Gi -- Esophagus

Front 1

What are the imaging findings of esophageal candidiasis?

Back 1

- Look for plaque-like filling defects which can be focal or diffuse.
- Nodularity, granularity, and fold thickening may occur as result of mucosal inflammation and edema. Can also see mucosal ulcerations.
- More severe disease presents as shaggy, irregular luminal surface.

NOTE: herpes esophagitis can also present as plaque like filling defects with or without ulcerations.

Front 2

What are the imaging findings of herpes esophagitis?

Back 2

- Discrete ulcerations on a normal esophageal mucosal background.
- Multiple plaque like filling defects may also be seen.
- Therefore, imaging features may overlap with candidiasis.
- CMV esophagitis can also present with small discrete ulceration, although large flat ulcerations are more typical.

Front 3

What are the imaging findings of CMV esophagitis?

Back 3

- Large flat ulcerations.
- More commonly affects the small bowel and colon.
- Most pts have AIDS or are immunocompromised.
- DX is made histologically by finding intranuclear inclusions.
- Looks similar to HIV related esophagitis.

Front 4

What are the imaging findings of Barrett's esophagus?

Back 4

- focal stricture at an abnormally high location (mid esophagus).
- Transition zone with active esophagitis above normal segment.
- 2/2 metaplasia of the normal squamous epithelium with gastric type adenomatous mucosa.
- NOTE: medication induced strictures can also occur above the GE junction and mimic stricture from Barret's esophagus.

Front 5

What are the differential possibilities for esophageal strictures?

Back 5

- Peptic stricture
- Barret esophagus stricture
- Carcinoma
- Achalasia
- Pseudoachalasia
- Caustic stricture
- Blistering skin disorders
- Radiation stricture
- Extrinsic compression due to adjancent lymph nodes

Front 6

1. What are the imaging findings of achalasia?
2. What is the cause of the imaging findings?
3. How is achalasia treated?
4. What tropical disease looks similar to Achalasia?
5. What are some complications of Achalasia?
6. What is vigorous Achalasia?

Back 6

1. Look for beak-like narrowing of the distal esophagus with a dilated proximal esophagus. Absence of peristalsis of the distal 2/3 of the esophagus (smooth muscle). The height of air-fluid level indicates the severity of the lower esophageal sphincter.
2. Achalasia is a motor disorder characterized by aperistalsis of the distal 2/3 of the esophagus and failure of the GE junction to relax.
3. Treated with balloon dilatation, botulin injection, surgical Heller myotomy.
4. Chagas disease
5. Increased risk of aspiration, squamous cell carcinoma, Candida esophagitis from chronic stasis.
6. Vigorous achalasia is a rare variant of the classic form of esophageal achalasia. May represent an early form of the diseease. In most instances, it results in chest pain due to high amplitude contractions. Thus, it has features of both achalasia and diffuse esophageal spasm.

Front 7

What is pseudoachalasia?

Back 7

Fixed narrowing of the gastroesophageal junction from cancer of the gastroesophageal junction.
- Like achalasia, there is absence of peristalsis of the distal esophagus.

Front 8

1. What are the imaging findings of caustic injury?
2. Are these patients at risk for esophageal cancer?
3. What other entities cause long segment narrowing of the esophagus?

Back 8

1. Acutely, look for fold thickening, ulcerations, intramural contrast extension, mucosal sloughing. Over 2-3 months, there is stricture formation. Strictures may be focal, multifocal, or diffuse with asymmteric regions of narrowing and sacculations.
2. Patients are at increased risk for developing SCC after 20 years.
3. Chronic reflux esophagitis, NG tube associated esophagitis, stricture due to bullous skin disease, radiation stricture.

Front 9

What are the differential considerations for a filling defect in the esophagus?

Back 9

1. Benign Tumors: GIST, Adenoma, Inflammatory polyp, Fibrovascular polyp.
2. Malignant Tumors: Carcinoma, Mets, lymphoma, spindle cell carcinoma (carcinosarcoma), Malignant GIST.
3. Non-neoplastic: Varices, Duplication cyst, ectopic gastric mucosa, foreign body.

Front 10

1. What are the imaging findings of a GIST tumor in the esophagus?
2. What is the most common submucosal mass of the esophagus?

Back 10

1. Filling defect with a smooth surface (due to submucosal location). Obtuse angle with the esophageal mucosa.
2. GIST are more common in the mid and distal esophagus where smooth muscle is more abundant. 3-4% can be multiple.

Front 11

1. What are the imaging findings of an esophageal adenoma?
2. Where do esophageal adenomas arise from?
3. Adenomas can be confused with what benign entity?

Back 11

1. Filling defect in the esophagus that resembles a polyp. Less than 1.5 cm in diameter.
2. Adenomas arise from adenomatous tissue in the distal esophagus, usually w/n Barrett esophagus. They can undergo malignant degeneration.
3. Esophageal papilloma (fibrovascular excresces covered with squamous epithelium).

Front 12

1. What are the imaging findings of an inflammatory polyp in the esophagus?
2. What is the underlying etiology?
3. What entiites can look similar to an inflammatory polyp and how can they be distinguished?

Back 12

1. Filling defect in the distal esophagus that is contiguous with an enlarged bulbous gastric fold.
2. Underlying esophagitis
3. Esophageal adenoma and papilloma can look similar as all entities occur in the distal esophagus, however, only an inflammatory polyp is connected to a gastric fold.

Front 13

1. What are the imaging findings of an esophageal fibrovascular polyp?
2. What malignant tumor can present as a large intraluminal mass?

Back 13

1. Filling defect in the esophagus with a thin stalk. They are composed of various mesenchymal elements. They are covered by normal squamous mucosa and arise from the cervical esophagus.
2. Spindle cell carcinomas can arise from a stalk, but the site of attachment is usually in the mid or distal esophagus.

Front 14

1. What are the growth patterns of esophageal carcinoma?
2. What are the 2 most common varities of esophageal cancers?
3. What is the most common underlying condition with adenocarcinoma?

Back 14

1. Esophageal carcinoma can present as a polypoid, ulcerative, or annular mass.
2. Squamous cell cancers occur proximally; Adenocarcinomas occur distally.
3. Barrett's esophagus. Adenocarcinomas arising in Barrett esophagus can extend into the stomach.

Front 15

1. What are the imaging findings of metastatic disease to the esophagus?
2. What are the imaging findings of lymphoma affecting the esophagus?

Back 15

1. Metastases of the esophagus usually arise from cancers of the stomach, lung, breast. Most tumors metastasize to the mediastinal lymph nodes and with growth they can displace or directly invade the esophagus. On imaging, this can present as a long, narrow stricture; displacement of the lumen by a nodal mass.
2. Lymphoma can closely resemble primary esophageal carcinoma. It can be polypoid, ulcerative, or infiltrative mass. Submucosal infiltration of the tumor may give a varicoid appearance.

Front 16

What malignant esophageal tumor can have intraluminal growth and mimics a fibrovascular polyp?

Back 16

Spindle cell carcinoma (carcinosarcoma) presents as a polypoid bulky mass in the mid to distal esophagus expanding the esophageal lumen. A stalk connecting the mass to the mid to distal esophagus may be visualized.

NOTE: The stalk of fibrovascular polyps is usually connected to the cervical esophagus.

Front 17

1. What are the imaging features of esophageal varices?
2. What malignant subtype of esophageal cancer mimics esophageal varices?
3. What is the difference between uphill and downhill varices and what are their respective causes?
4. What is the collateral pathway between the chest and abdomen?

Back 17

1. Serpentine shape, shape changes. Can also be present in the stomach.
2. Varicoid esophageal cancer (this subtype of adenocarcinoma has a substantial proportion of tumor extending within the submucosa causing distorted fold appearance). Lymphoma can also mimic varices.
3. Downhill varices develop as a result of SVC obstruction (bronchogenic CA, lymphoma, fibrosing mediastinitis). Downhill varices are usually clinically asymptomatic.
Uphill varices are seen in portal HTN.
NOTE: if there is thrombosis of a varix, then it may be indistinguishable from a submucosal tumor.
4. Portal vein <--> left gastric vein (coronary) <--> periesophageal venous plexus <--> azygous and hemiazygous <--> SVC

Front 18

1. What are the imaging features of esophageal duplication cysts?
2. What can this mass be confused with on esophagram?

Back 18

1. Smooth surface. Oblique angle with esophageal contour, lumen displacement away from mass. Water attenuation.
2. GIST.

Front 19

1. What are the imaging features of ectopic gastric mucosa?
2. What is the most common location of ectopic gastric mucosa?

Back 19

1. Filling defect measuring less than 2 cm.
2. Cervical esophagus as it is the last palce in the esophagus to undergo replacement with stratified squamous epithelium.

Front 20

What are the different types of esophageal diverticula?

Back 20

1. Zenker's diverticulum:
- occurs above the level of the cricopharyngeus.
- projects posterior to the esophagus.
- cricopharyngeus muscle is invariably prominent.

2. Killian-Jamieson:
- arises from the lateral aspect of the esophagus just below the cricopharyngeus muscle.
- lateral view may help differentiate Zenker's from KJ. Zenker's projects posteriorly; KJ projects over the esophagus or more anteriorly.

3. Traction diverticula:
- seen in the mid-esophageal level due to inflammatory lymph nodes (TB, histo) resulting in fibrosing mediastinitis.
- Diverticula has a triangular shape due to periesophageal fibrosis.

4. Epiphrenic diverticula:
- Associated with motor abnormalities, most commonly Achalasia.

5. Intramural pseudodiverticulosis:
- Dilated submucosal glands resulting in multiple small outpouchings that can be segmental or diffuse.
- the tiny necks may not fill, resulting in apparent lack of communication with the esophageal lumen.
- Usually due to chronic reflux esophagitis.
- 90% have an associated stricture in the mid or upper esophagus. Dilation of the stricture usually cures the symptoms.
- Candida is often cultured from the esophagus in these pts.

Front 21

1. What are the differences among primary, secondary, and tertiary contractions?
2. What is diffuse esophageal spams (DES)?
3. What is nutrcracker esophagus?

Back 21

1. Primary wave is initiated by swallowing and propaates a smooth, continuous contraction the length of the esophagus. Secondary wave is initiated by esophageal distention. Tertiary waves are non-propulsive waves that do not result in clearing of esophageal contents. These contrations increase in frequency with aging.
2. DES is characterized by repetitive tertiary contractions resulting in a corkscrew like appearance.
3. Nutcracker esophagus is characterized by high amplitude esophageal contractions with chest discomfort. Esophagram is usually normal with normal peristalsis.

Front 22

What is the differential diagnosis of transverse folds in the esophagus?

Back 22

1. Feline esophagus: TRANSIENT smooth, concentric regular rings that occur due to contration of the muscularis propria.
2. Chronic reflux esophagitis: results in fixed rings that may be non-circumferential.
3. Eosinophilic esophagitis: fixed rings seen in pts who are atopic and have food allergies.

Front 23

1. What is the differential diagnsosis of esophageal rings?

Back 23

A Ring:
- MUSCULAR ring that is TRANSIENT and thus does not cause dysphagia.
- marks the superior extent of the esophageal vestibule. The inferior extent of the esophageal vestibule is marked by the B ring.

B Ring:
- symptomatic, thin FIXED weblike constriction at the GE jxn.
- MUCOSAL ring amenable to endoscopic dilation
- pts are symptomatic when esophageal diameter < 1 cm (give barium pill which is 13mm to assess size of esophageal lumen).
- histologically, corresponds to the Z-line (squamo-columnar junction).

Front 24

1. What are the imaging manifestations of glycogen acanthosis?
2. Glycogen acanthosis can be confused with what other esophageal disorders?
3. What are the demographics of glycogen acanthosis? Do the patients have symptoms?

Back 24

1. Glycogen acanthosis presents with a reticular pattern of the esophageal mucosa with numerous nodular filling defects. Rarely, these nodules coalesce to form larger plaques.
2. Reflux esphagitis may also present with a reticular mucosal pattern. Candidiasis can also show plaque like filling defects.
3. Glycogen acanthosis is seen in elderly pts who are asymptomatic. Whereas, pts with candidiasis often have odynophagia.

Front 25

1. What are different types of esophageal hernias?
2. Which is at risk for incarceration and strangulation?

Back 25

1. Hiatal hernia (GE junction is located above the level of the hemidiaphragm) and Paraesophageal hernia (GE junction is located below the hemidiaphragm with part of the stomach herniating into the chest via the esophageal hiatus.
2. Paraesophageal hernia is at high risk for incarceration and strangulation from venous and lymphatic obstuction.

Front 26

1. What are the imaging findings of esophageal perforation on chest radiographs?
2. What is the most common cause of esophageal perforation?
3. Where are the perforations associated with pneumatic dilatation and Boerhave syndrome located?
4. If water soluble esophogram fails to demonstrate a leak, what should you do next?

Back 26

1. On radiographs, look for pneumomediastinum, widening of the mediastinum, subcutaneous emphysema, hydropneumothorax, left sided pleural effusion.
2. The most common cause of esophageal perforation is iatrogenic from endoscopic perforation. Boerhave syndrome is caused by violent retching (alcoholics).
3. Most endoscopic perforations involve the cervical esophagus near the cricopharyngeus muscle. Perforation related to Boerhave syndrome is usually located just above the GE junction on the left.
4. If water soluble contrast agent fails to demonstrate a leak, you should repeat the study with barium.

Front 27

1. What are the imaging manifestation of Scleroderma?
2. How do you differentiate scleroderma from achalasia?
3. Are pts with scleroderma aat increased risk of Candidiasis?

Back 27

1. Dilated atonic esophagus with decreased peristalsis in the distal 2/3 of the esophagus from degeneration and atrophy of smooth muscle and fibrosis.
2. GE junction is patulous in early scleroderma allowing GE reflux. Chronic reflux leads to peptic stricture formation and possibly Barret's esophagus.
3. Increased risk of candidiasis due to stasis.

Front 28

1. What are the imaging findings of aberrant right subclavian artery?
2. What additional finding is more related with dysphagia lusoria?

Back 28

1. Tubular smooth surfaced oblique filling defect along the posterior aspect of the esophagus.
2. Diverticulum of Komerell

Front 29

1. What are the imaging findings of an esophageal web?
2, Where are esophageal webs most commonly located?
3. Are they associated with any syndromes?

Back 29

1. Esophageal webs are thin folds of esophageal mucosa and submucosa that present as filling defects. If large, they can cause dysphagia.
2, Most commmonly located in the anterior aspect of the proximal esophagus.
3. Possible association with Plummer-Vinson syndrome (esophageal web and iron def. anemia).

Front 30

What are the features of reflux esophagitis on esophogram?

Back 30

The severity of reflux esophagitis can be graded into mild, moderate, and severe.

MILD REFLUX ESOPHAGITIS:
- characterized by fold thickening which may be nodular on the mucosal relief pattern.

MODERATE REFLUX ESOPHAGITIS:
- in addition to the fold thickening, look for superficial erosions that are surrounded by a mound of edema.
- may also see a reticular pattern of the mucosa (remember that the esophagus normally has a featureless mucosa). The reticular pattern is due to submucosal edema and ulcerations.

SEVERE REFLUX ESOPHAGITIS:
- in addition to the findings above, look for ulcerations.
- ulcerations are located in the distal esophagus.

Front 31

What are the radiographic features of chronic reflux esophagitis?

Back 31

look for contour abnormalities resulting from fixed non-circumferential transverse folds.
- smooth tapered narrowing/stricturing that begins immediately above the level of the GE junction.
- Esophagus may be shortened resulting in a hiatal hernia.

Front 32

What are the imaging features of medication induced esophagitis and what medications can lead to this type of esophagitis?

Back 32

- Radiographic findings are usually single or multiple shallow ulcerations with associated fold thickening that can be seen at sites of esophageal narrowing (aortic arch, left main stem bronchus, distal esophagus).
- Tetracycline, quinidine, and potassium

Front 33

What are the features of Crohns esophagitis?

Back 33

- Imaging findings can range from discrete aphthous ulcers with surrounding mound of edema to large confluent ulcerations.
- Crohn disease rarely affects the esophagus. When there is esophageal disease, there is usually disease seen in the small bowel and colon.

Front 34

Esophageal fold thickening

Back 34

Folds can be thickened due to edema, tumor, and blood (vessels)
EDEMA:
- Reflux esophagitis
- Acute radiation
- Acute caustic ingestion/medication
- Infection
TUMOR
- Verrucoid esophageal CA
BLOOD (VESSELS)
- Varices

Front 35

Esophageal erosion/ulceration

Back 35

REFLUX ESOPHAGITIS
INFECTIONS
- herpes, candida, HIV, CMV
INFLAMMATORY:
- Crohn's disease
ACUTE RADIATION
CAUSTIC INGESTION
MEDS
- KCl, tetracycline/ doxycycline, NSAIDS.

Front 36

Short segment esophageal stricture:

Back 36

REFLUX ESOPHAGITIS:
- typically in the distal esophagus
- associated with hiatal hernia
BARRET'S ESOPHAGUS
- mid-esophageal stricture
MEDICATION INDUCED
- upper, mid, or distal esophageal stricture
- can be multifocal
BLISTERING SKIN DISORDER:
- usually result in multifocal strictures
EXTERNAL COMPRESSION
- Vascular vs. LAD

Front 37

Esophageal dilation

Back 37

- Achalasia (Vigorous achalasia is variant of achalasia; think of it as DES + Achalasia)
- Chagas disease
- Scleroderma
- Pseudoachalasia (Esphageal or Gastric adenoCA)

Front 38

Long segment esophageal stricture:

Back 38

- Caustic ingestion
- Radiation
- Chronic reflux esophagitis associated with prolonged NGT
- Blistering skin disorder (usually result in multifocal strictures)

Front 39

Filling defects

Back 39

BENIGN:
- Food particle
- Leiomyoma/GIST
- Inflammatory polyp, adenoma, papilloma
- Fibrovascular polyp

MALIGNANT:
- Lymphoma
- Carcinosarcoma (Spindle cell CA)