X-ray signs of esophageal disease

Indications for X-ray examination (esophageal X-ray) of the esophagus are dysphagia and any unpleasant sensations in the esophagus. The examination is performed on an empty stomach.

Diverticula. A diverticulum is a saccular protrusion of the mucous membrane and submucous layer of the esophageal wall through the slits of the muscular layer. Most diverticula are located in the area of the pharyngeal-esophageal junction, at the level of the aortic arch and the bifurcation of the trachea, in the supradiaphragmatic segment. The pharyngeal-esophageal (border, or Zenker's) diverticulum is formed between the lower fibers of the inferior constrictor of the pharynx and the cricopharyngeal muscle on the posterior wall of the esophagus at the level of CVIII. This is a congenital diverticulum. Other diverticula usually develop during a person's life, especially often in old age, under the influence of the passage (propulsion) of food, and they are called pulsion diverticula. Under the pressure of the contrast mass, the diverticulum increases and gives an image in the form of a rounded formation with smooth contours. It may have a wide entrance or communicate with the esophageal cavity by a narrow channel (neck). The folds of the mucous membrane are not changed and enter the diverticulum through the neck. As the diverticulum empties, it decreases. As a rule, diverticula are an accidental finding that has no clinical significance. However, in rare cases, an inflammatory process (diverticulitis) develops in them. Cases of perforation of the esophageal diverticulum into the mediastinum have been described.

During the cicatricial process in the tissue surrounding the esophagus, local deformations of the esophagus may occur, in particular protrusions of its wall. These protrusions have an elongated or triangular shape and lack a neck. Sometimes they are incorrectly called traction diverticula, although they are not true diverticula.

Esophageal dyskinesia. Esophageal dyskinesia is manifested in its hypertension or hypotension, hyperkinesia or hypokinesia, in spasms or insufficiency of sphincters. All these disorders are recognized during X-ray examination in the form of acceleration or deceleration of the movement of the contrast mass, the appearance of spastic constrictions, etc. Of the functional disorders, the most common is insufficiency of the lower esophageal sphincter with gastroesophageal reflux, i.e. throwing the contents of the stomach into the esophagus. As a result, inflammatory phenomena develop in the esophagus, superficial and then deep esophagitis occurs. Wrinkling of the esophageal wall contributes to the formation of a hernia of the esophageal opening of the diaphragm.

The best way to detect gastroesophageal reflux is scintigraphy. The patient drinks 150 ml of water with a labeled colloid while standing. After 10-15 minutes, he assumes a horizontal position. Light pressure on the anterior abdominal wall provokes the manifestation of reflux (for this, it is convenient to use an inflatable cuff, increasing the pressure in it every 30 seconds). The passage of even a small volume of fluid from the stomach to the esophagus is documented on a series of scintigrams.

Another functional disorder is the disturbance of secondary and tertiary contractions of the esophageal wall. Increased secondary contractions are expressed in spasm of the retrocardiac segment of the esophagus. Spasm is relieved by sublingual nitroglycerin. Increased tertiary contractions cause numerous unstable retractions on the contours of the middle and lower sections of the thoracic part of the esophagus. Sometimes the esophagus resembles a rosary or a corkscrew (corkscrew esophagus).

Hernia of the esophageal orifice of the diaphragm. There are two main types of hernias of the esophageal orifice: axial and paraesophageal.

In an axial hernia, the intra- and subdiaphragmatic segments of the esophagus and part of the stomach are displaced into the chest cavity, the cardiac opening is located above the diaphragm. In a paraesophageal hernia, the subdiaphragmatic segment of the esophagus and the cardiac opening are located in the abdominal cavity, and part of the stomach exits through the esophageal opening of the diaphragm into the chest cavity next to the esophagus.

Large fixed hernias are easily recognized by X-ray examination, since barium fills the part of the stomach located in the posterior mediastinum, above the diaphragm. Small sliding hernias are detected mainly when the patient is in a horizontal position on the stomach. It is necessary to differentiate between the pictures of a hernia and an ampulla of the esophagus. Unlike an ampulla, a hernia does not have a subdiaphragmatic segment of the esophagus. In addition, folds of the gastric mucosa are visible in the prolapsed part, and, unlike an ampulla, it retains its shape during exhalation.

Esophagitis and esophageal ulcers.

Acute esophagitis is observed after a burn of the esophagus. In the first days, swelling of the mucous membrane of the esophagus and pronounced disturbances of its tone and motility are noted. The folds of the mucous membrane are swollen or not visible at all. Then, uneven contours of the esophagus and the "spotty" nature of its inner surface due to erosions and flat ulcers can be detected. Within 1-2 months, cicatricial stenosis develops, in the area of which there is no peristalsis. The patency of the esophagus depends on the degree of stenosis. If necessary, balloon dilation of the esophagus is performed under fluoroscopy control.

Chronic esophagitis is most often associated with gastroesophageal reflux. The esophagus is moderately dilated, its tone is decreased. Peristalsis is weakened, the contours of the esophagus are slightly uneven. Its secondary and tertiary contractions often increase. Sections of the esophagus in which the folds of the mucous membrane are tortuous and thickened alternate with zones of no folding, where it is replaced by a peculiar granularity and flocculent accumulations of contrast mass. Similar changes are observed in viral and fungal lesions of the esophagus.

Contrast agent accumulates in the ulcer area. In this place, a round or triangular protrusion appears on the esophagus contour - a niche. If the ulcer cannot be brought to the contour, then it gives an image in the form of a rounded accumulation of contrast agent, which does not disappear after one or two sips of water.

Achalasia of the esophagus. Achalasia - the absence of normal opening of the cardiac orifice - is a relatively frequently observed pathological condition. At the stage of the disease, the radiologist notes a conical narrowing of the subdiaphragmatic segment of the esophagus and a delay in it of the contrast mass for several minutes. Then the cardiac orifice suddenly opens, and the barium quickly enters the stomach. Unlike cancer of the cardiac section, the contours of the subdiaphragmatic segment and the upper part of the stomach are smooth; in these sections, clear longitudinal folds of the mucous membrane are traced. In case of a long-term delay of the contrast mass in the esophagus, a pharmacological test is used. Taking nitroglycerin or intramuscular injection of 0.1 g of acetylcholine promotes opening of the cardiac orifice.

In stage II of the disease, the thoracic part of the esophagus is dilated, and fluid accumulates in it. Peristalsis is weakened, and the folds of the mucous membrane are thickened. The subdiaphragmatic segment of the esophagus in front of the cardiac opening is narrowed, often curved in the form of a beak, but with deep breathing and straining its shape changes, which does not happen with cancer. Barium does not enter the stomach for 2-3 hours or more. The gas bubble in the stomach is sharply reduced or absent.

In stage III - the stage of decompensation - the esophagus is sharply dilated, contains liquid, and sometimes food residues. This leads to the expansion of the mediastinal shadow, in which the esophagus is visible even before taking the contrast mass. Barium seems to sink in the contents of the esophagus. The latter forms bends. Air is usually absent in the stomach. Emptying of the esophagus is delayed for many hours, and sometimes for several days.

Control radiographic studies are performed to check the effectiveness of conservative or surgical treatment, in particular after the imposition of an esophagogastric anastomosis.

Esophageal tumors. Benign epithelial tumors (papillomas and adenomas) of the esophagus have the appearance of a polyp. They cause a filling defect in the shadow of the contrast agent. The contours of the defect are sharp, sometimes finely wavy, the folds of the mucous membrane are not destroyed, but envelop the tumor. Benign non-epithelial tumors (leiomyomas, fibromas, etc.) grow submucosally, so the folds of the mucous membrane are preserved or flattened. The tumor produces a marginal filling defect with smooth outlines.

Exophytic cancer grows into the lumen of the organ and causes a filling defect in the shadow of the contrast agent in the form of a round, oblong or mushroom-shaped enlightenment (polypoid or mushroom-shaped cancer). If decay occurs in the center of the tumor, then the so-called cup-shaped cancer is formed. It looks like a large niche with uneven and raised, like a ridge, edges. Endophytic cancer infiltrates the wall of the esophagus, causing a flat filling defect and gradual narrowing of the lumen of the esophagus.

Both exophytic and endophytic cancers destroy the folds of the mucous membrane and transform the wall of the esophagus into a dense, non-peristaltic mass. As the esophagus narrows, the movement of barium along it is disrupted. The contours of the stenotic area are uneven, and a suprastenotic expansion of the esophagus is determined above it.

Insertion of an ultrasound sensor into the esophagus allows determining the depth of tumor invasion of the esophageal wall and the state of regional lymph nodes. Before surgery, it is necessary to establish whether there is invasion of the tracheobronchial tree and aorta. For this purpose, CT or MRI is performed. Penetration of tumor tissue beyond the esophagus causes an increase in the density of mediastinal tissue. Radiation studies are necessarily repeated after preoperative chemo- or radiation therapy and in the postoperative period.

Dysphagia

The term "dysphagia" refers to all types of difficulty swallowing. This is a syndrome that can be caused by various pathological processes: neuromuscular disorders, inflammatory and tumor lesions of the esophagus, systemic diseases of connective tissue, cicatricial strictures, etc. The main method of examining patients with dysphagia is radiography. It allows you to get an idea of the morphology of the pharynx and all parts of the esophagus and detect compression of the esophagus from the outside. In unclear situations, with negative X-ray results, as well as when a biopsy is necessary, esophagoscopy is indicated. In patients with functional disorders established by X-ray examination, esophageal manometry may be necessary (in particular, with achalasia of the esophagus, scleroderma, diffuse esophageal spasm). The general scheme of a comprehensive study for dysphagia is presented below.