Esophageal Fluoroscopy Part 2
Review of esophageal fluoroscopy for radiology board exams, part 2. Check out the free downloadable study guide for this episode by clicking here. Prepare to succeed!
Show Notes/Study Guide:
What is the most classic location of an esophageal web?
The cervical esophagus. These are often thin webs and may be concentric.
An esophageal web, painless dysphagia, and iron-deficiency anemia are the classic clinical triad for which syndrome?
Plummer-Vinson Syndrome. This is most classic in middle aged women. Other associated symptoms can include thyroid goiter, glossitis, splenomegaly, and spoon-shaped nails (koilonychia).
True or false? Esophageal webs pose a potential cancer risk.
True. Esophageal webs raise the risk for both pharyngeal and esophageal carcinoma.
What is medication induced esophagitis?
This is classically focal inflammation and possible ulceration of the esophagus that can occur if a pill becomes lodged in the esophagus, releasing its contents and inflaming or ulcerating the mucosa. This is perhaps most classic for doxycycline ingestion (consider teenager on doxycycline for acne with acute onset night-time esophageal pain after taking doxycycline before bed).
What is glycogenic acanthosis of the esophagus, and how can this present on a barium swallow study?
Glycogenic acanthosis results, as the name suggests, from glycogen accumulation in the lining of the esophagus. This can appear very similar to candida esophagitis on a barium swallow study, and usually manifests as a combination of discrete plaques and small nodules on an esophagram. If they tell you the patient is elderly, and do not mention any potential presence of an immunocompromised state, they may be asking you about glycogenic acanthosis.
What is the classic appearance of eosinophilic esophagitis on a barium esophagram?
A contiguous region of concentric ring-like thickening is the classic appearance of eosinophilic esophagitis on a barium swallow study. Alternatively, or additionally, a longer strictured segment may also be seen. This is most classically seen in young males with dysphagia.
What is the classic appearance of feline esophagus on a barium esophagram?
Buzzwords include fine transient circumferential horizontal transverse folds or bands which typically involve the mid and lower esophagus, potentially due to esophageal muscularis contraction in the setting of GERD which causes shortening and a bunching up of the esophageal mucosa.
What are tertiary contractions of the esophagus?
These are transient esophageal spasms that are often associated with esophageal pain. If severe, these may qualify, upon additional clinical evaluation, as nutcracker esophagus.
What are classic imaging findings of achalasia on a barium esophagram?
Achalasia classically presents as a dilated esophagus above smooth “birds’ beak” stricturing at the gastroesophageal junction. The cause is muscular dysfunction with loss of normal peristalsis in the mid and lower esophagus and loss of normal esophageal sphincter relaxation. However, with achalasia the esophageal sphincter can transiently relax.
True or false? Achalasia increases the risk of esophageal cancer.
True. Esophageal squamous cell carcinoma may result from chronic achalasia. Candida esophagitis is also more prevalent with achalasia.
What is pseudoachalasia?
Pseudoachalasia results from cancer, rather than muscular dysfunction, causing obstruction at the gastroesophageal junction and dilatation of the more proximal esophagus. Another term for pseudoachalasia is secondary achalasia.
What is the classic means whereby a radiologist should attempt to differentiate between achalasia and pseudoachalasia on a barium esophagram?
With the appearance of achalasia, a radiologist must continue watching the gastroesophageal junction to see if the lower esophageal sphincter will eventually relax (confirming achalasia) or if the obstruction is fixed (denoting a possible obstructing mass and pseudoachalasia).
What are esophageal manifestations of scleroderma?
Involvement of the esophagus is very common in scleroderma patients and often causes the lower esophageal sphincter to have insufficient contraction resulting in chronic reflux which may cause stricturing, Barrett’s esophagus, and potential distal esophageal adenocarcinoma. Scleroderma of the esophagus can result in some degree of lower esophageal dilatation. Of course, remember the “hide bound” appearance of the bowel (bunching up of the valvulae conniventes from muscular hypertrophy) as a buzzword for scleroderma, and on board exams consider this if they also show you co-existent lung CT changes of NSIP/interstitial lung disease. Scleroderma of the esophagus also increases risk of candida esophagitis due to motility issues.
How does lye ingestion, or ingestion of another caustic substance, manifest on a barium esophagram?
Classically, caustic ingestion of a substance such as lye causes long-segment esophageal stricturing.
What are key differences between a sliding hiatal hernia and a paraesophageal hernia?
With a sliding hiatal hernia (sometimes termed an axial hernia) the gastroesophageal junction is above the diaphragm, whereas with a paraesophageal hernia the gastroesophageal junction is below the diaphragm, while a portion of the stomach is otherwise above the diaphragm.
True or false? Incarceration of the herniated stomach is more common with a paraesophageal hernia than a sliding type hiatal hernia.
True.
True or false? Esophageal varices can be identified on a barium esophagram.
True. Esophageal varices can manifest as vessel-like (serpentine) filling defects on a double-contrast esophagram. Note that esophageal varices in the lower esophagus are most classically associated with portal hypertension and esophageal varices in the upper esophagus are most classically associated with superior vena cava obstruction.
What is dysphagia lusoria?
Dysphagia lusoria is dysphagia due to esophageal compression by an aberrant right subclavian artery. This can manifest on a barium esophagram as a vascular smooth impression on the posterior esophageal wall on a lateral view of the esophagus.
What are differential considerations for this appearance—smooth impression on the posterior esophageal wall on the lateral view?
This can be seen with a right aortic arch with an aberrant left subclavian artery, or a left aortic arch with an aberrant right subclavian artery.
An additional consideration would be a double aortic arch, which causes compression of both the posterior esophagus, and anterior trachea, though only the esophageal compression would be seen on a barium esophagram, but both could potentially be seen on radiography in a lateral view with barium in the esophagus. CT or MRI would provide optimal evaluation.
A pulmonary sling compresses which portion of the esophagus—anterior or posterior?
A pulmonary sling compresses the anterior aspect of the esophagus, and the posterior aspect of the trachea, due to course between the trachea and esophagus.
True or false? Innominate artery compression causes compression on the esophagus.
False. This compresses the anterior trachea only.
