Barrett carcinoma of the esophagus: clinical and radiographic analysis of 34 cases

Review of 34 cases of pathologically proved Barrett-type adenocarcinoma of the esophagus seen at the University of Michigan during 1962-1983 revealed that it constituted 5% of all carcinomas of the esophagus and 20% of all adenocarcinomas involving the esophagus during that period. Despite many similarities to conventional squamous cell carcinoma and gastric cardiac carcinoma, certain distinguishing features were identified. Radiologically, diagnosis of Barrett carcinoma should be suggested when a patient with a longstanding history of gastroesophageal reflux, chronic esophagitis, and hiatus hernia with or without features of Barrett esophagus demonstrates a long vertical segment of esophageal involvement by an infiltrating or varicoid-appearing lesion. This review analyzes the clinical and radiologic distinguishing features of Barrett carcinoma and compares those of gastric cardiac carcinoma and conventional squamous cell carcinoma of the esophagus.     

反流性食管炎和食管腺癌组织中P16、P53、PCNA表达及其临床意义

为了探讨Ｐ１６、Ｐ５３、ＰＣＮＡ基因表达在反流性食管炎、Ｂａｒｒｅｔｔ食管和食管腺癌中的临床生物学行为之间的关系。采用免疫组织化学法,检测了３０例食管腺癌、２０例反流性食管炎和１０例Ｂａｒｒｅｔｔ食管组织中Ｐ１６、Ｐ５３、ＰＣＮＡ基因表达,２０例正常人的食管组织作为正常对照。结果表明：三项基因在食管腺癌中的蛋白表达率均较正常对照组显著增高（Ｐ〈０．０５）。Ｐ５３在食管腺癌、Ｂａｒｒｅｔｔ食管和反流     

Early esophageal cancer

Early esophageal cancer (EEC) accounted for only seven (4.7%) of 148 cases of esophageal cancer diagnosed at the authors' hospital between 1977 and 1984. Two patients with EEC had squamous cell carcinoma and five had adenocarcinoma arising in Barrett's mucosa. All seven patients had associated clinical findings, including low-grade gastrointestinal bleeding (three cases), odynophagia (one case), and chronic reflux symptoms due to underlying reflux esophagitis and Barrett esophagus (three cases). Since Barrett esophagus is a premalignant condition, the high proportion of adenocarcinomas in this series presumably reflects the more frequent radiologic evaluation of symptomatic patients with Barrett esophagus. On esophagography, four patients had 3-4.5-cm polypoid intraluminal masses that could not be distinguished radiographically from advanced esophageal carcinoma. In the other three patients, esophagrams revealed secondary achalasia, irregular flattening of the esophageal wall, and diffuse nodularity of the mucosa. The authors conclude that "early" esophageal cancers are not necessarily small cancers, since they may undergo considerable intraluminal or intramural growth and still be classified histologically as EEC. Radiologists should be aware of these findings, since EEC has an excellent prognosis with a 5-year survival approaching 90%.     

Barrett食管及相关并发症的X线探讨

目的:通过16例经内窥镜及病理证实为Barrett食管的钡餐检查表现,初步探讨Barrett食管及其并发症放射学检查的意义。方法:回顾性分析16例Barrett食管的内窥镜和气钡检查的记录及表现,着重探讨气钡检查的X线表现。结果:食管内窥镜和组织学检查全部病例均有炎症改变,其他可见胃食管反流、食管溃疡和食管腺癌。放射学钡餐检查结果:Barrett食管炎4例,Barrett食管溃疡7例,Barrett食管癌5例。结论:Barrett食管及其并发症至今无明确放射学征象,改进对“Z”线的检查技术和方法,有可能提高其发现率。钡餐发现胃食管反流、食管裂孔疝同时并发食管炎、食管溃疡及食管癌者均应考虑到本症的可能。     

Pseudomembranes in reflux esophagitis

Three cases are presented in which double-contrast esophagograms revealed one or more plaquelike lesions in the distal esophagus, representing pseudomembrane formation in patients with severe reflux esophagitis. Although to our knowledge this finding has not been reported previously in the radiologic literature, pseudomembranes have been documented endoscopically in patients with reflux esophagitis and biopsy-proved Barrett esophagus. Radiologists should be aware of this finding, since these pseudomembranes may be indistinguishable radiographically from plaquelike carcinomas arising in Barrett esophagus.     

Esophageal involvement in Zollinger-Ellison syndrome

Review of 18 patients with Zollinger-Ellison syndrome (ZES) revealed pathologic evidence of esophageal disease in six (33%). Four patients manifested varying degrees of esophagitis, ranging from mild to severe ulcerations and stricture formation. In two patients, symptomatic Barrett esophagus was detected 4 and 6 months after total gastrectomy, respectively. It is postulated that due to longstanding gastroesophageal reflux, Barrett esophagus was present in these two patients before total gastrectomy, and esophageal symptoms became only apparent after more compelling symptoms of gastric peptic ulceration were controlled by definitive surgery. Esophageal involvement occurs with greater frequency in patients with ZES; the previously held notion that esophageal disease due to gastroesophageal reflux in ZES patients is uncommon is contrary to the results of this study. It is recommended that all patients with ZES irrespective of symptom-complex should be routinely evaluated for the presence or absence of esophageal disease because of its important bearings on adequate surgical management.     

Barrett esophagus as an extension of severe esophagitis: analysis of radiologic signs in 29 cases

Twenty-nine cases of Barrett esophagus verified by endoscopy and 16 cases confirmed by histology were reviewed for pertinent radiologic signs. All patients had barium-filled and mucosal relief films, and all but five cases had double-contrast films. Common radiologic signs in descending order were thickened and irregular mucosal folds (28/29), hiatal hernia (26/29), esophageal stricture (25/29), esophageal ulcer (20/29), distal esophageal widening (19/29), granular mucosal pattern (16/24), reticular mucosal pattern (9/24), and intramural pseudodiverticula (6/29), all of which are also recognized signs of reflux esophagitis. Midesophageal stricture, esophageal ulcer, and distal esophageal widening were particularly indicative of Barrett esophagus. Since there appears to be no specific sign of Barrett esophagus, a multifaceted approach is suggested concentrating on the association of Barrett esophagus with the radiographic signs of severe reflux esophagitis.     

Postesophageal narrowing associated with Barrett esophagus.

Two children have been found to have partially obstructing lesions beyond the esophagus in association with mid-esophageal stricture. Both were found to have columnar epithelium-lined (Barrett) esophagus, and gastro-esophageal reflux. The more distal obstruction, in the pylorus and descending duodenum respectively, may have contributed to the development of the Barrett esophagus. It is recommended that any barium study of the esophagus which reveals an unexplained stricture should include visualization through the duodenojejunal junction as an aid to diagnosis, management, and understanding.     

The radiologic diagnosis of Barrett esophagus: importance of mucosal surface abnormalities on air-contrast barium studies

Patients with Barrett esophagus are predisposed to the development of esophageal adenocarcinoma. Identification of these patients before this complication develops is essential. We prospectively made the diagnosis of Barrett esophagus on routine biphasic upper gastrointestinal series in nine patients in whom a mucosal surface pattern alteration was the only radiologic abnormality on the esophagogram. The diagnosis was confirmed by biopsy in eight patients and during surgery in one patient. Only a third of the patients had symptoms related to the esophagus. Two types of surface changes were noted. A reticular pattern was present in six cases and a villous pattern in five cases. Both patterns were noted in two patients. This series was obtained in a 5-year interval during which there were 15 additional patients with Barrett esophagus and corresponding esophagograms. None of these patients had normal results on esophagograms. Recognition of these subtle surface patterns, particularly in the absence of other reflux-induced abnormalities, may improve detection of Barrett esophagus and aid in the selection of patients for subsequent surveillance.     

Radiology of esophagitis: a pattern approach

This article presents a pattern approach for diagnosing esophagitis at double-contrast esophagography. In patients with nodular elevations of the mucosa, discrete plaques should suggest Candida esophagitis, whereas poorly defined nodules should suggest reflux esophagitis and a distinctive reticular pattern of the mucosa should suggest Barrett esophagus, particularly if adjacent to the distal aspect of a high stricture. In patients with ulceration, one or more shallow ulcers at or near the gastroesophageal junction should suggest reflux esophagitis, whereas discrete, superficial ulcers in the midesophagus should suggest herpes or drug-induced esophagitis, depending on the clinical setting. In contrast, one or more giant, relatively flat ulcers should suggest cytomegalovirus esophagitis, particularly in patients with acquired immunodeficiency syndrome. Finally, thickened longitudinal folds may be caused by esophagitis, varices, or, rarely, "varicoid" carcinoma, but these conditions usually can be differentiated on radiologic grounds. By carefully analyzing the appearance and location of nodules, plaques, ulcers, or abnormal folds in the esophagus, one can usually suggest a cause of the disease.     

Barrett's esophagus complicating lye ingestion. Demonstration by pertechnetate scintigraphy

Tc-99m pertechnetate scintigraphy was performed in a patient with Barrett's esophagus and a history of previous lye ingestion. Radionuclide uptake was present in the distal two-thirds of the esophagus and persisted after the drinking of water. This technique is simple and accurate and may be of significant benefit in determining the presence and extent of Barrett's esophagus, which carries an increased incidence of adenocarcinoma development. Examination of patients with chronic gastroesophageal reflux, using this technique, is advocated.     

Correlation between the radiologic study of deglutition and the clinical picture in systemic sclerosis (scleroderma)

Fifty-one patients with systemic sclerosis (scleroderma) were studied by means of videofluoroscopy in order to evaluate the abnormalities in the oropharyngeal and esophageal phases of deglutition and to correlate the radiological patterns with the clinical features of the disease. Thirteen patients (25.5%) exhibited swallowing disorders such as oral leakage, retention, penetration, mild or moderate aspiration and abnormal upper esophageal sphincter behavior. These dysfunctions were more evident in patients with esophageal motility abnormalities. A normal radiological pattern in the esophagus was not associated with swallowing alterations. Remarkably, patients with oral-pharyngeal disorders had a higher incidence of lung diseases. Forty-five patients (88%) exhibited disorders of the esophageal phase of deglutition, such as mild or severe motility abnormalities or hiatal hernia, gastro-esophageal reflux, reflux esophagitis, and stricture. Radiological findings in the esophagus can be abnormal in the early stages of the disease. On the other hand, the radiological pattern of esophageal motility can be occasionally negative in advanced or extensive disease. This indicates a discrepancy between clinical symptoms and radiological picture of the esophagus. The radiological examination of the oral-pharyngeal and esophageal phases of deglutition is important in patients with scleroderma in order to evaluate visceral involvement, motility disorders, and risk of aspiration. Such radiological information can be useful in preventing esophagitis and pulmonary complications.     

Esophageal scintigraphy: applications and limitations in the study of esophageal disorders

This study examines the scintigraphic transit pattern in a variety of esophageal disorders. Scintigraphy was performed with a semi solid bolus and the patient in an upright position. Condensed esophageal images were obtained from which we derived the esophageal transit time. The pattern of bolus transit was graded by the duration of transit and by the presence of hold up or retrograde motion. Scintigrams were performed in 11 volunteers and 88 patients whose esophageal function had been confirmed by conventional gastroesophageal techniques. Esophageal disorders examined included achalasia (20), scleroderma (9), esophageal carcinoma (8), Barrett esophagus (5), and reflux esophagitis (27). We also examined the effects of gastroesophageal surgery on esophageal function. Transit times distinguished grossly abnormal esophageal function from normal but did not distinguish between different esophageal disorders. Graded transit patterns were a more sensitive indicator of esophageal function and permitted some differentiation between esophageal disorders and allowed evaluation of the effects of gastroesophageal surgery.     

Esophageal scintigraphy: Applications and limitations in the study of esophageal disorders

This study examines the scintigraphic transit patern in a variety of esophageal disorders. Scintigraphy was performed with a semi solid bolus and the patient in an upright position. condensed esophageal images were obtained from which we derived the esophageal transit time. The pattern of bolus transit was graded by the duration of transit and by the presence of hold up or retrograde motion. Scintigrams were performed in 11 volunteers and 88 patients whose esophageal function had been confirmed by conventional gastroesophageal techniques. Esophageal disorders examined included achalasia (20), scleroderma (9), esophageal carcinoma (8), Barrett esophagus (5), and reflux esophagitis (27). We also examined the effects of gastroesophageal surgery on esophageal function. Transit times distinguished grossly abnormal esophageal function from normal but did not distinguish between different esophageal disorders. Graded transit patterns were a more sensitive indicator of esophageal function and permitted some differentiation between esophageal disorders and allowed evaluation of the effects of gastroesophageal surgery.     

胆囊切除术后胃十二指肠黏膜的内镜病理分析

目的探讨胆囊切除术后胃十二指肠黏膜的内镜和病理检查变化。方法对206例胆囊切除术后胆汁反流性胃炎患者行胃镜诊断,并进行活检病理检查,采用快速尿素酶法检测幽门螺旋杆菌。结果 206例中,胆汁反流合并反流性食管炎33例,Barrett食管15例,食管溃疡4例,胃溃疡25例,十二指肠溃疡50例,十二指肠炎56例,胃息肉10例,十二指肠息肉28例。内镜下表现为：充血水肿189例,糜烂106例,黏膜下出血88例,疣状糜烂67例,萎缩性胃炎35例,颗粒样增生48例,幽门功能不全45例（闭合不全弛缓）,胃底体黏膜皱襞增粗38例,胆汁由幽门进入胃窦66例;内镜下胆汁反流分级：Ⅰ级88例,Ⅱ级69例,Ⅲ级49例;慢性炎症176例,急性炎症32例,活动性炎症77例,肠腺化生56例,上皮内瘤变39例,萎缩性炎症37例,淋巴细胞增生33例,炎性息肉10例。幽门螺旋杆菌阳性66例,占32%,低于同期非胆汁反流性胃炎的61.9%。结论胆囊切除术与胆汁反流有关,胆汁反流可以造成多种食管、胃、十二指肠黏膜疾病,内镜和病理检查是诊断胆汁反流性胃炎的较好手段。幽门螺旋杆菌感染与胆汁反流性胃炎没有明确的关系。     

Esophageal inflammation and stricture: complication of chronic granulomatous disease of childhood

Esophagitis in children with immunodeficiency is most commonly due to opportunistic infection. The authors describe three patients with chronic granulomatous disease (CGD) of childhood who developed esophageal strictures that were believed to be complications of the primary disease. At radiologic examination, all three patients initially had a focal narrowing of the upper thoracic esophagus. Endoscopy showed no signs of opportunistic infection or Barrett esophagus. Biopsy of the strictures in two patients revealed findings consistent with CGD. In two of the three patients, inflammation extended to involve the middle and distal esophagus. Long-term response to balloon dilation was poor in the first two patients. The third patient was lost to follow-up after a partial clinical and radiographic response to dilation.     

The "foamy" esophagus: a radiographic sign of Candida esophagitis

OBJECTIVE: The purpose of this study was to describe the radiographic features of the "foamy" esophagus, a new sign of Candida esophagitis seen on double-contrast esophagography, in six patients. CONCLUSION: The foamy esophagus was characterized by innumerable tiny (1-3 mm), round lucencies (bubbles) that intermingled with the barium suspension along the top of the barium column, producing a layer of foam. Candida esophagitis should be strongly suspected when a foamy esophagus is detected on double-contrast esophagography, particularly in patients with underlying esophageal involvement by scleroderma.     

Transverse folds in the human esophagus

Fine transverse folds can be seen by double contrast technique in the human esophagus which are similar to those seen regularly in the feline esophagus. These folds are transient in nature and possibly represent contraction of the muscularis mucosae. This fold pattern can be seen in patients with gastroesophageal reflux and in those with no symptoms of esophageal disease. The marginal serration should not be mistaken for diffuse ulceration on barium filled views of the esophagus. Distortion of interruption of the normal fold pattern can be seen in patients with superficial ulceration due to reflux esophagitis or other invasive mucosal lesions. Although the pathophysiologic significance of this phenomenon is uncertain, the demonstration and recognition of these folds allows for better definition of mucosal surface abnormalities.     

Barrett氏食管四例报告

Barrett's esophagus is a complication of gastroesophageal reflux. Radiological findings included gastroesophageal reflux and oesophagitis. It is an important precancerous disorder in the development of esophageal adenocarcinoma. The authors reported 4 cases confirmed by endoscopy and pathology.     

The reticular pattern as a radiographic sign of the Barrett esophagus: an assessment

A two-part retrospective study was conducted to assess the value of a reticular pattern as a sign of columnar-lined esophagus. Radiographic, endoscopic, and histologic findings were reviewed in 124 patients with known Barrett esophagus; then all barium esophagrams done at our institution during a 3 1/2 month period were reviewed and presence of a reticular pattern was correlated with available endoscopic and histologic data. In patients with known Barrett esophagus, the reticular pattern was found in 26% of double-contrast examinations. Twelve of these patients underwent careful esophageal mapping biopsies: the pattern was in squamous mucosa with ulceration in two, in columnar epithelium with ulceration in six, and in columnar epithelium without ulceration in four. In the group of 314 unselected patients who had double-contrast examinations, the reticular pattern was found in 26 (8%). Thirteen of the 26 had had endoscopy and biopsy: the site of the pattern was located in a squamous carcinoma in one, in squamous epithelium adjacent to squamous carcinoma in three, in squamous epithelium with esophagitis in five (two of whom had columnar mucosa distally), in normal squamous mucosa in one, and in columnar epithelium with esophagitis in three. The reticular pattern is a strong indicator of important esophageal disease, but is not specific for Barrett esophagus.