Cervical thorotrast granuloma: An iatrogenic cause of dysphagia

Thorotrast granuloma of the neck is an extensive benign connective tissue overgrowth secondary to localized extravasation of contrast. This can present with dysphagia secondary to mass effect or motor disorder of swallowing related to demyelinization of the ninth through twelfth cranial nerves. The radiographic appearance is characteristic in both location and density.     

Evaluation of the esophagus with a marshmallow bolus: Clarifying the cause of dysphagia

We reviewed the radiographic examinations of the esophagus and medical records in 117 patients (55 women and 62 men; mean age, 52 years) in which a marshmallow bolus was also given. A one-third to one-half piece of a standard marshmallow was used with a mean size of 23 mm (±4.5 mm SD) measured in vivo. In 62 patients with no intrinsic structural narrowing of the esophagus, impaction occurred in only seven (11%). Four of these patients had an esophageal motility disorder, and three had a previous Nissen fundoplication. The remaining 55 patients had lower esophageal mucosal rings (47) or peptic strictures (8). Marshmallow impaction was seen in 27 of 47 rings (57%) and was inversely related to ring size, and in six of eight strictures (75%). Also, impaction was related to the ratio of bolus size to ring caliber, and invariably occurred when this ratio was greater than 1.5. Dysphagia was the presenting complaint in 76 (65%) patients, but was found equally in those without intrinsic narrowing and in those with ring or stricture. However, dysphagia was reproduced by the marshmallow bolus only in patients with esophageal narrowing or abnormal motility.     

Hemiazygos vein as a cause of posterior indentation of the esophagus: A case report

The hemiazygos vein crosses the midline at the level of D8 between the esophagus and spine to join the azygos vein. Any condition causing dilatation, from either obstruction or collateralization, can dilate the hemiazygos vein and produce posterior indentation of the esophagus. This vein is collapsible so it can easily be wedged between the esophagus and thoracic spine. Although various causes of indentations on the posterior wall of the esophagus have been described, we are not aware of any previous report of an esophageal impression from a dilated hemiazygos vein and therefore report such a case.     

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.     

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.     

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.     

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.     

Squamous cell carcinoma of the esophagus in patients with Acquired Immunodeficiency Syndrome

Two patients with Acquired Immunodeficiency Syndrome (AIDS) and infectious esophagitis developed squamous cell carcinoma of the esophagus. The clinical, radiographic, and endoscopic presentations in both cases were atypical. One patient developed a focal flat lesion that imitated segmental esophagitis, and the other patient developed a superficially spreading carcinoma that mimicked diffuse esophagitis. In the setting of AIDS, a changing radiographic or endoscopic mucosal pattern requires biopsy to exclude the possibility of a superimposed squamous cell carcinoma.     

Barrett's esophagus in scleroderma: Increased prevalence and radiographic findings

Ten of 27 patients (37%) with scleroderma who underwent endoscopy at our hospital between 1980 and 1984 for symptoms of reflux esophagitis had biopsy-proven Barrett's esophagus. Two of those 10 patients had esophageal adenocarcinomas. In a blinded review of esophagrams (all but 2 using double-contrast technique) from 16 of the 27 patients, only 1 patient was thought to be at high risk for Barrett's esophagus due to a high esophageal stricture with an adjacent reticular pattern of the mucosa. The latter patient had biopsy-proven Barrett's mucosa. Eight patients were thought to be at moderate risk for Barrett's esophagus due to reflux esophagitis and/or distal strictures in 6 and polypoid intraluminal masses in 2. Three of the 6 patients with esophagitis and/or strictures had Barrett's esophagus, and both patients with masses had adenocarcinomas arising in Barrett's mucosa. Finally, 7 patients who had no esophagitis or strictures were thought to be at low risk for Barrett's esophagus. None of those 7 had histologic evidence of Barrett's mucosa. Thus, the major value of double-contrast esophagography is its ability to classify patients into high-, moderate-, and low-risk for Barrett's esophagus to determine the relative need for endoscopy and biopsy in these patients.     

Gastrobronchial fistula: An unusual complication of Nissen fundoplication

Gastrobronchial fistula is a rare complication of antireflux surgery. Presentation can be subacute, with only productive cough. Endoscopy often fails to visualize these fistulae. Barium in the bronchial tree during postoperative upper gastrointestinal series is diagnostic, but can be confused with that appearing due to aspiration. Every case reported after antireflux surgery has followed intrathoracic Nissen fundoplication.     

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.     

Mucocele of the surgically isolated esophagus

A large esophageal mucocele causing chest pain developed in a 26-year-old woman who had undergone esophageal bypass surgery and gastric interposition because of involvement by scleroderma. Computed tomographic (CT) scans showed the mucocele as an elongated mediastinal mass which spontaneously reduced in size during conservative management. The clinical and radiological features of this unusual postsurgical complication are herein reviewed.     

Circumferential web of the upper esophagus

Two patients with circumferential webs of the upper esophagus are presented. Both patients had a long history of intermittent dysphagia, particularly with solid food. The clinical, endoscopic, and radiologic features of these webs are discussed.     

Double-contrast examination of the esophagus

A simple technique for double-contrast esophagography is described. The technique involves successive swallows of an excellent coating barium mixture and water to create the double contrast effect. Clinical and radiologic situations in which double-contrast esophagography have proven helpful include: (a) the detection of small esophageal tumors; (b) delineation of the morphologic features of neoplastic and inflammatory disease; and (c) assessment of the total vertical extent of esophageal disease. Accurate and/or confident diagnosis is aided considerably with double-contrast esophagography.     

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.     

Lymphatic metastases to the esophagus

The authors present 4 cases of esophageal involvement by lymphatic spread of tumors originating in the stomach, distal esophagus, and thyroid. Double-contrast radiographs of the esophagus showed discontinuous submucosal extension and multiple polypoid masses.     

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.     

Gastric interposition following transhiatal esophagectomy: Radiographic evaluation

Gastric interposition was achieved in 138 patients following transhiatal esophagectomy without thoracotomy. Among these, 33 had benign and 105 malignant lesions. All patients were evaluated on the 10th postoperative day with a barium swallow examination. However, if an anastomotic leak was suspected clinically before this time, a water-soluble contrast study was initially obtained. Early postoperative complications included anastomotic leaks (15), cricopharyngeal incoordination with aspiration (6), and gastric perforation (2). Late postoperative complications included anastomotic strictures (12), pyloric stenosis (4), recurrence of tumor (3), and transhiatal visceral herniation (2). Our technique of postoperative radiographic evaluation, particularly when a leak is suspected clinically, is discussed.     

Hemangiomas of the esophagus

Two cases of hemangioma of the esophagus are reported. The literature, etiology, clinical and radiologic findings, and therapeutic approach are reviewed.