptoms secondary to foreign body esophagitis and esophageal moniliasis are presented. The importance of esophageal abnormalities as a potential cause of stridor is emphasized.     

Radiology of colonic interposition and its associated complications

A retrospective review of the medical records, pathology reports, and radiographic studies of 81 patients who had undergone colonic interposition was undertaken, with special attention to postoperative complications. Both early (within 30 days postoperatively, 81 patients) and late (later than 30 days postoperatively, 57 patients) complications were reviewed. Early findings included anastomotic narrowing (18 patients), anastomotic leak (13), aspiration (11), and ischemic necrosis of the colon (3). Late findings included aspiration (9 patients), anastomotic strictures (8), gastric stasis (6), redundancy and tortuosity of the colon (5), anastomotic ulcers (4), gastrocolic reflux (3), and gastroesophageal reflux into the residual esophagus (2).     

Management of diffuse esophageal spasm with balloon dilatation

Of 1200 patients referred to the esophageal laboratory at Guy's Hospital for investigation of suspected esophageal motility disorders, 61 (5.1%) were diagnosed as diffuse esophageal spasm. Twenty of these patients whose symptoms were severe did not respond to conservative treatment and were treated by balloon dilatation. Results were good in 14 and poor in six patients, which included one esophageal perforation. Diffuse esophageal spasm was diagnosed where more than 30% nonperistaltic activity was demonstrated by manometry. Lower esophageal sphincter pressure and relaxation were normal in all cases except one. Gastroesophageal reflux was present in four of five poor responders who were examined by 24-h ambulatory pH monitoring, and in only one of 10 good responders. Three of the six patients in whom balloon dilatation was successful proceeded to full-length myotomy, with relief of symptoms in two. The indications for, and results of, balloon dilatation in this condition are discussed, and a new radiological sign is described.     

Reflux esophagitis revisited: Prospective analysis of radiologic accuracy

A prospective radiologic-endoscopic study of the esophagogastric region in 266 patients, including 206 normals and 60 with esophagitis, is reported. The endoscopic classification grading severity of esophagitis was grade 1 — normal; grades 2, 3, and 4 — mild, moderate, and severe esophagitis, respectively. Radiology detected 22% of patients with mild esophagitis, 83% with moderate esophagitis, and 95% with severe esophagitis. Although hiatal hernia was present in 40% of normals and 89% with esophagitis, absence of radiographic hiatal hernia excluded esophagitis with 95% accuracy. The implications of this study regarding the role of radiology in evaluating patients with suspected reflux esophagitis are discussed.     

Radiographic evaluation of achalasia immediately after pneumatic dilatation with the Rigiflex dilator

Radiographic evaluation of the lower esophagus was done immediately after pneumatic dilatation using the Rigiflex dilator in 34 patients (24 men, 10 women; mean age, 55 years) with achalasia. The dilator was positioned across the esophagogastic junction using fluoroscopy and the balloon was inflated for 1 min. The esophagus was intubated and injected sequentially with water-soluble and barium contrast materials. Radiographic analysis included changes in the appearance of the caliber and contour of the esophagogastric junction, rate of esophageal emptying, and presence of complications. In 23 patients with predilatation esophagrams, the mean esophagogastric junction caliber increased from 4.7–7.6 mm following dilatation. The postdilatation esophagrams in 33 patients showed a smooth contour in 22 (67%) and immediate esophageal emptying in 26 (79%). Esophageal perforation occurred in one (3%) patient and intramural hematoma in one (3%). Clinical follow-up (mean, 7 months) was available in 29 patients and 23 (79%) had symptomatic improvement. Five of the six patients who did not improve clinically all had previous Heller myotomy, pneumatic dilatation, or both.     

Tuberculous fistulas of the pharynx and esophagus

Four patients with tuberculous fistulas communicating with the pharynx or the esophagus are reported. In 1 patient, there was strong evidence to suggest primary involvement of the esophageal mucosa. The other 3 cases were related to involvement of the pharynx or the esophagus from adjacent tuberculous process, as confirmed by histopathological proof.The patients had varying degrees of symptoms, which in two dramatically responded to antituberculous therapy; the third patient needed surgery for complete cure and the last patient was lost to follow-up.     

Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis (EIP) is a rare condition of unknown etiology. It is characterized by multiple, small, flaskshaped outpouchings in the esophageal wall. Involvement may be segmental or diffuse. Since this entity was first reported in 1960, there have been 43 cases described in the English literature. These cases are reviewed and six additional cases are reported with emphasis on clinical and radiographic parameters of this entity.     

Granular cell tumors of the esophagus

Three cases of granular cell tumor of the esophagus are added to the 17 previously reported in the literature. These tumors, thought to be of neural origin, are difficult to diagnose preoperatively. The diagnosis should be considered in adult females presenting with an intramural mass of the proximal or distal third of the esophagus. Symptoms of dysphagia and substernal discomfort are likely to occur with lesions greater than one centimeter in diameter. Preoperative biopsy is not advised as a mistaken diagnosis of squamous cell carcinoma can result.     

Hirsute esophagus: Clinical and roentgen features

Clinical and roentgen features of hirsute esophagus in 3 patients are described. Exuberant hair growth and masses of hair in the endopharyngoesophagus produced the classic clinical triad of progressive dysphagia, hair-spitting, and choking spells. This unique and rare complication of reconstructive surgery of the pharynx and esophagus is related to the skin flaps which are mobilized and rotated to reconstruct a skin tube endopharyngoesophagus and to restore anatomical continuity of the gastrointestinal tract.     

Efficacy of radiology of the esophagus for evaluation of dysphagia

The efficacy of radiology in evaluating dysphagia was studied in 86 patients by comparison to endoscopic findings. In the 66 patients with endoscopic abnormalities radiology was correct in 54, for a sensitivity of 82%. Sensitivity of radiology improved to 95% if mild esophagitis was excluded. In the 20 patients with normal endoscopy, radiology was normal in 18 (90%). Thus radiology proved to be a reliable means of evaluating the esophagus in patients with dysphagia.     

Localized saccular dilatation of the esophagus: An unusual cause of dysphagia

Two young women who had undergone resection of an esophageal enteric cyst subsequently developed saccular dilatation of the esophagus. The abnormality was localized to the site of previous surgery and caused dysphagia in both patients.