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6.4 Esophageal Ulcerations

6.4 Esophageal Ulcerations

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Published by Naweed Ashraf

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Published by: Naweed Ashraf on May 16, 2012
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11/30/2012

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Naweed Ashraf

Case 1.3. Double-contrast esophagram. A large, flat ulcer is present in the distal esophagus (arrow) with associated diminished distensibility of the lower esophageal segment. There is also a long linear ulcer (arrowheads) with a surrounding halo of edema.

Case 1.4. Double-contrast esophagram. Mucosal nodularity, a deep ulcer, and luminal narrowing are present. Transverse folds due to chronic scarring and buckling of the mucosa also are present (arrows). Sharp spiculations are seen just superior to the deep ulcer; these are due to transverse folds seen in profile. Asymmetric scarring causes the distal deformity and narrowing.

Double-contrast esophagram. Luminal irregularity and narrowing are present in the distal esophagus with associated asymmetric sacculations.

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Case 1.6., Double-contrast esophagram,

A featureless

distal esophagus is prese:nt.. Above the featureless zone are

findings of active reflux esophagi tis (mucosal gran'ulari ty and superficial erosions [arrowsj).

Case 1.7.,D'ollble~contrast

esophagram.

Mucosal

reticularity is present in the esophagus. There is a short esophagus ... type hiatal hernia. A surgically induced deformity mimics an 'ulcer crater, A benign-appearing stricture also is prese,n,t.

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Single-contrast esophagram. An irregular, linearly oriented ulceration with a surrounding soft tissue mass (arrow) is present in the mid esophagus. There is also a region of reduced distensibility on the opposite wall.

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Double-contrast esophagram. A segmental region of deep ulceration affects a noncircumferential portion of the mid esophagus.

Case 1.1 o. Double-contrast esophagram. Multiple plaquelike filling defects are seen throughout the esophagus,

Case 1.11. Double-contrast esophagram. Shaggy, irregular luminal contours due to extensive plaquelike filling defects are present throughout the esophagus.

Case 1.. 2. Double-contrast esophagram. Multiple 1 discrete ulcerations (arrows) are present on a normal esophageal background. (From Laufer I. Double contrast

Case 1.13. Double-contrast esophagram. Multiple discrete ulcerations are clustered within the mid esophagus ..

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Herpes esophagitis

Double-contrast esophagram. A large, flat ulceration (arrow) is present in the distal esophagus. (Courtesy of

Diagnosis . .. . Cytomegalovirus esop hagltls ....• al
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A lateral view of the pharynx obtained! dlulningl ~ multiple, irreqular, 2-4 mm nodules (plaques) in the !Qn§ll@[fQ§g(bllaclk arrows lin and upper ~ (white arrow). Barium has coated the Ilaryngeallvestibule. A view of the Imid-~ ~ multiplle small (2-3 rnrn) well-circurnscribedplaques aligned lonqitudinally along mucosal folds. ,

Reflux ~ is the most common inflammatory condition in the upper gastrointestinal tract. Double contrast radiographs may demonstrate one or more shallow ulcers in the distal esophagus. Some ulcers may have an irregular appearance, while others may have a linear configuration with their long axis oriented perpendicular to the _ junction. Other patients may have a single large, relatively flat ulcer at or near the _ junction. Reflux ~ is more frequently manifested on double contrast images by a granular or finely nodular appearance with numerous ill-defined radiolucencies When ulceration is detected in patients with reflux ~, the correct diagnosis is almost always suggested by the following triad of findings: (1) predominantly distal esophageal involvement; (2) an associated ~ hernia and/or _ reflux; and (3) a clinical history of heartburn or other reflux symptoms. Even when there is a diffuse erosive ~, there is continuous mucosal disease extending proximally from the _ junction, so that the presence of superficial ulceration in the mid-esophagus with distal esophageal sparing should suggest another etiology for the patient's ~.

The classic radiologic features of Barrett's esophagus are a high esophageal stricture or ulcer, often associated with a ~ hernia and/or _ reflux. Because these findings are unusual in uncomplicated _ reflux disease, the presence of a high stricture or ulcer in patients with reflux symptoms should be highly suggestive of Barrett's esophagus. Nevertheless, the majority of Barrett's strictures are located in the distal esophagus, so that they cannot be distinguished ~ from ordinary peptic strictures. A reticular mucosal ~ also been described as a relatively specific sign of Barrett's esophagus, particularly if located adjacent to a stricture. This pattern is manifested by tiny, parallel or intersecting barium-filled grooves, sometimes resembling the ~ ~ seen on double contrast studies of the stomach. An adjacent stricture is often present in the mid-esophagus, with the reticular pattern extending distally a short. Occasionally, the reticular pattern is seen a considerable distance from the strictu rei. However, a reticular pattern is observed in only 5-10% of patients with Barrett's esophagus.

The herpes simplex virus type I has been recognized with increased frequency as an opportunistic esophageal invader. More than 50% of patients with herpes ~ have small, discrete, superficial ulcers on double contrast~. The ulcers may be clustered together in the mid-esophagus or widely separated by normal intervening mucosa. In the appropriate clinical setting, these findings should be highly suggestive of viral ~, particularly herpes ~. In contrast, in patients with ~ ~Iceration almost always occurs on a background of diffuse plaque formation. Although herpes ~ usually develops in immunocom romised patients, an acute, self-limited form of herpes ~ occasionally may develop in otherwise healthy individuals who have no underlying immunologic problems. In such cases, double contrast images may reveal numerous ~ areas of ulceration, often clustered together in the mid-esophagus near the level of the left ~ bronchus. Although reflux ~ could produce superficial ulceration as far proximally as the aortic arch, it would be extremely unusual for reflux ~ to be associated with relative sparing of the distal esophagus.

Cytomegalovirus (CMV) has been recognized as another cause of opportunistic infection in the esophagus in patients with AIDS. CMV ~ may be manifested by multiple small ulcers indistinguishable from those in herpes ~ or, even more commonly, by one or more giant, flat ulcers that can be 3 cm or greater in diameter. Because herpetic ulcers almost never become this large, the presence of one ~ more giant esophageal ulcers should suggest the possibility of CMV ~ in patients with AIDS.

Glycogenic ~.I There are multiple nodular and plaque-like lesions in the mid and distal esophagus. The nodules are diffusely distributed in the mid-esophagus and are not focally clustered. Although Candida ~ could produce a similar radiographic appearance, the lesions here tend to have a more rounded configuration, are not longitudinally arranged in rows, nor separated by normal mucosa. More importantly, this patient had no esophageal symptoms and was not immunocom romised. Patients with Candida ~ are usuallyimmunocom romised and have acute ~ or ~. The lack of esophageal ~ should therefore suggest the correct diagnosis of glycogenic ~. Naweed Ashraf

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