Читать книгу The Esophagus - Группа авторов - Страница 170

Barrett’s esophagus is characterized by progressive columnar metaplasia of the distal esophagus caused by chronic gastroesophageal reflux and reflux esophagitis. The classic radiologic signs of Barrett’s esophagus consist of a mid‐esophageal stricture or ulcer occurring at a discrete distance from the GEJ [82] (Figure 6.43). In the presence of a hiatal hernia or gastroesophageal reflux, a mid‐esophageal stricture or ulcer is thought to be highly suggestive, if not pathognomonic, of Barrett’s esophagus. A distinctive reticular pattern of the mucosa has also been recognized as a relatively specific sign of Barrett’s esophagus, particularly if adjacent to the distal aspect of a mid‐esophageal stricture [83]. This reticular pattern is characterized by tiny barium‐filled grooves or crevices resembling the areae gastricae on double‐contrast studies of the stomach (Figure 6.44). However, the classic radiologic signs of Barrett’s esophagus (a mid‐esophageal stricture or ulcer, or a reticular mucosal pattern) are seen in only 5–10% of all patients with Barrett’s esophagus [83, 84]. Other more common findings in Barrett’s esophagus, such as reflux esophagitis and peptic strictures, are often present in patients with uncomplicated reflux disease who do not have Barrett’s esophagus. Thus, those radiographic findings that are more specific for Barrett’s esophagus are not sensitive, and those findings that are more sensitive are not specific. As a result, many investigators have traditionally believed that esophagography has limited value in diagnosing Barrett’s esophagus.

Figure 6.27 Infiltrative squamous cell carcinoma of right aryepiglottic fold. (A) Frontal view of the pharynx during drinking shows diminished epiglottic tilt on the right (arrow). (B) Spot radiograph after drinking demonstrates thickening of the right aryepiglottic fold (short arrows) and nodularity of the mucosa overlying the muscular process of the right arytenoid process (open arrows).

Source: Reproduced from Rubesin [10], with permission.

Figure 6.28 Ulcerative squamous cell carcinoma of the epiglottis. (A) Lateral view of the pharynx shows that the epiglottic tip is missing. Fine mucosal nodularity is seen on the superior anterior wall of the laryngeal vestibule (thin arrow) and aryepiglottic folds (thick arrows). (B) Left posterior oblique view of the pharynx demonstrates amputation of the epiglottic tip (black arrow) and nodularity of the mucosa (white arrows).

Source: Reproduced from Rubesin [31], with permission.

Figure 6.29 Polypoid squamous cell carcinoma of the right piriform sinus. (A) Frontal view of the pharynx demonstrates loss of the normal contour of the right piriform sinus and a barium‐etched mass (arrows) protruding into the lumen. The valleculae and epiglottic tip are spared. (B) Lateral view of the pharynx demonstrates a large, lobulated barium‐etched mass (arrows). The epiglottic tip (e) and laryngeal vestibule (arrowhead) are spared.

Source: Reproduced from Rubesin and Glick [23], with permission.

Figure 6.30 Plaque‐like squamous cell carcinoma of the posterolateral pharyngeal wall. (A) Steep oblique view of the pharynx demonstrates focal mucosal nodularity and plaque‐like elevation (arrows) of the posterior pharyngeal wall. (B) Lateral view of the pharynx demonstrates mucosal nodularity (arrows) en face.

Figure 6.31 Ulcerated squamous cell carcinoma of the pharyngoesophageal segment. Lateral view of the pharynx shows a barium‐filled ulcer (large arrow) at the pharyngoesophageal segment. The posterior pharyngeal wall is destroyed by tumor (small arrows) centered at the pharyngoesophageal segment but extending vertically into the distal hypopharynx and proximal cervical esophagus.

Even so, other investigators have shown that double‐contrast esophagography can be a useful imaging test for Barrett’s esophagus in patients with reflux symptoms when these individuals are classified as being either at high, moderate, or low risk for Barrett’s esophagus based on specific radiologic criteria [85]. Patients who are classified at high risk for Barrett’s esophagus because of a mid‐esophageal stricture or ulcer or a reticular pattern are almost always found to have this condition, so endoscopy and biopsy should be performed for a definitive diagnosis. A larger group of patients are at moderate risk for Barrett’s esophagus because of esophagitis or peptic strictures in the distal esophagus, so the decision for endoscopy should be based on the severity of symptoms, age, and overall health of the patient. However, most patients are at low risk for Barrett’s esophagus because of the absence of esophagitis or strictures, and the risk of Barrett’s esophagus is so small in this group that these individuals can be treated empirically for their reflux symptoms without need for endoscopy. Thus, double‐contrast esophagography can be used to separate patients into various risk groups for Barrett’s esophagus to determine the relative need for endoscopy and biopsy in these patients.

Figure 6.32 Lymphoma of the palatine tonsil. Lateral view of the pharynx after instillation of intranasal barium shows a large, smooth mass (thick arrows) filling the lateral hypopharynx. A barium‐coated ring shadow (thin arrow) represents a central ulcer. The posterior pharyngeal wall is thickened (double arrow) and has a nodular surface. The epiglottic tip (e) is identified.

Source: Reproduced from Levine MS, Rubesin SE. Radiologic investigation of dysphagia. AJR Am J Roentgenol1990; 154:1157–1163, with permission.

Figure 6.33 Lymphoma of the base of the tongue. Lateral view of the pharynx shows that the base of the tongue is enlarged (thick arrows) and protruding posteriorly. The valleculae are obliterated (thin arrow).

Source: Reproduced from Rubesin and Laufer [57], with permission.

Figure 6.34 Diffuse radiation changes. (A) Frontal view of the pharynx shows that epiglottis (large arrow) is enlarged and has a smooth bulbous contour. The valleculae are flattened (left valleculae identified with a small arrow). The aryepiglottic folds are markedly but smoothly enlarged (right aryepiglottic fold identified by double arrow). The mucosa overlying the muscular processes of the arytenoids is elevated (white arrowhead identifies mucosa overlying muscular process of the left arytenoid cartilage). (B) Lateral view of the pharynx demonstrates a bulbous epiglottic tip (black arrow), elevated aryepiglottic folds (thin arrows), elevated mucosa overlying the muscular processes of the arytenoid cartilages (open arrow), and slit‐like valleculae (arrowhead). Barium fills the laryngeal vestibule (L).

Source: Reproduced from Rubesin [31], with permission.