Читать книгу The Esophagus - Группа авторов - Страница 168

Reflux esophagitis is by far the most common inflammatory disease involving the esophagus. This condition is characterized on single‐contrast esophagrams by thickened folds, marginal ulceration, and decreased distensibility, but such findings are detected only in patients with advanced disease. In contrast, double‐contrast esophagrams have a sensitivity approaching 90% for the diagnosis of reflux esophagitis because of the ability to detect superficial ulcers or other findings that cannot be visualized on single‐contrast studies [70, 71]. Thus, double‐contrast esophagography is the radiologic technique of choice for patients with suspected GERD.

Early reflux esophagitis may be manifested on double‐contrast studies by a finely nodular or granular appearance of the mucosa with poorly defined radiolucencies that fade peripherally as a result of mucosal edema and inflammation [72, 73] (Figure 6.36). In almost all cases, this nodularity or granularity extends proximally from the GEJ as a continuous area of disease. With more advanced disease, barium studies may reveal shallow ulcers and erosions in the distal esophagus. The ulcers may have a punctate, linear, or stellate configuration, and are frequently associated with surrounding halos of edematous mucosa, radiating folds, or sacculation of the adjacent esophageal wall [73] (Figure 6.37A). Other patients may have a solitary ulcer at or near the GEJ, often on the posterior wall of the distal esophagus [74] (Figure 6.37B). It has been postulated that the location of these ulcers is related to prolonged exposure to refluxed acid that pools posteriorly when patients sleep in the supine position [74]. Other patients may have widespread ulceration involving the distal third or even half of the thoracic esophagus. In such cases, however, the ulceration almost always extends distally to the region of the GEJ. Thus, the presence of ulcers that are confined to the upper or mid esophagus should suggest another cause for the patient’s disease.

Figure 6.24 Cervical esophageal web. (A) Frontal and (B) lateral views demonstrate a thin radiolucent band (white arrows) encircling the cervical esophagus. A jet of barium (black arrow) spurting through the opening in the web indicates that there is partial obstruction. Dilatation of the cervical esophagus (E) proximal to the web is also indicative of obstruction.

Source: Reproduced from Rubesin [24], with permission.

Reflux esophagitis may also be manifested on barium studies by thickened longitudinal folds as a result of edema and inflammation that extend into the submucosa [73] (Figure 6.38). These folds may have a smooth or irregular contour, occasionally mimicking the appearance of esophageal varices [75]. In general, thickened folds should be recognized as a nonspecific finding of esophagitis as a result of a host of causes. Other patients with chronic reflux esophagitis may have a single prominent fold that arises in the region of the gastric cardia and extends upward into the distal esophagus as a smooth, polypoid protuberance, also known as an inflammatory esophagogastric polyp [76, 77] (Figure 6.39). Because these lesions have no malignant potential, endoscopy is not warranted when barium studies reveal typical findings of an inflammatory esophagogastric polyp in the distal esophagus.

In advanced reflux esophagitis, extensive ulceration, edema, and spasm may cause the esophagus to have a grossly irregular contour with serrated or spiculated margins and loss of distensibility [73]. Occasionally, the narrowing and deformity associated with severe esophagitis can mimic the appearance of an infiltrating esophageal carcinoma, so endoscopy and biopsy may be required for a definitive diagnosis.