The document describes the gastro-intestinal tract, focusing on the esophagus. It discusses the anatomy of the esophagus and various pathologies that can affect it, including webs, diverticula, esophagitis from different causes, and tumors. Esophageal cancers are highlighted, including squamous cell carcinoma and adenocarcinoma, which typically appear on imaging as infiltrative lesions, polyps, strictures or ulcers. Benign tumors like leiomyomas are also addressed.

1. Gastro-Intestinal Tract
Esophagus

3. Esophagus
• 4 parts:
• Cervical:from cricoid to sternoclavicular
joint
• Thoracic:
o Upper-from thoracic inlet to carina
o Middle)-proximal & distal halves of the part
o Lower )that lies btw carina & GEJ.8 cm
each

4. Esophagus
a) Esophageal webs
b) Esophageal Diverticulae
c) Achalasia of the cardia
d) Esophageal strictures
e) Esophagitis
f) Esophageal motility disorders
g) Esophageal neoplasms

5. a) Esophageal webs
• Congenital/acquired
• Thin membranes 2-3 mm thick
• Pain,dysphagia
• Normal esophageal mucosa &
submucosa
Congenital webs:
• Middle & inferior thirds
• Circumferential with central/eccentric
orifice

6. Acquired
webs
• More common
• Cervical area
• Selective dysphagia(solids>liquids),
• thoracic pain
• Nasopharyngeal reflux
• Aspiration
• Plummer-Vinson syndrome

7. thin projections on the anterior esophageal
wall or multiple upper (cervical)
esophageal constrictions consistent with
esophageal webs.

8. Esophageal diverticulae:
• Zenker’s Diverticulum
• Mid esophageal diverticulum
• Epi-phrenic diverticulum
Saccular outpouchings –thoracic portion of
esophagus
Asymptomatic
Large diverticulae-dysphagia &
regurgitation

9. 1-Zenker’s Diverticulum
• Unknown etiology

10. a) Site :
• A Zenker diverticulum is a pulsion-
pseudodiverticulum and results from herniation of
mucosa and submucosa through the Killian triangle
(or Killian dehiscence), a focal weakness in the
hypopharynx at the normal cleavage plane
between the fibers of the two parts of the inferior
pharyngeal constrictor muscle - the
cricopharyngeus and thyropharyngeus. during
swallowing increased intraluminal pressure forces
mucosa to herniate through the wall
• Dysphagia,regurgitation,aspiration,neck mass

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

14. 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

15. 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

20. Mid esophageal diverticulae :
• true diverticulae-contains all 3 esophageal
layers
• traction from fibrous adhesions by lymph
node infection(TB)
• pulsion from increased intraluminal
pressure

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

24. Epiphrenic diverticulae:
• Occur less frequently than ZD ,
comprising less than 10% of all
oesophageal diverticula
• Usually a/w achalasia/distal esophageal
stricture
• False diverticulae involving herniation of
mucosa & submucosa through the
muscular layer of esophagus
• Increased intraluminal pressure a/w
distal obstruction

25. Barium swallow shows large epiphrenic diverticulum
(arrow)

26. Esophagitis:
1-Reflux Esophagitis
2-Barrett’s Esophagus
3-Candida Esophagitis
4-Viral
5-Caustic Ingestion
6-Radiation
induced
7-Crohn’s Disease
8-Drug Induced

27. 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

28. Reflux
esophagitis

29. Air-contrast esophagogram shows thick
esophageal mucosal folds (arrows) and an ulcer
(arrowhead) due to GERD.
Single contrast esophagogram shows stricture
(arrow) and sliding hiatus hernia

30. 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

31. 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

32. 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

33. 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

34. 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

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

36. 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

37. Herpes, double-contrast
esophagogram 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

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

39. 5-Caustic esophagitis :
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

40. 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

41. 6-Radiation induced esophagitis :
-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

42. 7-Crohn’s Disease :
- Aphthous ulcers

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

44. 8 Drug Induced :
-Due to prolonged contact with tetracycline ,
quinidine and potassium supplements

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

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

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

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

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

50. 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

51. 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

52. 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

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

54. 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

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

57. 1-Squamous Cell Carcinoma :
a) Incidence
b) Patterns
c) Radiographic Features

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

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

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

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

63. 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

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

65. (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

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

67. 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

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

69. -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

70. 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

71. 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

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

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

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

76. 3-CT :
-Eccentric or circumferential wall thickening > 5mm
-Peri-esophageal soft tissue and fat stranding
-Dilated fluid and debris-filled oesophageal lumen
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

77. • Eccentric or
circumferential wall
thickening >5 mm
• Periesophageal soft
tissue & fat stranding
• Dilated fluid-filled
esophagus proximal
to the lesion
• Tracheo bronchial &
aortic invasion

78. 2-Adenocarcinoma :
a) Incidence
b) Patterns
c) Radiographic Findings

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

80. 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

81. 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

82. (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

83. 4-Leiomyosarcoma :
-Polypoidal regular outline filling defect

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

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

86. 5-Metastasis :
-Direct (Thyroid , Lung & Stomach)
-Nodal (Lung , breast)
-Blood borne (Melanoma)

87. -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

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

89. 1-Inflammatory :
a) Peptic
b) Scleroderma
c) Corrosives

90. 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

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

93. 1-Incidence :
-The esophagus is affected in 80% of
scleroderma cases , symptoms include
heartburn and dysphagia

94. 2-Associations : CREST
-C : Calcinosis
-R : Reynaud's phenomenon
-E : Esophageal dysmotility
-S : Sclerodactyly
-T: Telangiectasia

95. 3-Radiographic Features :
-Dilatation of distal 2/3 of the esophagus
-Aperistalsis
-Free reflux >> stricture

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

97. 2-Neoplastic :
a) Leiomyoma
b) Carcinoma
c)Mediastinal Tumors (carcinoma of the
bronchus and lymph nodes)

98. 3 Iatrogenic :
-Prolonged use of a nasogastric tube
-Stricture in distal esophagus probably
secondary to reflux
4 Achalasia :
-See later

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

100. 1-Inflammatory:
Reflux esophagitis:
-Rarely irregular

101. 2-Neoplastic :
a) Carcinoma
b) Leiomyosarcoma
c) Lymphoma
3-Iatrogenic :
a) Radiotherapy , rare
b) Fundoplication

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

103. 1-Tertiary Contractions :
-Normally , a wave of relaxation precedes a
contractile wave thereby propelling the
bolus along the esophagus
-Tertiary contractions , uncoordinated non-
propulsive contractions , asymptomatic
-Seen in : elderly , alcoholics , GERD & HH

104. -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

105. 2-Diffuse Esophageal Spasms (DES) ,
Cork-Screw :
-Symptoms include chest pain , dysphagia
and gastro-oesophageal regurgitation
disease
-Barium swallow shows diffuse oesophageal
spasm with simultaneous and
uncoordinated contractions

108. 3-Achalasia :
a) Etiology
b) Radiographic Features

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

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

111. 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 gastric air bubbles
-Anterior displacement and bowing of trachea on
the lateral view
-Pneumonia & basal fibrosis

114. 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

117. Chaga’s Disease :
-Megaesophagus , aperistalsis & bird's beak
appearance at GEJ (achalasia look-alike)