Diagnositc Imaging of the Esophagus

1. Gastro-Intestinal Tract
Esophagus

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. -Oblique view of a
normal barium
swallow shows the
normal impressions
made by the (A) aortic
arch , (B) left
mainstem bronchus
and (LA) left atrium
on the esophagus

7. Esophagus
a) Diverticulum
b) Esophageal Ulceration
c) Esophageal Tumors
d) Smooth Esophageal Strictures
e) Irregular Esophageal Strictures
f) Motility Disorders
g) Hiatus Hernia
h) Esophageal Atresia & Tracheo-Esophageal
Fistula

8. a) Pharyngeal / Esophageal Pouches &
Diverticula :
-Upper Third
-Middle Third
-Lower Third

11. -Upper Third :
1-Zenker’s Diverticulum
2-Lateral Pharyngeal Pouch & Diverticulum
3-Lateral Cervical Esophageal Pouch &
Diverticulum

12. 1-Zenker’s Diverticulum :
a) Site
b) Radiographic Features

13. a) Site :
-Pulsion diverticulum originates in the midline of
the posterior wall of the hypopharynx at an
anatomic weak point known as Killian's
dehiscence (above cricopharyngeus at fiber
divergence with inferior pharyngeal constrictor) ,
during swallowing increased intraluminal
pressure forces mucosa to herniate through the
wall

16. b) Radiographic Features :
1-Plain Radiography :
-Lateral view , air fluid level

17. An air-fluid level is visible in the upper mediastinum (arrows) , the
lateral view shows anterior displacement of the trachea (arrows) by
a retrotracheal mass

18. Air fluid level in the superior mediastinum

19. 2-Barium Swallow :
-An (intermittent) outpouching arising from
the midline of the posterior wall of the
distal pharynx near the
pharyngoesophageal junction
-The pouch is best identified during
swallowing and is best seen on the lateral
view on which the diverticulum is typically
noted at the C5-6 level

25. 2-Lateral Pharyngeal Pouch & Diverticulum :
-Through the unsupported thyrohyoid membrane in
the anterolateral wall of the upper hypopharynx
-Pouches are common and patients are usually
asymptomatic
-Diverticula are uncommon and are seen in
patients with chronically elevated
intrapharyngeal pressure (e.g. glass blowers)

28. 3-Lateral Cervical Esophageal Pouch &
Diverticulum : (Killian-Jamieson)
-Through the Killian-Jamieson space
-Pouches are transient
-Diverticula are persistent
-Patients are usually asymptomatic
-The opening is below the level of
cricopharyngeus

29. AP view of barium swallow showing a small killian-
Jamieson diverticulum (arrow)

30. Left : Frontal view from a barium swallow shows an outpouching of
barium (white arrow) arising laterally from the cervical esophagus
Right : The diverticulum (yellow arrow) is anterior to the normal
esophagus

33. -Middle Third : (TID)
1-Traction
2-Developmental
3-Intramural

34. 1-Traction :
-At level of carina
-May be related to fibrosis after treatment for
TB
-Asymptomatic

36. 2-Developmental :
-Failure to complete closure of tracheo-
esophageal communication

37. 3-Intramural (Oesophageal Intramural
Pseudodivertoculosis “OIPD”) :
-Rare
-Multiple , tiny flask-shaped outpouchings
-90% have associated strictures
-Mainly in the upper third of the esophagus

39. -Lower Third :
1-Epiphrenic
2-Ulcer
3-Mucosal Tears
4-After Heller's operation

40. 1-Epiphrenic :
-Occur less frequently than ZD , comprising
less than 10% of all oesophageal
diverticula

41. Barium swallow shows large epiphrenic diverticulum
(arrow)

43. 2-Ulcer :
-Peptic or related to steroids / immunosuppression
and radiotherapy
3-Mucosal Tears :
-Mallory-Weiss syndrome , postesophagoscopy
4-After Heller's operation

44. b) Esophageal Ulceration :
-Inflammatory
-Neoplastic

45. -Inflammatory :
1-Reflux Esophagitis
2-Barrett’s Esophagus
3-Candida Esophagitis
4-Viral
5-Caustic Ingestion
6-Radiotherapy
7-Crohn’s Disease
8-Drug Induced
9-Behcet’s Disease
10-Intramural Diverticulosis

46. 1-Reflux Esophagitis :
-With or without hiatus hernia
-Signs characteristic of reflux esophagitis :
a) A gastric fundal fold crossing the gastro-
esophageal junction
b) Erosions , clots or linear streaks of
barium in the distal esophagus
c) Ulcers , round or more commonly linear
or serpiginous

47. Reflux

48. Air-contrast esophagram shows thick esophageal mucosal folds (arrows) and
an ulcer (arrowhead) due to GERD , single contrast esophagram shows
stricture (arrow) and sliding hiatus hernia

49. On the left Irregular stricture (arrowhead) and erosions (arrows) due to GERD

50. 2-Barrett’s Esophagus :
-Esophagus is abnormally lined with columnar
acid-secreting gastric mucosa
-It is usually due to chronic reflux esophagitis
-The diagnosis is strongly suggested by :
a) Mid or high esophageal ulcer
b) Mid or high esophageal web-like stricture
c) Reticular mucosal pattern
d) Hiatus hernia in 75-90% of patients

51. Barrett's , Upper GI swallow of patient with Barrett's esophagus , arrow
points to new transition point of squamo-columnar junction. , note
the irregularities of the mucosa inferior to transition point

52. Double-contrast esophagography shows a smooth stricture in the
midesophagus , multiple ulcerations in the region of the stricture are
seen , note the reticular mucosal appearance extending down from
the inferior aspect of the stricture

53. Reticular mucosa and web like stricture (arrow)

54. 3-Candida Esophagitis :
-In immunocompromised patients
-Discrete plaque-like lesions
-Larger plaques may coalesce to produce
"cobblestone" appearance
-Ulcers invariably appear only on a background of
diffuse plaque formation , not as isolated
findings
-Further coalescence produces (shaggy) contour

55. Shaggy esophagus associated with Candida infection , image "A" depicts the
longitudinally oriented plaque-like lesions visible in Candida esophagitis , image "B"
depicts the granular appearance of the esophageal mucosa secondary to edema and
inflammation

56. A double contrast esophagogram demonstrates difuse ulceration ,
thickened folds and mildly “shagy” borders in the distal esophagus

57. The esophagus is dilated and has “shagy” borders and
difuse ulceration , an area of narowing is present in the
proximal third of the esophagus

58. Double-contrast esophagram shows markedly nodular
mucosa with multiple discrete ulcers covering all of
esophagus

59. Numerous fine erosions and small plaques due to Candida
albicans in immunocompromised patient

60. 4-Viral :
-Herpes and CMV occurring mostly in
immunocompromised patients
-May manifest as discrete ulcers , ulcerated
plaques or mimic Candida esophagitis
-Discrete ulcers on an otherwise normal
background mucosa are strongly suggestive of a
viral etiology
-Herpes Simplex , small ulcers < 5 mm
-CMV , large ulcers

61. Herpes , double-contrast
esophagram shows small
discrete ulcers (arrows) in the
midesophagus on a normal
background mucosa , note the
radiolucent mounds of edema
surrounding the ulcers , in the
appropriate clinical setting ,
this appearance is highly
suggestive of herpes
esophagitis since ulceration in
candidiasis almost always
occurs on a background of
diffuse plaque formation

62. Cytomegalovirus
esophagitis in a
patient with AIDS
Double-contrast
esophagram shows a
large flat ulcer in
profile (large arrows)
in the midesophagus
with a cluster of small
satellite ulcers (small
arrows)

63. AIDS patient with an infectious esophagitis due to Cytomegalovirus. ,
such giant ulcers can also be due to HIV alone

64. 5-Caustic Ingestion :
a) Acute stage :
-In the first 10 days from ingestion , acute necrosis
with mucosal blurring and dilated atonic
esophagus
b) Subacute stage :
-10 to 20 days after ingestion and characterized by
esophageal ulceration
c) Chronic stage :
-Occurs after 21 days at which esophageal
inflammation healed by fibrosis resulted in
stricture

65. Image "A" and "B" both depict ulcerations of the distal esophageal
mucosa secondary to lye ingestion , image "C" depicts irregular
narrowing of the esophagus with ulcerations

67. 6-Radiotherapy :
-Double contrast studies can demonstrate
superficial esophageal ulceration as shallow
irregular collections of barium within 7 to 10 days
of radiotherapy
-In severe cases , the esophagus may have an
irregular serrated contour due to ulceration and
sloughing
-After this acute phase , the most frequent finding
on contrast studies is abnormal esophageal
motility

68. 7-Crohn’s Disease :
- Aphthous ulcers

69. Aphthous ulcers (arrows) , this is an uncommon manifestation of
Crohn's disease , the figure on the right shows the more common
colonic aphthous ulcers

70. 8-Drug Induced :
-Due to prolonged contact with tetracycline ,
quinidine and potassium supplements
9-Behcet’s Disease
10-Intramural Diverticulosis

71. -Neoplastic :
1-Carcinoma
2-Leiomyosarcoma and leiomyoma
3-Lymphoma
4-Melanoma

72. c) Esophageal Tumors :
-Benign Tumors :
1-Leiomyoma , 50%
2-Fibrovascular polyp , 25%
3-Cysts , 10%
4-Papilloma , 3%
5-Fibroma , 3%
6-Hemangioma , 2%

73. -Leiomyoma :
a) Incidence
b) Radiographic Features

74. a) Incidence :
-Most common benign tumor of the
esophagus
-It is most frequently presents in young and
middle age groups

75. b) Radiographic Features :
1-Barium Swallow
2-CT

76. 1-Barium Swallow :
-May be seen as a discrete ovoid mass that
is well outlined by barium
-Its borders form slightly obtuse angles with
the oesophageal wall

77. On the left an asymptomatic patient with a leiomyoma , on the chest
film an abnormal opacity is seen behind the heart (arrow) , the
barium study demonstrates a lobulated mass (arrow) that does not
obstruct despite its large size

78. A calcified esophageal mass is almost always a leiomyoma , on the left a
patient with a calcified esophageal lesion (arrows) protrudes into
azygoesophageal recess on radiograph , lesion (arrow) on CT and surgical
specimen radiograph showing calcification

79. The ovoid filling defects caused by the leiomyoma , the smooth surface
and obtuse angles formed are characteristic of submucosal masses

80. 2-CT :
-Ovoid intramural solitary mass with a smooth
surface
-The presence of calcification is almost
pathognomonic
-Narrowing of esophageal lumen
-May displace the esophagus
-Moderate diffuse contrast enhancement
-No signs of invasion of adjacent tissue

83. -Malignant :
1-Squamous cell carcinoma , 75%
2-Adenocarcinoma , 25% , usually in distal
esophagus at GEJ
3-Lymphoma
4-Leiomyosarcoma
5-Metastasis

84. 1-Squamous Cell Carcinoma :
a) Incidence
b) Patterns
c) Radiographic Features

85. a) Incidence :
-Squamous cell carcinomas are associated
with :
1-Head and neck cancers
2-Smoking
3-Alcohol
4-Achalasia
5-Lye ingestion

86. b) Patterns :
1-Infiltrative
2-Polypoid
3-Annular stenotic
4-Ulcerative
5-Varicoid

88. Infiltrative ulcerated carcinoma , esophageal carcinoma with ulcerations
(arrows) and sharp right angle junction with esophageal wall
(arrowheads)

89. Left : Small polypoid carcinoma , right : Large polypoid lesion

90. Left : long irregular distal stricture due to carcinoma , right : distal
narrowing is not tapered and more proximal than achalasia ,
irregularity (arrow) at narrowed site is subtle but persistent

91. Varicoid carcinoma , unchanging appearance of filling defects indicate
tumor rather than varices , note sharp upper margin of lesion and
ulceration (arrows)

92. (a) AP orthostatic projection shows several filling defects in the middle and distal
segments of the esophagus , (b) Left posterior oblique projection shows sharply
marginated longitudinal and serpentine lesions that mimic varices and that did not
change in size or configuration with respiratory maneuvers or repositioning of the
patient ,esophageal peristalsis was normal

93. c) Radiographic Features :
1-Plain Radiography
2-Barium Swallow
3-CT

94. 1-Plain Radiography :
Many indirect signs can be sought on a chest
radiograph and these include :
-Widened azygo-oesophageal recess with
convexity toward right lung (in 30% of distal and
mid-oesophageal cancers)
-Thickening of posterior tracheal stripe and right
paratracheal stripe >4 mm (if tumor located in
upper third of esophagus)
-Widened mediastinum
-Tracheal deviation

95. -Posterior tracheal indentation / mass
-Retrocardiac mass
-Esophageal air-fluid level
-Lobulated mass extending into gastric air
bubble
-Repeated aspiration pneumonia (with
tracheo-oesophageal fistula)

96. -The azygo-esophageal
recess (AER) is a
prevertebral space
formed by the
interface of the
posteromedial right
lower lobe of the lung
and the azygos vein
and esophagus

97. Normal Widened
-The right paratracheal stripe is a normal finding on the frontal CXR and
represents the right tracheal wall , adjacent pleural surfaces and
any mediastinal fat between them , it is visible because of
the silhouette sign created by air within the trachea medially and air within
the lung laterally , It normally measures less than 4 mm

98. 2-Barium Swallow :
-Esophageal cancer may appear as an infiltrating , polypoid
, ulcerative or varicoid lesion
-Infiltrating cancers show irregular narrowing of the lumen
with an associated nodular or ulcerated mucosa with
well-defined borders
-Polypoid lesions are usually greater than 3.5 cm in
diameter and appear as lobulated or fungating
intraluminal masses with possible areas of ulceration
-Ulcerative carcinomas appear as well-defined ulcers with a
radiolucent rim of tumor surrounding the ulcer
-Varicoid carcinomas mimic esophageal varices and
therefore appear as thickened tortuous or serpiginous
filling defects because of the submucosal spread of the
cancer

99. Squamous cell carcinoma , A-Polypoid lesion , B-Multiple polypoid tumors , C-
Long ulcerative tumor , D-Stenotic, infiltrative tumor

100. Irregular stricture in the esophagus with ulceration of the esophageal mucosa ,
also noticed the shouldered margins of the lesions

101. Carcinoma esophagus , a barium swallow showing irregular narrowing
with "shouldered edges" suggestive of a malignant stricture

104. 3-CT :
-Eccentric or circumferential wall thickening > 5mm
-Peri-esophageal soft tissue and fat stranding
-Dilated fluid and debris-filled oesophageal lumen
is proximal to an obstructing lesion
-Tracheobronchial invasion appears as
displacement of the airway (usually the trachea
or left mainstem bronchus) as a result of mass
effect by the oesophageal tumor
-Aortic invasion

110. 2-Adenocarcinoma :
a) Incidence
b) Patterns
c) Radiographic Findings

111. a) Incidence :
-Associated with Barrett's esophagus
-Less common than SCC
-Usually in distal esophagus at GEJ
b) Patterns :
-As before
c) Radiographic Features :

112. Image "A" the red arrows show mucosal invasion with ulceration
whereas the yellow arrow points out a stricture at the GE junction ,
in image "B“ , an irregular filling defect in the distal esophagus
associated with adenocarcinoma

115. Barrett's esophagus with ulcerated (arrow) adenocarcinoma

116. 3-Lymphoma :
-Because the esophagus and stomach do
not normally have lymphocytes , primary
lymphoma is rare unless present from
inflammation
-Secondary metastatic lymphoma is more
common
-Radiographic Features : as before

117. (A) A barium swallow revealed a well-demarcated submucosal mass
(arrowheads) of 10×3×3 cm in size in the upper thoracic esophagus without
surface ulceration or a stalk , (B) CT showed a sharply demarcated
homogeneous mass within the esophagus , note the eccentric location ,
crescent-shape esophageal lumen (compressed by the mass) and the
laterally displaced trachea

118. 4-Leiomyosarcoma :
-Polypoidal regular outline filling defect

119. Barium Swallow showing a smooth filling defect in mid-esophagus

120. Large lesion distorts esophageal lumen , CT shows lesion distorting but
not obstructing esophageal lumen (arrow)

121. 5-Metastasis :
-Direct (Thyroid , Lung & Stomach)
-Nodal (Lung , breast)
-Blood borne (Melanoma)

122. -Left : normal esophagus , Right : Mediastinal nodes (arrows) displace
esophagus to right
-The esophagus (arrow) protrudes under aortic arch into right side of AP
window , next to it mediastinal nodes (arrows) that displace the esophagus
to right in a patient with bronchogenic carcinoma

123. d) Smooth Esophageal Strictures :
1-Inflammatory
2-Neoplastic
3-Iatrogenic
4-Achalasia

124. 1-Inflammatory :
a) Peptic
b) Scleroderma
c) Corrosives

125. a) Peptic :
-The stricture develops relatively late
-Most frequently at the GEJ and associated
with reflux and a hiatus hernia
-Less commonly , more proximal in the
esophagus and associated with
heterotopic gastric mucosa (Barrett's
esophagus) ± Ulceration

126. b) Scleroderma :
1-Incidence
2-Associations
3-Radiographic Features

127. 1-Incidence :
-The esophagus is affected in 80% of
scleroderma cases , symptoms include
heartburn and dysphagia

128. 2-Associations : CREST
-C : Calcinosis
-R : Reynaud's phenomenon
-E : Esophageal dysmotility
-S : Sclerodactyly
-T: Telangiectasia

129. 3-Radiographic Features :
-Dilatation of distal 2/3 of the esophagus
-Aperistalsis
-Free reflux >> stricture

130. Barium swallow of patient with scleroderma , note the
dilated esophagus (arrows)

133. c) Corrosives :
-See before

134. 2-Neoplastic :
a) Leiomyoma
b) Carcinoma
c) Mediastinal Tumors (carcinoma of the
bronchus and lymph nodes)

135. 3-Iatrogenic :
-Prolonged use of a nasogastric tube
-Stricture in distal esophagus probably
secondary to reflux
4-Achalasia :
-See later

136. e) Irregular Esophageal Strictures :
1-Inflammatory
2-Neoplastic
3-Iatrogenic

137. 1-Inflammatory :
a) Reflux :
-Rarely irregular
b) Crohn’s Disease :
-Rare

138. 2-Neoplastic :
a) Carcinoma
b) Leiomyosarcoma
c) Lymphoma
3-Iatrogenic :
a) Radiotherapy , rare
b) Fundoplication

139. f) Motility Disorders :
1-Tertiary Contractions
2-Diffuse Esophageal Spasms (DES)
3-Achalasia
4-Chalasia
5-Scleroderma
6-Chaga’s Disease

140. 1-Tertiary Contractions :
-Normally , there is a wave of relaxation
precedes a contractile wave propelling the
bolus along the esophagus
-Tertiary contractions , uncoordinated non-
propulsive contractions , asymptomatic
-Seen in : elderly , alcoholics , GERD & HH

141. -Causes of tertiary contractions in the esophagus :
1-Reflux esophagitis
2-Presbyoesophagus (impaired motor function due to
muscle atrophy in the elderly , occurs in 25% of people >
60 years)
3-Obstruction at the cardia
4-Neuropathy :
-Early achalasia (before dilatation occurs)
-DM
-Alcoholism
-Malignant infiltration
-Chaga’s disease

142. 2-Diffuse Esophageal Spasms (DES) ,
Cork-Screw , Nutcracker :
-Symptoms include chest pain , dysphagia
and gastro-oesophageal regurgitation
disease
-Barium swallow shows diffuse oesophageal
spasm with simultaneous and
uncoordinated contractions

145. 3-Achalasia :
a) Etiology
b) Radiographic Features

146. a) Etiology :
-Failure of relaxation of GOJ when the
contractile wave arrives , the esophagus
retains much of its contents then dilates
progressively

147. b) Radiographic Features :
1-Plain Radiography
2-Barium Swallow

148. 1-Plain Radiography :
-Dilated esophagus with air-fluid level ,
characteristic linear shadow extends along the
right side of mediastinum
-Mottled appearance in superior mediastinum (due
to mixture of air & retained fluid in the dilated
esophagus)
-Superior mediastinum air-fluid level
-Small / absent of gastric air bubbles
-Anterior displacement and bowing of trachea on
the lateral view
-Pneumonia & basal fibrosis

153. 2-Barium Swallow :
-Two diagnostic criteria must be met :
*Primary and secondary peristalsis absent
throughout esophagus
*LES fails to relax in response to swallowing
-Tertiary waves
-Beaked tapering at GEJ

159. 4-Chalasia :
-GOJ is lax and widely patent
5-Scleroderma :
-See before
6-Chaga’s Disease :
-Megaesophagus , aperistalsis & bird's beak
appearance at GEJ (achalasia look-alike)

160. g) Hiatus Hernia :
1-Definition
2-Types

161. 1-Definition :
-Occurs where there is herniation
of stomach through the oesophageal
hiatus of the diaphragm

162. 2-Types :
a) Sliding Hernia
b) Paraesophageal (Rolling) Hernia
c) Mixed Type

163. a) Sliding Hernia :
-This is the most common type of hiatus
hernia (95%)
-The gastro-esophageal junction (GOJ) is
usually displaced by more than 1cm above
the hiatus
-The oesophageal hiatus is often abnormally
widened to 3-4cm

164. b) Paraesophageal (Rolling) Hernia :
-The rolling (paraesophageal) hiatus hernia
is much less common than the sliding type
-The GOJ remains in its normal location
while a portion of the stomach herniates
above the diaphragm

165. c) Mixed Type :
-The mixed or compound hiatal hernia is the most
commonest type of paraesophageal hernia
-The GOJ is displaced into the thorax with a large
portion of the stomach which is usually
abnormally rotated , in these hernias where
large portions of the stomach may be contained
within the thoracic cavity , there are
significant risks for volvulus , obstruction and
ischemia

166. Sliding Rolling Mixed

168. 1-Normal 2-Sliding 3-Rolling

169. Sliding Rolling

170. Sliding Hernia

171. Sliding Hernia

172. Sliding Hernia

173. Rolling Hernia

174. Rolling Hernia

175. h) Esophageal Atresia & Tracheo-
Esophageal Fistula :
1-Definition
2-Incidence
3-Types
4-Radiographic Features

176. 1-Definition :
-Esophageal Atresia :
Absence in contiguity of the esophagus due to an
inappropriate division of the primitive foregut into
the trachea and esophagus
-TOF :
Congenital pathological communication between
the trachea and esophagus

177. 2-Incidence :
-Tracheo-oesophageal fistula
and esophageal atresia have a combined
incidence of approximately 1 in 3500 liver
birth

178. 3-Types :
a) Proximal atresia with distal fistula : 85 %
b) Isolated oesophageal atresia : 8-9 %
c) Isolated fistula (H-type) : 4-6 %
d) Double fistula with intervening atresia : 1-
2 %
e) Proximal fistula with distal atresia : 1%

180. 4-Radiographic Features :
a) Antenatal U/S
b) Plain Radiography
c) Barium Swallow

181. a) Antenatal U/S :
-Antenatal ultrasound may shows
polyhydramnios or even in some cases a
distended proximal blind ending
esophagus

182. b) Plain Radiography :
-Demonstration of the nasogastric tube curled in
the proximal esophagus in a child where
passage of the tube has been unsuccessful is
usually sufficient for diagnosis
-The presence of air in the stomach and bowel in
the setting of oesophageal atresia implies that
there is a distal fistula
-Often the lungs demonstrate areas of
consolidation / atelectasis due to recurrent
aspiration

183. Esophageal Atresia with TOF

184. TOF with lung atelectasis

185. c) Barium Swallow :
-H-type fistulas can be difficult to diagnose
and may require contrast studies , looking
for contrast passing into the tracheo-
bronchial tree

186. H-Type