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Diseases of the Esophagus: Diagnosis with Esophagography¹

¹ From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received February 8, 2005; revision requested April 7; revision received April 25; accepted June 2. Address correspondence to M.S.L. (e-mail: marc.levine{at}uphs.upenn.edu). The authors are paid consultants for EZ-Em, Westbury, NY.

View larger version (67K): [in a new window]   Figure 1. Upright LPO spot image from double-contrast esophagography shows normal esophagus with smooth homogeneous appearance en face.

View larger version (124K): [in a new window]   Figure 2. Recumbent right-side-down, lateral spot image of normal gastric cardia shows stellate folds radiating to central point (white arrow) at gastroesophageal junction. Note hooding fold (black arrows) above cardia.

View larger version (96K): [in a new window]   Figure 3. Upright LPO spot image from double-contrast esophagography shows reflux esophagitis with extensive granularity of lower esophagus due to edema and inflammation of mucosa.

View larger version (96K): [in a new window]   Figure 4. Upright LPO spot image from double-contrast esophagography shows reflux esophagitis with small linear ulcers (black arrows) in distal esophagus just above hiatal hernia (white arrows).

View larger version (96K): [in a new window]   Figure 5. Prone RAO spot image from single-contrast esophagography shows inflammatory esophagogastric polyp as enlarged fold (small arrows) extending upward into distal esophagus, where it terminates as a smooth polypoid protuberance (large arrow). Inflammatory polyps are thought to be a sign of chronic reflux esophagitis.

View larger version (75K): [in a new window]   Figure 6. Upright LPO spot image from double-contrast esophagography shows smooth tapered segment of concentric narrowing (white arrows) due to peptic stricture in distal esophagus above a hiatal hernia (black arrow).

View larger version (91K): [in a new window]   Figure 7. Upright LPO spot image from double-contrast esophagography shows asymmetric peptic stricture in distal esophagus above hiatal hernia (small black arrows), with sacculation of wall both en face (large black arrow) and in profile (large white arrow). Note fixed transverse folds (small white arrows) from associated longitudinal scarring of distal esophagus above the stricture.

View larger version (103K): [in a new window]   Figure 8. Upright LPO spot image from double-contrast esophagography shows short ringlike peptic stricture (white arrow) in distal esophagus above a hiatal hernia (black arrows). Although this stricture could be mistaken for a Schatzki ring, it has a longer vertical height than does a true Schatzki ring.

View larger version (112K): [in a new window]   Figure 9. Upright LPO spot image from double-contrast esophagography shows thin transverse striations due to transient contraction of longitudinally oriented muscularis mucosae in patient with "feline" esophagus. This finding is often associated with gastroesophageal reflux.

View larger version (108K): [in a new window]   Figure 10. Upright LPO spot image from double-contrast esophagography shows mild ringlike constriction (large white arrows) in midesophagus in a patient with Barrett esophagus. Also note distinctive reticular pattern (black arrows) extending distally from the stricture, a classic radiographic sign of Barrett esophagus. This patient also has fixed transverse folds (small white arrows) just above the stricture due to longitudinal scarring in this region.

View larger version (104K): [in a new window]   Figure 11. Upright LPO spot image from double-contrast esophagography shows multiple discrete plaquelike lesions (arrows) in the esophagus in a patient with Candida esophagitis. Note how plaques have a linear configuration and are separated by normal intervening mucosa.

View larger version (92K): [in a new window]   Figure 12. Upright LPO spot image from double-contrast esophagography shows multiple small plaques and nodules in midesophagus in an elderly patient with glycogenic acanthosis. Note how nodules have a more rounded appearance than the fungal plaques in Figure 11.

View larger version (84K): [in a new window]   Figure 13. Upright LPO spot image from double-contrast esophagography shows shaggy esophagus of fulminant Candida esophagitis in a patient with AIDS. This shaggy contour results from innumerable pseudomembranes and plaques, with trapping of barium between lesions.

View larger version (94K): [in a new window]   Figure 14. Upright LPO spot image from double-contrast esophagography shows multiple small superficial ulcers (arrows) in midesophagus of a patient with herpes esophagitis.

View larger version (106K): [in a new window]   Figure 15. Upright LPO spot image from double-contrast esophagography shows giant diamond-shaped HIV ulcer (arrows) in the midesophagus in HIV-positive patient with odynophagia. Although CMV esophagitis can produce identical findings, endoscopic brushings and biopsy specimens revealed no evidence of CMV.

View larger version (107K): [in a new window]   Figure 16. Upright LPO spot image from double-contrast esophagography shows two small superficial ulcers as ring shadows (arrows) in midesophagus. This patient had drug-induced esophagitis after taking doxycycline.

View larger version (72K): [in a new window]   Figure 17. Upright LPO spot image from double-contrast esophagography shows radiation stricture as a long segment of smooth tapered narrowing (arrows) in upper thoracic esophagus. This patient had undergone mediastinal irradiation.

View larger version (61K): [in a new window]   Figure 18. Prone RAO spot image from single-contrast esophagography shows long smooth stricture (arrows) in the thoracic esophagus caused by lye ingestion. Also note cardiac pacemaker wires.

View larger version (103K): [in a new window]   Figure 19. Upright LPO spot image from double-contrast esophagography shows leiomyoma as a smooth submucosal mass (black arrows) in the midesophagus. Note how lesion forms slightly obtuse angles with adjacent esophageal wall. Also note kissing artifact (white arrows) due to apposition of opposing esophageal walls.

View larger version (103K): [in a new window]   Figure 20. Upright LPO spot image from double-contrast esophagography shows giant fibrovascular polyp as smooth sausage-shaped mass (black arrows) expanding the lumen of the upper thoracic esophagus. Note polypoid distal tip (white arrow) of polyp. Fibrovascular polyps usually arise from the region of the cricopharyngeus muscle. (Reprinted, with permission, from reference 50.)

View larger version (109K): [in a new window]   Figure 21. Upright LPO spot image from double-contrast esophagography shows early esophageal cancer in profile as plaquelike lesion (black arrows) with flat central ulcer (white arrows) on left lateral wall of the midesophagus.

View larger version (139K): [in a new window]   Figure 22. Upright LPO spot image from double-contrast esophagography shows superficial spreading carcinoma as focal area of mucosal nodularity (arrows) in midesophagus, without a discrete mass. Note how nodules merge with one another, producing a confluent area of disease.

View larger version (77K): [in a new window]   Figure 23. Upright LPO spot image from double-contrast esophagography shows advanced infiltrating carcinoma as irregular area of narrowing, with mucosal nodularity, ulceration, and shelflike margins (arrows) in midesophagus.

View larger version (119K): [in a new window]   Figure 24. Upright LPO spot image from double-contrast esophagography shows advanced esophageal carcinoma as polypoid mass (white arrows) with a large area of ulceration (black arrows) on the right posterolateral wall of the distal esophagus (small rounded defects abutting mass are air bubbles).

View larger version (109K): [in a new window]   Figure 25. Upright LPO spot image from double-contrast esophagography shows varicoid carcinoma as lobulated submucosal lesion in the distal esophagus that could be mistaken for varices. However, this lesion had a fixed appearance at fluoroscopy and an abrupt proximal demarcation (arrows) from normal esophagus.

View larger version (76K): [in a new window]   Figure 26. Prone RAO spot image from single-contrast esophagography shows uphill esophageal varices as serpiginous defects in lower esophagus. This patient had portal hypertension.

View larger version (76K): [in a new window]   Figure 27. Upright LPO spot image from double-contrast esophagography shows downhill esophageal varices as serpiginous defects in midesophagus above the level of the carina. This patient had superior vena cava syndrome.

View larger version (102K): [in a new window]   Figure 28a. Schatzki ring. (a) Prone RAO spot image from single-contrast phase of esophagography shows Schatzki ring as smooth, symmetric, ringlike constriction (white arrow) in distal esophagus directly above a hiatal hernia (black arrows). (b) Upright LPO spot image from double-contrast phase of same examination shows mild narrowing of distal esophagus without demonstration of the ring because of inadequate distention of this region.

View larger version (77K): [in a new window]   Figure 28b. Schatzki ring. (a) Prone RAO spot image from single-contrast phase of esophagography shows Schatzki ring as smooth, symmetric, ringlike constriction (white arrow) in distal esophagus directly above a hiatal hernia (black arrows). (b) Upright LPO spot image from double-contrast phase of same examination shows mild narrowing of distal esophagus without demonstration of the ring because of inadequate distention of this region.

View larger version (95K): [in a new window]   Figure 29. Upright LPO spot image from double-contrast esophagography shows multiple esophageal intramural pseudodiverticula as flask-shaped outpouchings (black arrows) in longitudinal rows parallel to the long axis of the esophagus. Note how some pseudodiverticula (white arrows) appear to be floating outside the esophagus without apparent communication with the lumen.

View larger version (61K): [in a new window]   Figure 30. Upright frontal spot image from double-contrast esophagography shows typical findings of primary achalasia, with dilated aperistaltic esophagus and tapered beaklike narrowing (arrow) of distal esophagus due to incomplete opening of the lower esophageal sphincter. This image was obtained in a middle-aged patient with long-standing dysphagia.

View larger version (93K): [in a new window]   Figure 31. Prone RAO spot image from single-contrast esophagography shows beaklike narrowing (black arrows) of distal esophagus caused by secondary achalasia. Note greater length of narrowed segment than is usually seen in primary achalasia (see Fig 30). Also note metallic esophageal stent (white arrow) for palliation of esophageal carcinoma, which presumably had spread to gastroesophageal junction via periesophageal lymphatics. This image was obtained in an elderly patient with recent onset of dysphagia and weight loss.