Pharynx and Esophagus (for PBR 2) Flashcards
This is attributable to failure of complete relaxation of the upper esophageal sphincter
Commonly resulting in dysphagia and aspiration
Cricopharyngeal achalasia`
This demonstrate a shelf-like impression (cricopharyngeal bar) on the barium
column at the pharyngoesophageal junction at the level of C5–6
Cricopharyngeal achalasia
The cricopharyngeal bar seen during swallowing indicates dysfunction and incomplete opening
Cricopharyngeal achalasia is commonly associated with what diseases?
GERD
Zenker diverticulum
Neuromuscular disorders of the pharynx
This disease is characterized by:
- Absence of peristalsis in the body of the esophagus
- Marked increase in resting pressure of the LES
- Failure of the LES to relax with swallowing
Achalasia
Imaging findings of achalasia
- Uniform dilation of the esophagus, usually with an air–fluid level present
- Absence of peristalsis, with tertiary waves common in the early stages of the disease
- Tapered “beak” deformity at the LES because of failure of relaxation
- Findings of esophagitis including ulceration
- increased incidence of epiphrenic diverticula and esophageal carcinoma
This disease is caused by the destruction of ganglion cells of the esophagus due to a neurotoxin released by the protozoa (Trypanosoma cruzi, endemic to South America, especially eastern Brazil)
Chagas disease
The radiographic appearance of the esophagus is identical to achalasia
Associated finding of Chagas disease
Cardiomyopathy
Megaduodenum
Megaureter
Megacolon
*Creator’s note:
Megaheart
Mega man
This disease may mimic achalasia, but tends to involve a longer (>3.5 cm) segment of the distal esophagus, is rigid
Tends to show more irregular tapering of the distal esophagus and mass effect
Carcinoma of the gastroesophageal junction
A syndrome of unknown cause characterized by multiple tertiary esophageal contractions thickened esophageal wall, and intermittent dysphagia and chest pain
Diffuse esophageal spasm
Barium study finding of diffuse esophageal spasm
Intermittently absent or weakened primary esophageal peristalsis with simultaneous, nonperistaltic contractions that compartmentalize the esophagus, producing a classic corkscrew appearance
Neuromuscular disorders are a common cause of abnormalities of the oral, pharyngeal, or esophageal phases of swallowing
What are some of the most common cause of neurologic disease?
Cerebrovascular disease and stroke
*Additional causes include:
Parkinsonism, Alzheimer disease, multiple sclerosis, neoplasms of the central nervous system, and posttraumatic central nervous system injury
This is a systemic disease of unknown cause characterized by progressive atrophy of smooth muscle and progressive fibrosis of affected tissues
The esophagus is affected in 75% to 80% of patients
Scleroderma
Imaging findings of scleroderma
- Weak to absent peristalsis in the distal two-thirds (smooth muscle portion) of the esophagus
- Delayed esophageal emptying
- A stiff dilated esophagus that does not collapse with emptying
- Wide-gaping LES with free gastroesophageal reflux.
This occurs as a result of incompetence of the LES
Increases in intra- abdominal pressure exceed LES pressure, and gastric contents are allowed to reflux into the esophagus
Gastroesophageal reflux disease
What are the complications of GERD
Reflux esophagitis (RE)
Stricture, development of Barrett esophagus
Esophageal dysmotility
Findings associated with GERD on barium esophagrams
- Hiatal hernia (associated with presence of RE)
- Shortening of the esophagus
(a finding of importance to treating GERD surgically) - Impaired esophageal motility
- Gastroesophageal reflux
(often demonstrated only by provocative maneuvers such as Valsalva, leg raising, and cough) - Prolonged clearance time of refluxed gastric contents
Most common cause of hiatal hernia
Sliding hiatus hernia
Findings of sliding hiatal hernia
The GEJ, marked by the B ring and Z line displaced more than 1 cm above the hiatus
The gastric fundus may be displaced above thediaphragm and present as a retrocardiac mass on chest radiograph
The presence of an air–fluid level in the retrocardiac mass suggests the diagnosis
Type of hiatal hernia in which the gastroesophageal junction remains in normal location while a portion of the stomach herniates above the diaphragm
Paraesophageal hiatus hernia
When large, with most of the stomach in the thorax, are at risk for volvulus, obstruction, and ischemia
These are protrusions of pharyngeal mucosa through areas of weakness of the lateral pharyngeal wall, most common in the region of the tonsillar fossa and thyrohyoid membrane
They reflect increased intrapharyngeal pressure and are seen most commonly in wind instrument players
Lateral pharyngeal diverticula
Pouches of sufficient size to retain food and liquid may be associated with laryngeal penetration and aspiration
This outpouching arises in the hypopharynx just proximal to the UES
It is located in the posterior midline at the cleavage plane, known as Killian dehiscence, between the circular and oblique fibers of the cricopharyngeus muscle.
Zenker diverticulum
The diverticulum has a small neck that is higher than the sac, resulting in food and liquid being trapped within the sac
The distended sac may compress the cervical esophagus
Symptoms include
dysphagia, halitosis, and regurgitation of food
These outpouching originate on the anterolateral wall of the proximal cervical esophagus in a gap just below the cricopharyngeus and lateral to the longitudinal tendon of the esophagus
Killian–Jamieson diverticula
Persistently left-sided or, less frequently bilateral (25%)
Killian–Jamieson diverticula also are less likely to cause symptoms and are less likely to be associated with overflow aspiration or gastroesophageal reflux than is Zenker diverticulum.
Two types of mid-esophageal diverticulla
Pulsion or traction diverticula
This diverticula occur as a result of disordered esophageal peristalsis
Pulsion diverticula
This diverticula occur because of fibrous inflammatory reactions of adjacent lymph nodes and contain all esophageal layers
Traction diverticula
Why are most mid-esophageal diverticula asymptomatic?
They have large mouths that empty well
Outpouchings that occur just above the LES, usually on the right side
They are rare and usually found in patients with esophageal motility disorders
Epiphrenic diverticula
Because of a small neck, higher than the sac, they may trap food and liquids and cause symptoms
These are small outpouchings of the esophagus that usually occur as a sequela of severe esophagitis
They are thought to result from the healing and scarring of ulcerations
Sacculations
They tend to change in size and shape during fluoroscopic observation
Smooth contours help to differentiate sacculations from ulcerations
These are dilated excretory ducts of deep mucous glands of the esophagus
They appear as flask-shaped barium collections that extend from the lumen or as lines and flecks of barium outside the esophageal wall
Intramural pseudodiverticula
They tend to occur in clusters and in association with strictures
Liner tracks of barium (“intramural tracking”) commonly bridge adjacent pseudodiverticula
Radiographic signs of esophagitis
- Thickened esophageal folds (>3 mm)
- Limited esophageal distensibility (asymmetric flattening)
- Abnormal motility
- Mucosal plaques and nodules
- Erosions and ulcerations
- Localized stricture
- Intramural pseudodiverticulosis
(barium filling of dilated 1 to 3 mm submucosal glands)
CT usually reveals nonspecific findings of thickening of the wall (>5 mm) and target sign with hypoattenuating thickened wall and high attenuation enhancing mucosa
Hallmarks of esophagitis
Ulcers
Causes of small ulcers in esophagitis (<1 cm)
Reflux esophagitis Herpes Acute radiation Drug-induced esophagitis Benign mucous membrane pemphigoid
Causes of larger ulcers (>1 cm) in esophagitis
Cytomegalovirus
HIV
Barret esophagus
Carcinoma
This inflammation is the result of esophageal mucosal injury caused by exposure to gastroduodenal secretions
The severity depends on the concentration of caustic agents including acid, pepsin, bile salts, caffeine, alcohol, and aspirin, as well as the duration of contact with the esophageal mucosa
Reflux esophagitis
Findings of RE are always most prominent in the distal esophagus and GEJ
Early changes in reflux esophagitis
Mucosal edema, which manifest as a granular or nodular pattern of the distal esophagus
Nodules have poorly defined borders
Most common cause of esophageal ulceration
Reflux esophagitis
The ulcers appear as discrete linear, punctate, or irregular collections of barium, usually surrounded by a radiolucent mound of edema
Key to differentiation RE ulcers from those of herpes or drug-induced esophagitis
In RE - prominence of the ulcerations are in the distal rather than proximal or mid-esophagus
Complications of reflux esophagitis
Ulceration
Bleeding
Stricture
Barret esophagus
This is an acquired condition of progressive columnar metaplasia of the distal esophagus caused by chronic gastroesophageal reflux
Barret esophagus
Columnar rather than squamous epithelium lines the distal esophagus
Characteristic radiographic appearance of Barrett esophagus
High (mid-esophageal) stricture or deep ulcer in a patient with GERD
This pattern is also suggestive of Barrett esophagus
A reticular mucosal pattern of the esophageal mucosa, resembling areae gastricae of the stomach
Esophageal disease found most commonly in patients with compromised immune systems
It is increasingly common because of the use of steroids, cytotoxic drugs, and prevalence of AIDS
Infectious esophagitis
Pathogen that is by far the most common cause of infectious esophagitis and is highly prevalent in immunocompromised patients
Candida albicansis
Additional risk factors include diabetes, malignancy, radiation, chemotherapy, and steroid
treatment
Prominent symptom of Candida of the oropharynx (trush)
Odynophagia
Imaging finding of Candida esophagitis
Discrete plaque-like lesions demonstrated by air-contrast esophagrams are most characteristic
Ulcers tend to be small (<1 cm) and may be punctate, round, oval, or linear
Fulminant disease produces the “foamy esophagus” with a pattern of tiny bubbles at the top of the barium column
Appearance of plaque in Candida esophagitis
The plaques appear as longitudinally oriented linear or irregular discrete filling defects etched in white with intervening normal-appearing mucosa
The lesions may be tiny and nodular, or giant and coalescent with pseudomembranes
Esophageal disease that begins as discrete vesicles that rupture to form discrete mucosal ulcers
The ulcers may be linear, punctate, or ring-like and have a characteristic radiolucent halo
Herpex simplex esophagitis
Most characteristic finding of Herpes simplex esophagitis
Discrete ulcers on a background of normal mucosa involving the mid-esophagus are most characteristic of herpes
Nodules and plaques are usually absent
Imaging finding of Cytomegalovirus esophagitis
Characteristically manifest as one or more large, flat mucosal ulcers
Cytomegalovirus is a cause of fulminant esophagitis in patients with AIDS
Endoscopic biopsy or culture confirms the diagnosis
Esophageal disease that causes giant ulcers and severe odynophagia
Ulcers are large, flat, and usually in the mid-esophagus similar to those with cytomegalovirus esophagitis
HIV esophagitis
The esophagus is the most common portion of the gastrointestinal (GI) tract to be involved by tuberculosis
True or false?
False
The esophagus is the least common portion of the gastrointestinal (GI) tract to be involved by
tuberculosis
Manifestations include ulceration, stricture, sinus tract, and abscess formation
Esophageal disease that is the result of intake of oral medications that produce a focal inflammation in areas of contact with the mucosa
Drug-induced esophagitis
Drugs that cause this condition include tetracycline, doxycycline, quinidine, aspirin, indomethacin, ascorbic acid, potassium chloride, and theophylline
What is the radiographic appearance of drug-induced esophagitis
The radiographic appearance may be identical to herpes esophagitis, with discrete ulcers separated by normal mucosa in the mid-esophagus
The diagnosis is suggested by a history of recent drug ingestion
Healing usually occurs within 7 to 10 days of discontinuing the offending medication
Corrosive ingestion usually occurs as an accident in children or a suicide attempt in adults
What agents produce deep (full-thickness) coagulation necrosis?
a. Alkaline agents
b Acid agents
a. Alkaline agents (liquid lye)
Acid agents tend to produce more superficial injury
Ulceration, esophageal perforation, and mediastinitis may complicate the acute injury
Late complications are fibrosis and long or multiple strictures
Manifestation of Crohn disease in the esophagus
Manifest as discrete aphthous ulcers
Involvement of the small or large bowel by Crohn disease is virtually always present
Crohn disease of the esophagus should not be considered unless Crohn disease of the bowel is already evident
UGI finding of radiation esophagitis
UGI shows a variable length segment of esophageal narrowing multiple discrete ulcers or a granular mucosal pattern within the radiation field
Strictures are defined as any persistent intrinsic narrowing of the esophagus
What is the most common causes of esophageal strictures?
Fibrosis induced by inflammation and neoplasm
Causes of distal esophageal strictures
GERD
Scleroderma
Prolonged nasogastric intubation
Causes of upper and middle esophageal strictures
Barret esophagus
Mediastinal radiation
Caustic ingestion
Skin disease (pemphigoid, erythema multiforme, and epidermolysis bullosa dystrophica)
Smooth tapering concentric narrowing is a characteristic of:
a. Benign stricture
b. Malignant stricture
a. Benign strictures
Malignant strictures are characteristically abrupt, asymmetric, eccentric narrowings with irregular, nodular mucosa
Tapered margins may occur with malignant lesions because of the ease of submucosal spread of tumor
*Creator’s notes: Similar to biliary stricture
Common cause of esophageal stricture
Reflux esophagitis (GERD)
Reflux strictures are confined to what part of the esophagus?
Confined to the distal esopahgus
May be tapered, smooth, and circumferential (the classic appearance) or asymmetric and irregular
Small smooth sacculations and fixed transverse folds are characteristic and caused by scarring
Most reflux esophagitis measure how many cm in length?
1 to 3 cm in length
This is a pathologic fixed ring-like stricture at the level of the B ring, caused by RE
Schatzi ring
Typical Schatzki rings measures how many mm in length?
2 to 4 mm
How does nasogastric intubation causes esophageal strictures (long segment)?
Nasogastric tubes prevent closure of the LES, resulting in continuous bathing of the distal esophagus with acid reflux from the stomach
Zollinger–Ellison syndrome can lead to severe RE because of the high acid content of refluxed gastric contents
True or false?
True
Location of Barret esophagus strictures
Tend to be high in the mid-esophagus and may be smooth and tapered or ring-like narrowings
The high position is because of a tendency for strictures to occur at the squamocolumnar junction, which has been displaced to a position well above the GEJ
Esophageal disease that occur in patients who have undergone partial or total gastrectomy
Alkaline reflux esophagitis
Reflux of bile or pancreatic secretions into the esophagus results in the development of severe alkaline reflux esophagitis and distal esophageal strictures whose length and severity increase rapidly over a short period of time
A procedure that helps prevent reflux of bile and pancreatic secretion into the esophagus
Roux-en-Y reconstruction
What stricture should be suspected when barium examination performed in patients who have undergone partial or total gastrectomy or gastrojejunostomy reveals a long stricture in the distal esophagus?
Alkaline reflux stricture
Esophageal disease that barium studies demonstrate smooth long-segment narrowing of the esophagus or a series of ring-like strictures, called the “ringed esophagus”
Eosinophilic esophagitis
CT reveals circumferential wall thickening and submucosal edema
Biopsy reveals eosinophilic infiltration of the wall of the esophagus
The cause may be related to ingested food allergens
Radiation strictures are confined to the radiotherapy field usually following doses of how many Gy?
50 to 60 Gy
Strictures appear 3 to 6 months after radiation treatment
They are smooth and tapered and usually in the upper or mid- esophagus
Typical features of a malignant esophageal stricture
Irregular, ulcerated, circumferential narrowing with nodular shoulders
Infiltrative tumors may cause smooth, rigid narrowing of the esophagus without a clear zone of transition
The mucosa may not be altered until tumor spread is substantial
Because longitudinal spread of tumor along the length of the esophagus is typical, long-segment strictures caused by carcinoma are common
This are thin (1 to 2 mm), delicate membranes that sweep partially across the lumen
Webs
They occur in both the pharynx and esophagus and are commonly multiple
Pharyngeal webs arise most commonly at what part of the hypopharynx?
Arise from the anterior wall of the hypopharynx
Most common location of esophageal webs
Esophageal webs may occur anywhere, but they are most common in the cervical esophagus just distal to the cricopharyngeus impression
Most are incidental findings; however, they occasionally cause sufficient obstruction to result in dysphasia
Malignancy or inflammation in the mediastinum may encase the esophagus and narrow its lumen
What are the causes?
Lung carcinoma
Lymphoma
Metastasis to mediastinal nodes
Tuberculosis and histoplasmosis
Causes of enlarged esophageal folds
Esophagitis
Varices
Lymphoma
Varicoid carcinoma
Two types of esophageal varices
Uphill varices
Downhill varices
This refer to the portosystemic collateral veins that enlarge because of portal hypertension
a. Uphill varices
b. Downhill varices
a. Uphill varices
Coronary vein collaterals connect with gastroesophageal varices that drain into the inferior vena cava via the azygos system
Uphill varices are usually only present in the distal esophagus
This are formed as a result of obstruction of the superior vena cava with drainage from the azygos system through esophageal varices to the portal vein
a. Uphill varices
b. Downhill varices
Downhill varices
Usually predominate in the proximal esophagus
Radiographic signs of pharyngeal carcinomas
- Intraluminal mass seen as a filling defect, abnormal luminal contour, or focal increased density
- Mucosal irregularity owing to ulceration or mucosal elevations
- Asymmetrical distensibility due to infiltrating tumor or extrinsic nodal mass.
Most pharyngeal tumors are what type of carcinoma?
Squamous cell carcinomas (SCCs) that may arise on the base of the tongue, palatine tonsil, posterior pharyngeal wall, or the piriform sinus
Laryngeal tumors may impress on the pharynx or extend into it. Staging is best performed by CT or MR
Theses are benign lesions that typically involve the valleculae and should not be mistaken for pharyngeal neoplasms
They appear as small, smooth, well-defined, round, or oval filling defects best appreciated on frontal views
They arise from dilation of mucus glands caused by chronic inflammation
They are never malignant
Pharyngeal retention cysts
Malignancy of the pharynx that manifest as a large , bulky tumor of the lingual or palatine tonsils
Lymphoma
Constitutes 15% of oropharyngeal tumors
Most esophageal neoplasms are:
Benign or malignant?
Malignant 80%
Primarily adenocarcinoma or SCC
In the United States, adenocarcinoma is now the most common cell type of esophageal cancer, related to the increasing incidence of GERD
SCC risk factors are smoking and alcohol consumption
What is the presenting signs and symptoms of esophageal carcinoma
Presenting signs and symptoms include: Dysphagia Weight loss Bleeding leading to anemia Chest or epigastric pain Cough Recurrent pneumonia
Type of esophageal carcinoma that arises from malignant transformation of columnar epithelium of Barrett esophagus in the lower third of the esophagus
Adenocarcinoma
SCC arises from the stratified squamous epithelium that lines the entire esophagus
Imaging of the two types of esophageal are indistinguishable
Except that adenocarcinoma is almost always located where?
Distal
Usually invades the GEJ, and is much more likely to invade the stomach
Four basic imaging patterns of esophageal carcinoma
- Annular constricting
- Polypoid pattern
- Infiltrative
- Ulcerated mass
Most common pattern of esophageal carcinoma
Annular constricting
Appearing as an irregular ulcerated stricture
Pattern of esophageal carcinoma that causes an intraluminal filling defect
Polypoid pattern
Pattern of esophageal carcinoma that grows predominantly in the submucosa and may simulate a benign stricture
Infiltrative pattern
Least common pattern of esophageal carcinoma
Ulcerated mass
Why does esophageal carcinoma spread quickly by direct invasion into adjacent tissues
Because of the lack of a serosal covering on the esophagus
Hematogenous spread of esophageal carcinoma
To lung, liver, and adrenal glands
Image findings of esophageal carcinoma
Irregular thickening of the esophageal wall (> 5mm)
Eccentric narrowing of the lumen
Dilation of the esophagus above the area of narrowing
Invasion of periesophageal tissues
Metastases to mediastinal lymph nodes and the liver
This finding is highly indicative finding of tumor spread of esophageal carcinoma
Obliteration of the fat space between the aorta, esophagus, and vertebral body
Gastric adenocarcinoma cannot spread from the fundus and GEJ into the distal esophagus
True or false
False
Gastric adenocarcinoma may spread from the fundus and GEJ into the distal esophagus
Adenocarcinoma of the distal esophagus may be either primary esophageal or primary gastric
Most common benign neoplasm of the esophagus
Leiomyoma
Accounting for 50% of all benign esophageal neoplasm
Tumor is firm, well encapsulated, and arises in the wall
Ulceration is rare
Most cause no symptoms and are discovered incidentally
Imaging finding of esophageal leiomyoma
Barium esophagograom:
- Most are small and appear as smooth, well-defined wall lesions, although rarely they may be pedunculated or polypoid
- Coarse calcifications are occasionally present and strongly indicative of leiomyoma
CT:
- Smooth, well-defined mass of uniform soft tissue density
- The esophageal wall is eccentrically thickened
This is a rare cause of esophageal filling defect
They are benign and composed of fatty and fibrous tissue with accompanying blood vessels
Fibrovascular polyps
Long polyps may be regurgitated into the pharynx or mouth obstructing the airway
They appear as large elongated intraluminal masses in the upper esophagus
These are congenital abnormalities of the esophagus that are usually incidental findings presenting without symptoms
CT shows well-defined cystic mass
Barium examination will show extrinsic or intramural compression due to close contact with the esophagus
Esophageal duplication cysts
Most (60%) occur in the lower esophagus
Differential diagnosis include bronchogenic and neurenteric cyst
Causes of extrinsic lesions that invade the esophagus or simulate an esophageal mass or filling defect
Mediastinal adenopathy
Lung carcinoma
Vascular structures
This vascular congenital disease causes a characteristic upward-slanting linear filling defect on the posterior aspect of the esophagus
Aberrant right subclavian artery
It arises from the aorta distal to the left subclavian artery
To reach its destination, it must cross the mediastinum behind the esophagus
Imaging finding of esophageal perforation
Conventional radiographs:
Subcutaneous, cervical, or mediastinal emphysema within 1 hour of perforation
Chest radiographs:
May show a widened mediastinum and pleural effusion or hydropneumothorax
Barium study:
The key finding is focal or diffuse extravasation of contrast outside the esophagus
CT:
Fluid collections, extraluminal contrast, and air in the mediastinum
This refers to rupture of the esophageal wall as a result of forceful vomiting
Boerhaave syndrome
Tear of Boerhaave syndrome is located where?
Virtually always in the left posterior wall near the left crus of the diaphragm
Esophageal contents usually escape into the left pleural space or into the potential space between the parietal pleura and left crus
Tears may result in intramural dissections and hematomas in the wall of the esophagus
Disease that involves only the mucosa and not the full thickness of the esophagus
Caused usually by violent retching
Mallory–Weiss tear
Endoscopy usually identifies the lesion
The lesion is commonly missed on UGI
It may be a cause of copious hematemesis
When seen on UGI, what is the appearance of Mallory-Weis tear?
Appears as a longitudinally oriented barium collection, 1 to 4 cm in length, in the distal esophagus
Foreign body impaction:
Bones are usually lodge where?
In the pharynx, most often near the cricopharyngeus muscle
Foreign body impaction:
Meat are usually lodge where?
Impacts in the distal or mid-esophagus
Foreign body impaction:
Perforation occurs in only 1% of cases, but the risk increases if impaction persists more than how many hours?
More than 24 hours
