3. GI (The Oesophagus)

Question 1

Oesophageal Anatomy (7)

Answer 1

A ring: Muscular ring above the vestibule
B ring: Mucosal ring below the vestibule
- Thin constriction at the OG junction, narrowing can cause symptomatic dysphagia (defined as <13mm in diameter).
- If narrowed & symptomatic = Schatzki ring
Z line: Squamo-columnar junction (between oesophageal and gastric epithelium).
- Endoscopy finding, rarely seen as thin, serrated line
Mucosa should have thin, parallel, uniform folds

Question 2

Oesophageal anatomy - trivia (6)

Answer 2

Hypopharynx - location of Zenker diverticula
Cervical oesophagus - location of Killian-Jamieson divertiucla
Cricopharyngeus:
- True upper oesophageal shincter
- Muscle represents border between pharynx and cervical oesophagus
- Typically at the level of C5-6
Swallowing
- Moves the larynx up and anteriorly

Question 3

Reflux oesophagitis - progression & Rx (5)

Answer 3

Reflux –> Thick folds
More reflux –> Thicker folds
Even more reflux –> Strictures & Barretts
Still even more reflux –> Cancer (adenocarcinoma)
Rx: PPIs, H2 blockers, and if those fail, Fundoplication

Question 4

Barretts (4)

Answer 4

Precursor to adenocarcinoma.
Develops 2ndary to chronic reflux.
Classically shown as high stricture with associated hiatal hernia.
Buzzword “Reticular Mucosal Pattern”

Question 5

Eosinophillic Oesophagitis (4)

Answer 5

Classically young man with long Hx dysphagia (and atopia and peripheral eosinophilia).
Barium shows concentric rings (distinct look).
Fails to respond to PPIs but responds to steroids.
Buzzword “Ringed Oesophagus”

Question 6

Fundoplication - definition (3)

Answer 6

Gastric fundus is wrapped around lower end of oesophagus and stitched in place.
This reinforces the lower oesophageal sphincter.
“Nissen” refers specifically to a 360 degree rotation, but looser wraps can also be done.

Question 7

Early complications of Fundoplication (4)

Answer 7

Oesophageal obstruction or narrowing:
- Due to either post op oedema or too tightly wrapped.
- Often seen around week 2
- Barium shows total or near total oesophageal obstruction

Question 8

Failure of Fundoplication (4)

Answer 8

Defined as recurrence of hiatal hernia or reflux (the original indication).
Commonest reason for recurrent reflux is slipped nissen (telescoping of the OG junction through the wrap).
Commonest cause of slipped nissen is short oesophagus
Fundoplication should have <2cm length of narrowed oesophagus, anything more is a slipped nissen.

Question 9

Short oesophagus (2)

Answer 9

Defined (by some) as fixed/non reducible hiatus hernia >5cm.
Rx: Collis gastroplasty (lengthening + fundoplication)

Question 10

Fundoplication trivia

Answer 10

One cannot vomit after a fundoplication

Question 11

Oesophageal cancer - imaging

Answer 11

Barium: “Irregular contour” and “Abrupt (shouldered) edges.

Question 12

Squamous oesophageal cancer (3)

Answer 12

• More common in drinkers, smokers and black people.
• Associated with previous alkaloid ingestion.
• Stricture/ulcer/mass is in mid oesophagus

Question 13

Oesophageal adenocarcinoma (4)

Answer 13

• More common in white people
• Associated with chronic stress and chronic reflux.
• Associated with Barretts.
• Mass/stricture in lower oesophagus

Question 14

Oesophageal cancer - critical stage (2)

Answer 14

Stage 3 (adventitia) vs stage 4 (invasion into adjacent structures) - needs CT to diagnose.
Earlier stages can be distinguished by endoscopy, so not likely to be tested in radiology exams

Question 15

Oesophageal candidiasis (5)

Answer 15

Associated with immunocompromise (HIV/Transplant) or Motility disorders (achalasia, scleroderma).
Most commonly discrete, plaque like lesions.
Other findings: Nodularity, granularity, fold thickening (due to mucosal inflammation and oedema).
More severe form looks shaggy with irregular luminal surface

Question 16

Glycogen acanthosis (2)

Answer 16

Mimic of candidiasis.
Multiple elevated nodules in adymptomatic elderly patient.

Question 17

Ulcers DDx (2)

Answer 17

Herpes ulcer: Small and multiple with halo of oedema.
CMV and HIV: Large flat ulcer

Question 18

Oesophageal varices (3)

Answer 18

Linear, often serpentine, filling defects causing a scalloped contour.
DDx includes varicoid carcinoma (need to be distended on study).
Dynamic appearance (flattens out with large barium bolus) proves it’s not a fixed, varicoid looking cancer.

Question 19

Uphill vs Downhill varices (4)

Answer 19

Uphill:
- Caused by portal hypertension
- Confined to bottom half of oesophagus
Downhill:
- Caused by SVC obstruction (catheter or tumour related)
- Confined to top half of oesophagus

Question 20

Oesophageal (enteric) duplication cysts (4)

Answer 20

Will be shown on CT as water density cyst in the posterior mediastinum.
Most commonly in ileum, 2nd commonest in oesophagus.
Present incidentally in adults or, if big enough, in infants with dysphagia or breathing problems.
Benign, no malignancy risk.

Question 21

Oesophageal diverticulum - types (5)

Answer 21

Zenker diverticulum,
Killian-Jamieson diverticulum,
Traction diverticulum,
Epiphrenic diverticulum,
Oesophageal pseudodiverticulosis

Question 22

Zenker diverticulum (3)

Answer 22

Posteriorly located.
Site of weakness is Killian Dehiscence or Triangle.
Arises from hypopharynx, not the cervical oesophagus.

Question 23

Killian-Jamieson Diverticulum (3)

Answer 23

Anterior and lateral.
Protrudes through area of weakness below attachment of cricophaeyngeus muscle and lateral to ligaments that suspend oesophagus on the cricoid cartilage.
Seen in cervical oesophagus.

Question 24

Traction diverticulum (2)

Answer 24

Mid oesophageal, often triangular in shape.
Occur from scarring, often due to granulomatous disease or TB

Question 25

Epiphrenic Diverticula (2)

Answer 25

Just above diaphragm, usually on the right (para-oesophageal hearnis is usually on the left).
Considered pulsion types (associated with motor abnormality)

Question 26

Oesophageal pseudodiverticulosis (3)

Answer 26

Dilated submucosal glands that cause multiple small outpouchings.
Usually due to chronic reflux oesophagitis.
Candida often cultured but not thought to be definately the causative factor.

Question 27

Oesophageal papilloma (2)

Answer 27

Most common benign mucosal lesion of oesophagus.
Essentially hyperplastic squamous epithelium.

Question 28

Feline oesophagus (2)

Answer 28

Transient, fine transverse folds which course the oesophagus.
Can be normal, can be associated with oesophagitis.

Question 29

Hiatus hernias - types (5)

Answer 29

Most commonly classified by the relationship of the OG junction to the diaphragm
Axial (sliding)
- OG junction above the diaphragm
Paraoesophageal (rolling)
- OG junction below the diaphragm, with piece of the stomach above it
- Higher rate of incarceration.
- Usually on the left (epiphrenic diverticula usually on the right)

Question 30

Oesophageal spasm (2)

Answer 30

Tertiary contractions with pain.
“Nutcracker oesophagus” requires manometry findings (>180mmHg)

Question 31

Oesophageal web (4)

Answer 31

Most commonly at the cervical oesophagus, near the cricopharyngeus.
Ring caused by thin mucosal membrane.
Risk factor for oesophageal and hypopharyngeal carcinoma.
Plummer-Vinson syndrome: Iron deficiency anaemia, dysphagia, thyroid issues, “spoon shaped nails” is associated.

Question 32

Vascular impressions - types (4)

Answer 32

Pulmonary sling
Double aortic arch
Innominate artery compression
RIght arch with abberant left or left arch with abberant right subclavian

Question 33

Pulmonary sling (8)

Answer 33

Only variant that goes between oesophagus and trachea.
Associated with tracheal stenosis.
Associated with other cardiopulmonary and systemic anomalies
- Hypoplastic right lung
- Horseshoe lung
- TE fistuls
- Imperforate anus
- Complete tracheal rings

Question 34

Double aortic arch

Answer 34

Most common symptomatic vascular ring anomaly

Question 35

Left arch with aberrant right subclavian (3)

Answer 35

Most common aortic arch anomaly - not necessarily symptomatic.
Dysphagia lusoria - Difficulty swallowing in the setting of this variant anatomy.
Diverticulum of Kommerell - pouch like aneurysmal dilatation of proximal portion of an aberrant right subclavian artery.

Question 36

Dilated Oesophagus - causes (3)

Answer 36

Achalasia.
Pseudoachalasia.
Scleroderma

Question 37

Achalasia (6)

Answer 37

Motor disorder causing distal 2/3 to not have normal peristalsis (absent primary peristalsis) and lower oesophageal sphincter won’t relax.
Oesophaus dilated above a smooth stricture at OG junction “Bird’s Beak”.
“Vigorous achalasia” - early, less severe form with repetitive, non-propulsive contractions
- more common in women, but secondary cancers occur more in men.
Causes increased risk of candida.
“Chagas disease” - oesophagus is paralysed by a parasite. Appearance is identical to achalasia (some consider then the same pathology).

Question 38

Pseudoachalasia (3)

Answer 38

aka secondary achalasia.
Appearance of achalasia but secondary to cancer at OG junction.
Real achalasia will eventually relax, pseudo won’t. Pseudo will also have a mass.

Question 39

Scleroderma (5)

Answer 39

Involved oesophagus in 80% of cases.
Lower 2/3 stops functioning normally.
Lower oesophageal shincter is incompetent, causing chronic reflux (leading to scarring, barretts and adenocarcinoma).
Associated with lung changes (NSIP).
Small bowel can have closely spaced valvulae conniventes

Question 40

Medication induced oesophagitis

Answer 40

Ulcers, usually at level of arch or distal oesophagus

Question 41

Crohn’s oesophgitis

Answer 41

Ulcers, can be confluent in severe disease

Question 42

Long stricture DDx (3)

Answer 42

Radiation,
NG tube in too long,
Caustic ingestion