Читать книгу The Esophagus - Группа авторов - Страница 172

The herpes simplex virus is another frequent cause of infectious esophagitis. Most patients with this condition are immunocompromised, but herpes esophagitis may occasionally develop as an acute, self‐limited disease in otherwise healthy patients who have no underlying immunologic problems [91]. Herpes esophagitis is initially manifested by small esophageal vesicles that subsequently rupture to form discrete, punched‐out ulcers on the mucosa. Although some patients have associated herpetic lesions in the oropharynx, most do not have oropharyngeal disease, and others with herpetic infection of the oropharynx have Candida esophagitis.

Herpes esophagitis may be manifested on double‐contrast studies by small, discrete ulcers on a normal background mucosa [92, 93]. The ulcers can have a punctate, stellate, or volcano‐like appearance and are often surrounded by radiolucent mounds of edema (Figure 6.47). Multiple discrete ulcers are found on double‐contrast esophagography in about 50% of patients with herpes esophagitis [93]. In the appropriate clinical setting, the presence of small, discrete ulcers without plaques should be highly suggestive of herpes esophagitis because ulceration in candidiasis almost always occurs on a background of diffuse plaque formation. As the disease progresses, however, herpes esophagitis may be manifested by a combination of ulcers and plaques, mimicking the appearance of Candida esophagitis. Occasionally, herpes esophagitis in otherwise healthy patients may be manifested by innumerable tiny ulcers that tend to be clustered together in the mid esophagus below the level of the left main bronchus [91] (Figure 6.48). The ulcers are even smaller than those in immunocompromised patients with herpes esophagitis, presumably because these individuals have an intact immune system that can prevent the ulcers from enlarging.

Figure 6.36 Reflex esophagitis with granular mucosa. Double‐contrast view shows fine nodularity or granularity of the distal esophagus caused by edema and inflammation of the mucosa. Compare this image to the smooth, featureless appearance of the normal esophagus in Figure 6.35A.