Diseases of the esophagus: diagnosis with esophagography

The barium esophagram is a valuable diagnostic test for evaluating structural and functional abnormalities of the esophagus. The study is usually performed as a multiphasic examination that includes upright double-contrast views with a high-density barium suspension, prone single-contrast views with a low-density barium suspension, and, not infrequently, mucosal-relief views with either density of barium suspension. The double-contrast phase optimizes the ability to detect inflammatory or neoplastic diseases, whereas the single-contrast phase optimizes the ability to detect hiatal hernias and lower esophageal rings or strictures. Fluoroscopic examination of the esophagus is also important for assessing motility disorders such as achalasia and diffuse esophageal spasm. This article is a review of gastroesophageal reflux disease, other types of esophagitis, benign and malignant esophageal tumors, varices, lower esophageal rings, diverticula, and esophageal motility disorders, all of which can be diagnosed with the aid of esophagography.     

Transnasal US of the esophagus: preliminary morphologic and function studies.

High-frequency catheter-based ultrasound (US) transducers can be inserted into the esophagus transnasally to evaluate esophageal wall structures. Studies were performed in two sheep esophagus specimens in vitro, in 17 healthy human subjects, and in 16 patients with esophageal abnormalities (eight with achalasia, four with scleroderma, three with esophageal carcinoma, and one with esophagitis). In the sheep specimens, endoluminal US delineated seven layers of the esophageal wall; these results correlated closely with histologic findings. Real-time US of the normal esophageal wall was performed during resting and swallowing. Muscles at the lower esophageal sphincter (LES) were shown to be thicker than muscles in the body of the esophagus. Thickening of the muscular layers at the LES in achalasia, dilated blood vessels within the submucosa in esophagitis, and fibrotic changes within the muscular layers in scleroderma were demonstrated. Extramural structures adjacent to the esophagus were also seen. These preliminary results suggest that transnasal esophageal US may become an important diagnostic tool in evaluation of the esophagus.     

Adenocarcinoma of the esophagus in patients with scleroderma

Three cases of patients with esophageal involvement by scleroderma, chronic reflux esophagitis, and adenocarcinoma of the distal esophagus are presented. An underlying columnar metaplasia (Barrett esophagus) was identified in two patients and postulated in the third. It is believed that scleroderma patients with symptomatic chronic gastroesophageal reflux should be investigated for Barrett epithelium. If it is present, these patients should be followed and considered as having an increased risk for development of adenocarcinoma of the esophagus.     

Update on esophageal radiology

This article reviews the current status of double-contrast radiography in diagnosing pharyngeal tumors and opportunistic esophagitis and the radiologic evaluation of esophageal motility disorders in patients with chest pain. Double-contrast pharyngography is a valuable technique for detecting pharyngeal tumors. These lesions may be manifested by an intraluminal mass, mucosal irregularity, or asymmetric distensibility. Furthermore, barium studies may demonstrate lesions involving the valleculae, tongue base, lower hypopharynx, and pharyngoesophageal segment that are difficult to visualize at endoscopy. Double-contrast radiography is also a valuable technique for detecting opportunistic esophagitis and for differentiating the underlying causes. Mucosal plaques should suggest Candida esophagitis, whereas discrete ulcers should suggest herpes esophagitis, and one or more large, relatively flat ulcers should suggest cytomegalovirus esophagitis. Finally, in evaluating patients with chest pain, in only a small percentage are esophageal motility disorders found to be a possible cause of their pain. Instead, the majority are found to have cardiac disease, structural esophageal lesions, or gastroesophageal reflux, so that barium studies are more useful in documenting normal motility or structural abnormalities in these patients.     

Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation

OBJECTIVE: The aim of this study was to evaluate whether specific patterns of swallowing dysfunction occur in symptomatic patients after long-term intubation. SUBJECTS AND METHODS: Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities. RESULTS: There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%. CONCLUSION: Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.     

Radionuclide gastroesophageal motor studies.

Disorders of the upper digestive tract have a high impact on modern society, in terms of both direct and indirect health care costs and of social burden. The most common presenting symptom is either dysphagia or dyspepsia. Discriminating specific diagnoses within this wide group of diseases requires sound clinical judgment and application of procedures to distinguish organic from nonorganic disease and to further characterize the functional or motility disturbance of nonorganic diseases. Non-radionuclide-based diagnostic techniques include both noninvasive tests (upper gastrointestinal barium series, ultrasonography, and breath test for gastric emptying) and invasive procedures (fiberoptic endoscopy, esophagogastroduodenoscopy, pharyngeal manometry, stationary esophageal manometry, 24-h pH monitoring, esophageal biliary reflux monitoring, multichannel intraluminal impedance, and electrogastrography). Some of these techniques are not well tolerated by patients or not widely available. Radionuclide transit/emptying scintigraphy provides a means of characterizing exquisite functional abnormalities with a set of low-cost procedures that are easy to perform and widely available, entail a low radiation burden, closely reflect the physiology of the tract under evaluation, are well tolerated and require minimum cooperation by patients, and provide quantitative data for better intersubject comparison and for monitoring response to therapy. Despite the relatively low degree of standardization both in the scintigraphic technique per se and in image processing, these methods have shown excellent diagnostic performance in several function or motility disorders of the upper digestive tract. Dynamic scintigraphy with a radioactive liquid or semisolid bolus provides important information on both the oropharyngeal and the esophageal phases of swallowing, thus representing a useful complement or even a valid alternative to conventional invasive tests (such as stationary esophageal manometry) for evaluating abnormalities of oropharyngoesophageal transit. Clinical applications of esophageal transit scintigraphy include disorders such as nutcracker esophagus, esophageal spasm, noncardiac chest pain of presumed esophageal origin, achalasia, esophageal involvement of scleroderma, and gastroesophageal reflux and monitoring of response to therapy (either medical or surgical treatment of disease-for example, organic disease such as esophageal cancer). Scintigraphy with a radiolabeled test meal represents the gold standard for evaluating gastric emptying, whereas more recent radionuclide methods include dynamic antral scintigraphy and gastric SPECT for assessing gastric accommodation. Clinical applications of gastric-emptying scintigraphy include, among others, evaluation of patients with dyspepsia and evaluation of gastric function in various systemic diseases affecting gastric emptying. The present review includes the proposal of clinical algorithms for evaluating patients with the main disorders of the upper digestive tract. These algorithms, originally derived from available literature, have been developed on the basis of a vast clinical experience in conjunction with the specialists more deeply involved in the care of patients with such disorders (medical and surgical gastroenterologists and nuclear medicine physicians). The role of radionuclide gastroesophageal motor studies is clearly identified in the various steps of patients' management, from the initial diagnostic approach to functional characterization to postoperative follow-up or monitoring of medical therapy.     

Radiological imaging of the upper gastrointestinal tract. Part 1. The esophagus

In the diagnosis of diseases of the esophagus, conventional x-ray evaluation still plays a more important role than endoscopy in the visualization of stenoses. CT plays a major role in the staging of malignancies of the esophagus, while MRI plays does not play a major part in the diagnostic evaluation of the upper GI-tract but is equal to CT for the staging and evaluation of the extent of local infiltration. The main indication for the radiological examination of the esophagus by barium studies is dysphagia. The use of barium allows a functional examination of esophageal motility. Swallow motility disorders can be diagnosed by videofluorography using high frame rate imaging. Zenker's diverticulum and other pulsion diverticula should also be investigated by functional esophageal imaging. Candida esophagitis can be identified by its characteristic ulcerations using barium swallow. The extension of gastroesophageal hernias are more accurately evaluated with barium studies than with endoscopy. The diagnosis of gastroesophageal reflux disease should be made by barium studies, but discrete inflammation as well as epithelial dysplasia are best investigated by classic endoscopy and modern endoscopic techniques. In cases of esophageal carcinoma, radiology adds to the findings of endoscopy and endosonography.     

Radiographic findings in children and young adults with Barrett's esophagus

The upper-gastrointestinal examinations of 32 patients (mean age, 11 years) with histologically proven Barrett's esophagus were reviewed to evaluate the radiologic findings in children. All patients had symptoms of chronic gastroesophageal reflux and/or esophagitis, including atypical findings such as aspiration pneumonia, seizures, and failure to thrive. Fourteen patients had other diseases that might predispose them to abnormal esophageal motility and gastroesophageal reflux. Twenty-five patients had single-contrast and seven patients had double-contrast examinations. Four patients had normal single-contrast studies; 24 had gastroesophageal reflux; 12 had strictures; 10 had esophageal ulcers; and only four had hiatal hernias. The most notable difference between the results of endoscopy and the upper-gastrointestinal studies was the rate of detection of esophageal ulcers. Ten of the patients with single-contrast studies had ulcers seen at endoscopy but not shown radiologically. No specific radiologic signs of Barrett's esophagus were found, although most of our patients had abnormal upper gastrointestinal studies.     

Radiologische Bildgebung des oberen Gastrointestinaltrakts

In the diagnosis of diseases of the esophagus, conventional x-ray evaluation still plays a more important role than endoscopy in the visualization of stenoses. CT plays a major role in the staging of malignancies of the esophagus, while MRI plays does not play a major part in the diagnostic evaluation of the upper GI-tract but is equal to CT for the staging and evaluation of the extent of local infiltration. The main indication for the radiological examination of the esophagus by barium studies is dysphagia. The use of barium allows a functional examination of esophageal motility. Swallow motility disorders can be diagnosed by videofluorography using high frame rate imaging. Zenker’s diverticulum and other pulsion diverticula should also be investigated by functional esophageal imaging. Candida esophagitis can be identified by its characteristic ulcerations using barium swallow. The extension of gastroesophageal hernias are more accurately evaluated with barium studies than with endoscopy. The diagnosis of gastroesophageal reflux disease should be made by barium studies, but discrete inflammation as well as epithelial dysplasia are best investigated by classic endoscopy and modern endoscopic techniques. In cases of esophageal carcinoma, radiology adds to the findings of endoscopy and endosonography.     

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.     

Morphological findings in dynamic swallowing studies of symptomatic patients

The aim of this study was to assess the role of videofluoroscopy in the detection of structural abnormalities of the pharynx and esophagus in patients with different symptoms of impaired deglutition. Dynamic radiographic recording of deglutition was performed in 3193 consecutive patients (1578 men, 1615 women; mean age 54 years) suffering from dysphagia, suspicion of aspiration, globus sensation, and non-cardiac chest pain. We assessed different structural lesions from the oral cavity to the esophagus and classified them into eight categories. Their frequency and association with the different clinical symptoms were evaluated. Videofluoroscopy revealed 1040 structural abnormalities in 833 patients (26%) including mass lesions from the oral cavity to hyoid/larynx ( n=66), pharyngeal diverticula ( n=181), pharyngeal masses ( n=78), other pharyngeal narrowings ( n=71), webs ( n=98), masses ( n=39), and other narrowings ( n=73) of the upper esophageal sphincter, esophageal diverticula ( n=80), esophageal webs, rings and strictures ( n=194), and intrinsic and extrinsic esophageal lesions ( n=160). There was a considerable variance of findings for different symptoms. In a large proportion of symptomatic patients videofluoroscopy detects morphological abnormalities along pharynx and esophagus often combined with functional disorders. This fact underlines the role of videofluoroscopy as a diagnostic test for function as well as morphology.     

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.     

Videofluoroscopy of deglutition in children after repair of esophageal atresia

PURPOSE: To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children. MATERIAL AND METHODS: 19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined. RESULTS: The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient. CONCLUSION: Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.     

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.     

Motility disorders of the esophagus: diagnosis with barium-rice administration

Purpose: To evaluate the role of barium-rice administration for a standardized diagnosis of dysphagia and esophageal motility disorders. Materials and methods: Sixty healthy volunteers and 218 patients with various esophageal disorders (achalasia, scleroderma and other connective tissue diseases, neurologic diseases, esophagitis and others) were examined both by a conventional barium study and by a barium-rice study. The barium-rice meal consisted of barium sulfate and boiled rice, mixed half and half. The time required for esophageal clearance of one sip was measured. Results: Normal esophageal transit time in healthy controls was between 5 and 15 s for both methods. In patients, the conventional barium study revealed a prolonged transit time in only 16.5% (36 of the 218 cases). The barium-rice study was abnormal in 51.8% (113 of 218 cases), independent of the underlying disease. The barium-rice study was pathological in 77 of those 182 patients (42.3%) who had normal barium transit time. In 24 patients the radiologic results were confirmed by endoscopy and manometric measurements. Conclusions: Esophageal motility abnormalities are detected by a barium-rice study with a high sensitivity. With this simple and low-cost method, quantitative and reproducible results can be obtained. Barium-rice administration is a suitable tool for screening and follow-up of patients with dysphagia and esophageal motility disorders.     

Radiologic double-contrast aspects of small esophageal cancers. 38 cases

Double contrast radiological features of thirty eight small esophageal carcinoma are described. Double contrast study is essential in the detection of small esophageal carcinomas: localized thickening of the folds (29%), localized wall stiffness (23.6%), superficial ulcers (13%), discrete superficial nodule (42%), nodularity (15.7%), and ulcerated nodule (15.7%). In our series, six carcinomas arising from reflux esophagitis have the nodular appearance. As in the majority of the cases, small esophageal carcinomas are asymptomatic, when radiologic study of esophagus is performed in patients over 40 years with heavy alcohol and tobacco use, it is imperative to use the double contrast method and to carefully search for minor mucosal abnormalities.     

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     

Swallowing abnormalities in multiple sclerosis: correlation between videofluoroscopy and subjective symptoms

Cartilage degenerative diseases, such as osteoarthritis, affect million of people. Magnetic resonance imaging is presently the most accurate imaging modality in evaluating the state of hyaline cartilage; however, clinical MRI does not accurately reveal early degenerative alterations in cartilage, due mainly to low spatial resolution. Magnetic resonance microscopy (MRM, or μMRI) appears exceptionally well suited to the in vitro or ex vivo study of this heterogeneous tissue, due to its high spatial resolution; however, despite this, further studies are necessary to evaluate the potential of MRM in the detection of early cartilage damage. Herein we briefly review the current applications of MRM in the study of hyaline cartilage. In particular, we review the MR appearance of hyaline cartilage on high-resolution images, the different MRM techniques used to image normal and enzymatically or chemically degraded cartilage and the potential use of contrast agents. The future directions and the relevance of MRM findings for a better understanding of cartilage physiology in health and disease are also discussed. Electronic Publication     

Dynamic radiologic study of deglutition in oro-pharyngeal-laryngeal neoplasms and results of their treatment

Swallowing disorders due to oro-pharyngo-laryngeal cancer, or due to the consequences of surgical resection and radiotherapy, should be accurately evaluated to manage properly both nutritional therapy and dysphagia rehabilitation techniques. The site, size, and local spread of such tumors and, especially, the nature and extent of surgical resection and reconstruction, are important factors which are closely related to the functional disorders of deglutition. The aim of this paper is to demonstrate video-fluoroscopy capability to evaluate the incidence, type, and severity of such functional disorders. For this purpose we studied by means of dynamic radiology 23 patients with oral cancer and 33 patients with pharyngeal-laryngeal cancer, most of them after surgical and/or radiological treatment. Eighty-four per cent of the patients had swallowing disorders such as poor oral processing (25%), retention of the bolus in the pharynx (41%), penetration (41%) or aspiration (37%) of the bolus in the airway, dysmotility of upper esophageal sphincter (9%), and structural lesions (61%). The association of these functional disorders was closely related to the pathological background of each patient. In conclusion, a dynamic radiological study is recommended for both pre and postoperative evaluation of these patients, to choose the appropriate nutritional therapy and dysphagia rehabilitation technique.