Esophageal Perforation

• most commonly by iaotragenic causes (75% endoscopy)
• most involve cervical esophagus, cricopharyngeaus muscle
• untreated, 70% mortality
• chest XR: pneumomediastinum, widened mediastinum, hydropneumothorax, pleural effusion, subcutaneous emphysema
• confirm with gastrograffin esophogram = water soluble materal
• CT good for further evaluation, finding location of leak

Achalasia

• dysphagia, regurgitation, aspiration PNA
• aperistalsis of the distal 2/3 and failure of the LES to relax
• single contrast UGI = bird-beak narrowing and column of contrast opacifying dilated esophagus.
• recommend Manometry
• Rx: balloon dilatation and Heller myotomy (surgical incision)
• DDx: Chagas disease, pseudoachalasia (carcinoma of the GE junction)

• Eventual LES relaxation with continued drinking, distinguishes this from pseduoachalasia

• Complications: Candida from stasis and Carcioma in upper/mid esophagus (20 years).

Diffuse Esophageal Spasm

• dysphagia and chest pain
• nonpropulsive contraction
• impaired LES relazation
• increased resting pressures
• corkscrew, curling, rosary bead, shish kabob
• nutcracker esophagus
• >180 mm Hg on manometry

Feline esophagus

• multiple thin transverse folds
• transient (distinguish from chronic reflux esophagitis)
• cross entire esophageal lumen
• normal varient

Esophageal Filling Defects

Benign

• GIST
• Adenoma
• Inflammatory polyp
• Fibrovascular polyp

Malignant

• carcinoma
• mets
• lymphoma
• spindle cell carcinoma
• malignant GIST

Nonneoplastic

• varices
• duplication cyst
• ectopic gastric mucosa
• foreign body

Esophageal duplication cyst

• type of foregut cyst
• lined with squamous epithelium, smooth muscle wall
• mass effect
• anywhere in posterior mediastinum
• CT shows liquid vs solid (GIST)

Infectious Esophagitis

• Candidiasis – plaquelike, shaggy
• Herpes – multiple discrete ulcers
• CMV – large, flat, solitary ulcer
• HIV – indistinguishable from CMV

Peptic and Inflammatory Esophagitis

• mild reflux – thickened folds only
• mod reflux – thickened folds and tiny ulcers
• severe reflux – folds and moderate to large ulcers
• chronic reflux – stricture above GEJ, scarring deformity, transverse folds
• Barrett esophagus – stricture at high location, transition zone, reticulated mucosal pattern
• Medication-induced – ulcer with edema, level or arch or distal
• Crohn esophagitis – aphthous ulcers, confluent

Multiple Esophageal Mucosal Masses

Nonneoplastic

• Candida Esophagitis
• Reflux Esophagitis
• Glycogenic Acanthosis
• Crohn’s Disease
• Pemphigoid and Epidermolysis Bullosa
• Hairy Esophagus

Neoplastic

• Papillomatosis
• Superficial Spreading Carcinoma
• Cowden’s Syndrome
• Leukoplakia

Intussusception in Adults

• LIPOMA
• malignant tumor
• Meckel diverticulum
• Lymphoma
• Mesenteric nodes
• Foreign body

Video Esophagram Dictation

Indication: [x]

Technique: Standard video esophagram.

Comparison: [x]

Findings:
The patient was given thin and thick barium liquid, applesauce mixed with barium paste and crackers mixed with barium.
The oral and pharyngeal phases of swallowing are normal. No nasal regurgitation, laryngeal penetration or aspiration is identified. No pharyngeal morphologic abnormalily is visualized.

Esophageal motility is grossly within normal limits. No gastroesophageal reflux is identified, despite the performance of maneuvers to ellicit GE reflux. No gross morphologic esophageal abnormality is detected.

Impression: Unremarkable videoesophagram.

Double Contrast Esophagram Dictation

Indication: [x]

Technique: A standard air contrast esophagram was performed.

Comparison: [x]

Findings:
The patient swallowed barium without difficulty. The oral and pharyngeal phases of swallowing are normal. There is no nasal regurgitation, laryngeal penetration or aspiration identified. Esophageal motility is within the limits of normal.
The esophagus is structurally normal without intrinsic or extrinsic masses. The esophageal mucosa appears normal. No gastroesophageal reflux was demonstrated during this examination, despite the performance of maneuvers to elicit GE reflux.

Impression: Unremarkable esophagram.

Esophageal Carcinoma

• most common risk factor is smoking and ETOH
• presents with chest pain or progressive dysphagia
• Squamous < Adenocarcinoma (Barrett’s)
• Gastric invasion and distal location suggest adenocarcinoma
• most common benign tumor = leiomyoma
• tracheoesophageal stripe >5 mm

UGI Findings

• irregular contour
• abrupt shouldering edges
• central ulcer that does not project beyond mucosa
• polypoid or varicoid appearance = Adenocarcinoma

Esophageal Masses

• Pharyngeal carcinoma: proximal
• Lymphoma = resembles primary neoplasm; polypoid, ulcerative, infiltrating
• Adenoma = distal, forms within Barrett; malignant degeneration can occur
• Esophageal carcinoma: SSC > adenocarcinoma: irregular thickening, eccentric narrowing, dilation above, shouldered margins; pseudoachalasia
• Esophageal Lymphoma
• Gastric adenoacarcinomas (that extends up)
• Leiomyoma (GIST)
• Inflammatory esophagogastric polyp (enlarged gastric fold projecting into lower esophagus; no malignant potential; from reflux; recommend endoscopy)
• Fibrovascular Polyp = large intraluminal fat-filled mass with stalk; dilated esophagus; B9; frequently in cervical esophagus; LONG 7-20cm; can regurgitate polyp)
• Esophageal duplication cysts
• Extrinsic lesions
• Spindle Cell Carcinoma = carcinoma + sarcoma; bulky, polypoid, intraluminal; pedicle attaches it to esophagus.

Esophageal Varices

Uphill

• cause bleeding
• from portal HTN (reversal of flow “uphill” from portal vein > left gastric > periesophageal venous plexus > azygous and hemiazygous collaterals > SVC)
• collapsing, long serpentine filling defects in the distal esophagus on UGI study; differentiate from varicoid carcinoma

Downhill

• asymptomatic
• obstruction of SVC > collateral enlargement in supreme intercostal, bronchial and inferior thyroid veins
• tubular thickened folds in upper thoracic esophgus
• look for reason for SVC syndrome (bronchogenic carcinoma, lymphoma, or fibrosing mediastinitis)

Esophageal Strictures

• Esophagitis: Reflux, Barrett, Corrisive, Radiation
• Neoplasm: SCC, adenocarcinoma, mets, lymphoma
• Webs
• Extrinsic
• Infection: TB, candida, syphilis
• Achalasia
• Pemphigoid, epidermolysis bullosa

Esophageal Outpouchings

• Lateral pharyngeal diverticula
• Zenker Diverticulum; through Killian dehiscence = posterior
• Killian-Jamieson diverticulum = anterior
• Midesophageal diverticula (pulsion > traction)
• Epiphrenic diverticula (pulsion)
• Sacculations
• Intramural pseudodiverticula = multiple and tiny

Pulsion = pressure; fusiform –> most common today, from motor disorders

Traction = tugging; jagged, extrinsic –> TB