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Roentgenologic Examination of the Esophagus
ROENTGENOLOGIC EXAMINATION OF THE ESOPHAGUS LILIAN DONALDSON, M.D.*
Excellence in the roentgen diagnosis of lesions of the esophagus depends not only on the knowledge and skill of the examiner, but to a considerable extent on the adequacy of the equipment at his command. Because of the rapidity with which the hypopharynx and esophagus may empty themselves of the radiopaque contrast material, a filming fluoroscope capable of recording a series of views in rapid succession and in sharp detail is needed if the smaller and less obvious lesions are to be filmed for study. Large lesions can of course be recorded with almost any type of x-ray apparatus, but with the development of esophageal surgery it has become important not only that any suspected esophageal lesion be searched for with great care, but that its nature, location and extent be' determined as accurately and as early as possible. EQUIPMENT
A machine which allows easy and rapid movement of the fluorescent screen during fluoroscopy and which at any desired instant can be rigidly locked and switched to filming with a minimum of time and effort best achieves the desired end. This will be obvious when certain technics, such as those for demonstration of esophageal varices, are described later. There are certain lesions whose nature is best explored when several views of the area concerned can be made without the delay of changing cassettes. Varices, early cardiospasm, and the differentiation of phrenic ampulla and small concentric diaphragmatic hernia are among such conditions. To obtain rapid flpot films of the desired area is of little value, however, if the quality of the film taken is poor, as it seems to have been so frequently in the past. This has driven many examiners back to "blind" raying with the overhead tube after the general area has been determined fluoroscopically. Consistently poor quality of spot films may be ascribed in large measure to four factors: (a) failure of the spotfilming device to lock rigidly so that vibration blurs film detail; (b) insufficiently fine focal spot for the relatively short focal spot-film distance inherent in the use of under-table tubes; (c) insufficiently fine stationary grid to clean up adequately the scattered secondary radiation from adjacent soft tissues; and (d) improper exposure factors (kilovoltage, milli* Radiologist to the,Woodlawn Hospital, Chicago. 21
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amperage, exposure time). If these are corrected, spot-films of consistently fine quality are relatively easy to obtain. In the postwar years considerable improvement has been made in the spot-film devices commercially available, so that all the necessary aids can be obtained by those who wish to do such work. The filming fluoroscope which we are using at Woodlawn Hospital was built for us by Mr. Raymond Angrabright and is a modification of the one designed by Dr. Paul C. Hodges more than a decade ago for use at the University of Chicago. The device can be built into any good motor-driven commercial tilt table, and for all but large institutions it is more economical of machinery to combine this unit with the presence of an overhead tube running on floor or ceiling rail and a Potter-Bucky grid suspended beneath the table top, so that the machine can be used for other types of special examination during that part of the day when it is not needed for fluoroscopy. In our machine the kilovoltage used for fluoroscopy and filming are independent of each other. We routinely fluoroscope. all adults at 70 kvp and 3 ma., and take spot-films at 90 kvp and 100 mao Exposure time is controlled by a photoelectric cell so that the examiner is free to de':ote himself to the patient and his lesion. While the examiner asks the patient to stop breathing, he locks the machine in position with one movement of the left hand, while his right hand brings the film into place, thereby automatically transferring the active circuit to filming and causing the photocell to fall into reading position over the screen. Immediately on completion of these movements, the foot initiates the filming exposure, which is terminated automatically by the photoelectric cell as soon as suffici{lnt radiation has passed through the patient's body and the film to reach the fluorescent screen. With rare exceptions all films taken are made with the fluoroscopic tube which has a rotating anode with twin 1.5 mm. focal spots. A focal spot of this size makes for fine definition of the film image, and the fact that the anode rotates allows prolonged use of the tube without overheating of the anode in spite of the small focal spot. We use a B-2 Patterson fluoroscopic screen backed by a very finegrain magnesium-dipped Lysholm grid, the lines of which are set transversely across the field. By reducing the number of scattered rays which reach the examiner's eye or the film, sharper definition is obtained. A fine cross-hatch or honeycomb type of grid has also recently become commercially available should one prefer it. It is a grave mistake to purchase an elaborately designed filming fluoroscope into the screen of which no grid or only a relatively coarse one has been incorporated, for really fine delineation of detail can never be obtained with it. We fluoroscope and film through a screen aperture nearly 7 inches
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. long by a little over 4 inches wide. It is possible, when occasion requires, to open the aperture to twice this width for a large spot view, but this is not needed for work on the esophagus. It is also possible to incorporate electrically driven shutters which will. enable one to reduce the field to a tiny fraction of its usual size, but this device is seldom needed for work on the upper alimentary tract. A vertical length of 7 inches is practical for spot-filming of the esophagus, since it is long enough to .enable one to record the entire length of most localized lesions with some adjacent normal portion above and below the lesion, together with the shadow of an easily identifiable adjacent structure, such as clavicle, aortic knob or diaphragm, so that the lesion can be localized accurately within the thorax for the benefit of the surgeon. Four views of this size can be obtained in rapid succession without change of the 7 by 17 inch film used, and this is of particular value in some of the technics used for lesions of the esophagus where a rapid series of views may be needed to show satisfactorily the nature of the lesion, as described later. RADIOPAQUE MATERIAL
We'begin by giving the patient a mouthful of a watery suspension of barium sulfate, made with equal parts by volume of barium and water, flavored with chocolate syrup. If th~s mixture does not adhere sufficiently well to the esophageal mucosa to give satisfactory views of the rugal pattern, we resort to use oia. smooth barium and water paste. Gelatinbarium bougies can also b~;ised, but we are of the opinion that most of the information needed can be obtained quite as well or better by the use of the first two types of mixture. Some examiners find a thin bariumacacia suspension of value in coating the mucosa. With these mixtures the esophagus is examined with the patient first in the erect position and then in the horizontal. HYPOP~ARYNX
AND CERVICAL ESOPHAGUS
Of great' aid to the radiologist in enabling him to state whether or not a lesion is present is a thorough knowledge of the roentgen appearance of the normal. In the frontal plane the hypopharynx and cervical esophagus, when filled with the passing bolus of barium, present the appearance of slightly flared funnel with a wide stem. When the bolus has passed, the valleculae and pyriform sinuses are frequently seen delicately outlined by barium. All these structures are quite symmetrical. However, if the patient is allowed to turn the head even slightly from the true frontal position during swallowing, the bolus will travel in much greater quantity down the side of the hypopharynx from which the head is turned, causing the region to assume an asymmetric appear-
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ance and giving rise to a false impression of the asymmetry which may be encountered in this region as a result of unilateral bulbar palsy.
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many months 'in whom laryngoscopy and esophagoscopy had at first shown nothing. On
10. Posterior pharyngeal diverticulum . . a, In active phase of deglutition. b, After the bolus has passed the hypopharynx leaving the diverticulum still barium filled. c, During performance of the Valsalva test.
after the bolus has passed, leaving the lumen delineated by air-barium contrast, it is easy to demarcate the hypopharynx from the cervical esophagus by asking the patient to perform a modified Valsalva test. To do this, the patient is asked to take a deep breath, close his lips, pinch his nose and then blow against these closed openings so that his cheeks become roundly puffed. During this effort the contracting mass of the cricopharyngeus muscle invaginates the posterior wall of the passageway so markedly as practically to obliterate the lumen at the point where hypopharynx joins' cervical esophagus, just anterior to the sixth
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cervical vertebra (Fig. 9, b). This muscle mass may be so prominent that competent radiologists have been known to mistake it for a tumor mass when recorded in tracheal films made while a patient was spontaneously performing the Valsalva test. It is at this level that Zenker's diverticulum is found as a pouch of mucosa protruding from the posterior pharyngeal wall at a weak point in the crossing of fibers of the cricopharyngeus, and therefore the latera] projection is the more useful one in search for an early stage of develop-
Fig. 11. Webs in a case of Plummer-Vinson syndrome. This case is unusual in that the webs can be seen posteriorly as well as anteriorly and laterally in this anemic woman of 62 who had developed rather marked dysphagia . .a, Frontal view. b, Lateral view at a phase of deglutition corresponding to that shown in (a). The indentation of a thickened fold is seen in the hypopharynx just above the level of the cricopharyngeus. Shadow of shoulder girdle obscures the condition of cervical esophagus. c, Lateral view during the Valsalva test. The bolus has passed the hypopharynx and the web there is no longer visualized, but another one can be seen in the barium filled cervical esophagus just below the cricopharyngeus.
ment of this diverticulum. A large diverticulum assumes a dependent position and commonly displaces the adjacent esophagus anteriorly compressing its lumen; a position of slight obliquity as compared with the true lateral may be necessary to bring out this relationship fully (Fig. 10). Another important though relatively rare condition best shown by lateral views of the hypopharynx and cervical esophagus is the web formation found in the Plummer-Vinson syndrome, in which dysphagia is associated with a microcytic hypochromic anemia. Chronic thickening of the mucosa throws it into weblike folds (Fig. 11) which in lateral
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roentgenograms may be seen indenting the anterior surface of the gullet just above or below the level of the cricopharyngeus. Webs are seen only when the region concerned is well filled with barium, and are relatively difficult to record because of the rapid passage of barium across this region. However, if the fluoroscopist first observes the interval required by the erect patient to initiate the act of swallowing, and then places the film in position for exposure, again asks the patient to swallow a large bolus of barium, and initiates the exposure at the previously ascertained interval, good views may be obtained. Another methodl is to place the examiner's finger lightly over the thyroid cartilage, and as the cartilage begins to rise with initiation of the act of swallowing, the finger is quickly removed and the exposure immediately made. INTRATHORACIC ESOPHAGUS
Immediately after the patient has swallowed a mouthful of barium the pharynx contracts, forcing the bolus into the esophagus and initiating the primary peristaltic wave which carries the opaque material downward in a rapid stream so that the intrathoracic esophagus becomes visualized as a smooth-walled relatively straight distensible tube (Fig. 12), which quickly collapses after passage of the main stream of contrast material to a narroW tube identified by the presence of three or four thin radiopaque longitudinal lines of barium caught in valleys between the thin rugal folds. If the patient is standing, the rate of progress is greatly enhanced by the action of gravity; hence, although the vertical position is of major value in the early evaluation of an obstruction, particularly in the region at or just above the cardia, the study of fine detail is better carried out with the patient horizontal or in slight Trendelenburg position. Several angles should be viewed, but of special value is the left posterior oblique position (a designation which refers to that portion of the body nearest the fluoroscopic screen) in which the intrathoracic esophagus is thrown into relief against the radiolucent pulmonary tissue, free of the denser shadows of spine and heart. The primary peristaltic wave usually carries the contrast all the way down the relatively straight esophageal lumen to the cardia, but if the patient is asked to take a deep breath during its passage, hold the breath against the closed glottis and then bear down as though his bowels were about to move (the Valsalva test), the wave will cease about 3 cm. above the diaphragmatic hiatus, and the distal end of the intrathoracic esophagus assumes a relaxed bulbous form. After several seconds the bulbous portion will gradually contract, causing the barium to be regurgitated upward along the intrathoracic esophagus. When the patient exhales
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LILIAN DONALDSON
after this Valsalva test, it is seen that the fold pattern of the distalmost portion of the intrathoracic esophagus is of the same delicate linear type as that of the rest of the tube. This fleetingly bulbous portion of the esophagus is known as the phrenic ampulla,t and can be demonstrated in a high proportion of subjects if the Valsalva test is carefully carried out with the patient preferably in the horizontal left oblique position. It -is to be sharply differentiated from the supradiaphragmatic pouches formed by small gastric diaphragmatic hernias. When these are of the
Fig. 12. Normal intrathoracic esophagus. a, Upper half, in left posterior oblique position. The long smooth indentation of the anterior wall is caused by the arch of the aorta. The oblique radiolucent shadow just below it is that of left main stem bronchus. b, Distal half. Note the delicate linear fold pattern of the intra-abdominal esophagus.
eccentric type,2 showing the cardioesophageal junction on medial aspect of the pouch, there is no difficulty in identification. Further, in those concentric diaphragmatic hernias where the herniated portion is not under any great tension and so retains its usual cerebriform fold pattern, the diagnosis is obvious (Fig. 13), but small concentric hernias in which the rugal fold pattern is of a linear type (such as may be seen particularly in short esophagus of whatever origin) require more careful evaluation to avoid confusion with normal phrenic ampulla. The Valsalva test is of value here, for in the case of hernia the barium often flows
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down from the pouch through the widened hiatus during the test, instead of being regurgitated up the esophagus as in phrenic ampulla; and the folds in the pouch and those passing through the hiatus are coarser and more multiple than in phrenic ampulla. The Short Esophagus. We have had little experience with true congenital short esophagus, but have examined subjects whose esophagus has been shortened secondary to some disease process. The prime ex-
Fig. 13. Concentric gastric diaphragmatic hernia in hiatus insufficiency, showing the cerebriform fold pattern commonly found in the gastric fundus. Numerous coarse gastric folds across the widened hiatal area; compare this region with the corresponding one in Figure 12, b. a, Frontal view with patient supine. b, Left posterior ob.lique projection with patient in a slight Trendelenburg position.
ample of this in our experience has been scleroderma in which the esophageal shortening results from diffuse fibrous connective tissue changes in the esophagus. 3 To compensate for this loss of length, a small amount of stomach may be pulled up through the diaphragmatic hiatus. On fluoroscopic examination the coarse gastric rugae are seen stretched taut by the shortened esophagus, causing the pouch in some instances to have a rather triangular shape with the apElf{ at the concentrically placed . cardioesophageal junction (Fig. 14). Just above this point it is not uncommon to find a sharply bordered ulcer niche, and, as this heals, a
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stricture may form, involving only a short segment and usually not of marked degree, but sufficient to cause some obstruction in an esophagus which even relatively early in the disease process may be observed not to clean itself of barium as readily as the normal does. This lack of cleansing power is ascribable to the enfeebled peristalsis observed in such cases. The change in muscular function is also reflected in the diffi-
Fig. 14. Esophageal scleroderma. a, The .shortened' esophagus has pulled a small nubbin of stomach above the I;liaphragmatic hiatus and stretched it taut (endoscopic confirmation). i~b, The small niche seen protruding anteriorly just above the cardioesophageal junction was identified as a shallow ulcer on endoscopic examination. c, The midesophagus is slightly dilated, shows two persistent linear flecks along its anterior margin, which probably represent very shallow ulcerations, The esophagus showed impaired peristalsis, failed to clean itself well, Good esophageal rugal pattern could not be obtained, but gastric fold pattern was not difficult to visualize.
culty in deglutition which these patients manifest. This may be. sufficiently marked so that barium is repeatedly regurgitated up the nasopharynx. Another change is diffuse loss of normal linear rugal fold pattern. In some advanced instances of this disease in which superficial ulcerations are present in the furrows between large hyperkeratotic plaques, several of the shallow ulcerations may penetrate sufficiently to be recognizable roentgenologically as shallow linear ulcers scattered anywhere along the course of the intrathoracic esophagus.
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Malignant Neoplasms. The most important lesion of the esophagus demonstrable by x-ray is, of course, maligant neoplasm, and the typical advanced ragged ulcerating, constricting, and polypoid lesion is usually obvious when the first mouthful of barium flows down the esophagus. Neoplasm may be found anywhere in the esophagus, but as a primary lesion it is surely commoner in the intrathoracic portion. The typical advanced lesion offers at least moderate obstruction to passage of barium, so that that portion of the esophagus proximal to it usually be-
•
Fig. 15. Three cases of malignant neoplasm of intrathoracic esophagus.
a, Ragged ulcerating type. b, Infiltrating annular constricting type with conspicuous mushrooming of the tumor mass into adjacent normal lumen. c, Diffuse type which .spread widely along the mucosa, but was found to have infiltrated submucosa only at the point where slight irregularity of luminal width is shown above.
comes somewhat dilated. The tumor tissue which encroaches on the lumen is often visualized fluoroscopically as an irregular luminal filling defect so that the luminal margins appear ragged. When the main bolus of barium has passed the lesion, the rugal pattern there is seen to have been destroyed and an oval pool of barium may persist within one of the tumor masses, indicative of ulceration (Fig. 15, a). While little effort is necessary on the part of the radiologist to demonstrate the nature of such a spectacular lesion, it is necessary that he record on film, for the information of the surgeon, the preci~e location of the lesion in relation
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LILIAN DONALDSON
tQ other mediastinal structures such as the aortic arch, the carina, or the diaphragm, and to adjacent bony landmarks, and that he determine how long a segment of esophagus is involved and whether any barium seen spilling into the bronchial tree arrives there through aspiration of material regurgitated from a severely obstructed esophagus or through a fistula at the site of the lesion. Neoplasms such as these are unlikely to be confused with any other disease process.
Fig. 16. Benign midesophageal stricture showing the typical hour-glass deformity, in a young adult male who had ingested carbolic acid twelve days before. At this time only a threadlike stream of barium traversed the most severely involved region.
Other primary carcinomas may cause smooth annular constrictions. usually narrow the esophageal lumen abruptly both at the proximal and distal end of the lesion, and the tumor mass around the remaining narrowed lumen tends to invaginate the adjacent normal portions of the esophagus (Fig. 15, b). These features serve to distinguish this type of neoplasm from benign stricture, which narrows the esophagus gradually in concentric fashion, so that the lesion has an hour-glass shape in which the constricted area gradually and smoothly widens both proximally and distally until normal or, in the proximal portion, dilated luminal width is reached. Long strictures of this type are usually the Th~se
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result of ingestion of corrosive of some type (Fig. 16). Where these are fresh there is a complete loss of rugal pattern of the esophagus, but after healing has taken place the linear pattern may be partially reconstituted. Stricture resulting from the scarring of benign esophageal ulcer usually involves only a short segment of the esophagus, and the degree of·constriction is frequently not marked. The ulcer which causes it is usually small, sharply bordered, and best seen protruding from the margin of the esophageal lumen as a small barium-filled niche bordered by a narrow collar of radiolucency representing a little adjacent inflammatory edema. Such craters most often occur in the distal third of the esophagus as a result of regurgitation of acid gastric content, particularly when this regurgitation is made easy by the presence of a gastric diaphragmatic hernia, or in association with repeated vomiting, and they may be a'3so:)iated with an esophagitis. This last condition, if severe, is identifiable roentgenologically by fine, diffuse marginal serration in an esophagus that tends to remain slightly contracted. While the two types of neoplasm which have been described are easily identifiable, there are neoplasms which are difficult to differentiate either from other types of lesion or from the normal. The small tumor is of course always apt to be a difficulty, and there is a diffuse type of neoplasm which one can be certain of only after meticulous observation. An example of this is the case shown in Figure 15, c. This patient was complaining of mild dysphagia. Within a week he had been esophagoscoped twice and examined roentgenologically once, and no lesion had been seen. When he was re-fluoroscoped at the end of the week, however, it was noted that the slight indentation of the anterior wall of the esophagus in its distal third persisted during all phases of filling of the esophagus, and during both cardiac systole and diastole. When the esophagoscopist then biopsied this area, carcinoma cells were found. The' distal half of the esophagus was resected, and histologic examination showed that this neoplasm was spreading along the mucosa extensively, although at only one point, that identified in the film, was there even minimal invasion of the submucosa. Since cardiac impression is common in this region in older persons with moderate cardiac enlargement, it is solely by repeated and discriminating observation that the fluoroscopist should venture to label such an appearance as intrinsically abnormal. When neoplasm is found affecting only the intra-abdominal portion of the esophagus, the lesion is not usually primary in the esophagus, \ but in the stomach and has involved the esophagus by direct extension. Such an involvement may be polypoid in type, in which case differentiation must be made from varices, or it may be of the annular constricting tyPe which requires differentiation from cardiospasm. Of course if the neoplasm of the gastric fundus or corpus is readily identifiable and
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extending toward the cardia, then any distortion of intra-abdominal esophagus may usually be ascribed with confidence to direct neoplastic extension. However, some gastric neoplasms begin to infiltrate the cardia and intra-abdominal esophagus before any sizable mass is readily identifiable at the primary site. The most useful p~ints in recognizing the nature of the small rounded filling defects that occur in the extension of polypoid neoplasm into intra-abdominal and distal intrathoracic esophagus are that these defects tend to cause obstruction, are constant, and tend to distort the fold pattern of the esophagus in an irregular fashion. The polypoid filling defects of varices, on the other hand, are inconstant during certain phases of esophageal observation (unless they are thrombosed) and tend to impinge upon the rugal fold pattern in regular rows, forming a lacelike pattern. When neoplasm extends from the gastric cardia through intra-abdominal esophagus, narrowing, with resultant partial obstruction of the affected portion of the esophagus, is usually an outstanding finding. The normal esophagus above it will be slightly or moderately dilated. If the fold pattern of the intra-abdominal segment can be shown to be distorted instead of lying in normal delicate linear pattern, it speaks for neoplasm, but in cases in which the tumor cells have invaded the outer coats of the distalmost esophagus, but have not yet involved the muscularis mucosa, the rugal pattern may appear normal. This then necessitates a nice differentiation from cardiospasm in those occasional cases in which one is not certain of the presence of a primary gastric cancer. Esophageal Varices. Roentgen proof of esophageal varices is obtained by a three-phase observation. When the distal esophagus is well filled with barium, it expands widely and smoothly and appears normal, and no obstruction is offered to the progress of the barium. If the barium is allowed to pass downward into the stomach, leaving the folds of the intrathoracic esophagus lightly coated with barium as the patient rests in horizontal or Trendelenburg left posterior oblique position, the rugal pattern appears essentially regular and normal; but if the patient is asked to take a deep breath and perform the Valsalva test, small regular rounded filling defects appear in rows along the rugal folds of the esophagus, indenting in regular fashion the barium-filled fold valleys. When the patient is allowed to exhale, these rounded areas of radiolucency disappear. Cardiospasm. Examinations for cardiospasm are best done with the patient in the vertical position facing the examiner. With the esophagus about half filled with barium, some degree of esophageal dilatation is seen down to the funnel-like tapering of the esophagus which occurs just above the diaphragmatic hiatus, together with the persistent narrowing of the intra-abdominal portion. Except in the mildest form of
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this condition, the narrowing is usually sufficient to restrict sharply the rate of barium flow into the stomach (Fig. 17). When this picture has been recorded on spot films, the patient is then asked to inhale the vapor from a crushed ampule of amyl nitrite while the narrowed area is kept under fluoroscopic observation. As the affected region widens under influence of the drug, it is rapidly filmed. In all but very advanced cases
Fig. 17. Cardiospasm, with typical funnel-like tapering of the esophagus just above the level of the diaphragmatic hiatus, and persistent narrowing down to the cardia. A little barium has escaped through it to coat the adjacent gastric rugae. This view was taken with the patient standing. Under the influence of amyl nitrite the narrowed portion attained a width three times as great as that shown here with resultant good momentary drainage of the esophagus by gravity.
the widening is usually sufficient to empty the esophagus fairly well. An esophagus markedly stiffened by neoplastic infiltration, on the other hand, does not show this good response. The success of the procedure depends on keeping the patient erect so that advantage is taken of the force of gravity, and in continuing the inhalation of amyl nitrite until the patient becomes a little faint or dizzy. This can be done without accident, provided the tilt control on the filming fluoroscope is so 10-
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LILIAN DONALDSON
cated as to make it possible to start lowering the table immediately if the patient seems about to faint. We have seen only one case of cardiospasm in which amyl nitrite used in this manner was not effective in substantially widening the narrowed lumen. This occurred in a woman with a history of marked cardiospasm for many years resulting in gross esophageal dilatation, in whom had recently developed, as shown at exploration, a superimposed napkin-ring carcinoma of the intra-abdominal esophagus. In long-standing cardiospasm causing great esophageal dilatation there is usually loss of an effective primary peristaltic wave; tertiary contractions are prominent, and the esophageal margins therefore appear coarsely irregular, with the location of the irregularities changing as the contractions come and go. Metastatic Neoplasm. The esophagus may be narrowed anywhere along its course by direct extension of neoplasm arising elsewhere in the mediastinum, but metastasis to the esophagus from a distant primary tumor is rare. It may be suspected if multiple tumor nodules are seen scattered along a segment of the esophagus. In one such case the primary site was a melanosarcoma of the skin. Benign Esophageal Tumors. Benign esophageal tumors 4 are rare j the writer has seen only two, both leiomyomas. This type tends to cause smooth displacement of the lumen of the involved esophageal segment rather than to narrow it significantly. Benign tumors arising in mucosa or submucosa may become pedunculated and are more apt to cause obstruction. If one encounters a smooth oval mass causing a filling defect in one wall of the esophagus, but not affecting the flexibility of the surrounding wall, the possibility of benignity may be considered, but it is more likely that further investigation will prove the lesion to be malignant. Esophageal Diverticula. Intrathoracic esophageal diverticula should be mentioned, but whether of the traction or pulsion type they are seldom of clinical importance, and radiologically they present few problems in recognition and recording. Occasionally, however, they do give rise to symptoms of importance. We recently examined a middle-aged woman who was suspected clinically of having a carcinoma of the esophagus. For two months she had noted mild midsubsternal distress after deglutition, associated with a tendency to regurgitation, Because of this she had reduced her food intake. At fluoroscopy, with the patient in supine position, a moderately large wide-mouthed diverticulum of the midintrathoracic esophagus was seen which filled promptly as a bolus of barium was driven downward by the primary peristaltic wave. Only occasionally, however, did the wave carry barium further down the esophagus; instead, as the bolus distended the diverticulum, a reverse
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peristaltic wave appeared to be initiated there, which caused much of the barium to be regurgitated up to the cervical esophagus (Fig. 18).
Fig. 18. Diverticulum of the intrathoracic esophagus, causing dysphagia and regurgitation. . a, Shows only the diverticulum and proximal esophagus filled with barium. This view was made just as the primary peristaltic wave had caused filling of the diverticulum and then had become reversed, forcing the stream of barium back up the esophagus. b, In this view a little barium makes visible the distal esophagus, but onlv very occasionally did enough barium traverse this portion at anyone time to distend it widely. The small pouch just above the diaphragm when examined carefully fulfilled the criteria for phrenic ampulla rather than small hiatus hernia.
CLINICAL HISTORY
Since the examples given are only an introduction to the lesions which the radiologist may encounter when asked to examine the upper alimentary tract, it becomes obvious that before he begins his search he should be sufficiently informed of the patient's complaints, either by the referring physician or by questioning the patient himself, to form some idea of the location and possible nature of the lesion for whi~h search is to be made. Such information enables the examiner, after brief survey of the whole region, to concentrate his efforts first in that area and on those technics most likely to yield information of value. Such an approach reduces the amount of time, radiation and expense necessary to answer the clinical question in the majority of patients, while
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in no sense hampering the investigation of areas less likely to be involved. REFERENCES 1. Templeton, F. E.: X-Ray Examination of the Stomach. A Description of the
Roentgenologic Anatomy, Physiology, and Pathology of the Esophagus, Stomach, and Duodenum. Chicago, The University of Chicago Press, 1944, pp. 70-119. 2. Harrington, S. W.: Diagnosis and Treatment of Various Types of Diaphragmatic Hernia. Am. J. Surg. 50:381-446, 1940. 3. Lindsay, J. R.: Esophageal Lesions in Diffuse Scleroderma. Laryngoscope. 59:82-112, 1949. 4. Harper, R. A. K., and Tiscenco, E.: Benign Tumor of the Esophagus and Its Differential Diagnosis. Bl·it. J. Radio!. 18:99-107, 1945.
r
Excellence in the roentgen diagnosis of lesions of the esophagus depends not only on the knowledge and skill of the examiner, but to a considerable extent on the adequacy of the equipment at his command. Because of the rapidity with which the hypopharynx and esophagus may empty themselves of the radiopaque contrast material, a filming fluoroscope capable of recording a series of views in rapid succession and in sharp detail is needed if the smaller and less obvious lesions are to be filmed for study. Large lesions can of course be recorded with almost any type of x-ray apparatus, but with the development of esophageal surgery it has become important not only that any suspected esophageal lesion be searched for with great care, but that its nature, location and extent be' determined as accurately and as early as possible. EQUIPMENT
A machine which allows easy and rapid movement of the fluorescent screen during fluoroscopy and which at any desired instant can be rigidly locked and switched to filming with a minimum of time and effort best achieves the desired end. This will be obvious when certain technics, such as those for demonstration of esophageal varices, are described later. There are certain lesions whose nature is best explored when several views of the area concerned can be made without the delay of changing cassettes. Varices, early cardiospasm, and the differentiation of phrenic ampulla and small concentric diaphragmatic hernia are among such conditions. To obtain rapid flpot films of the desired area is of little value, however, if the quality of the film taken is poor, as it seems to have been so frequently in the past. This has driven many examiners back to "blind" raying with the overhead tube after the general area has been determined fluoroscopically. Consistently poor quality of spot films may be ascribed in large measure to four factors: (a) failure of the spotfilming device to lock rigidly so that vibration blurs film detail; (b) insufficiently fine focal spot for the relatively short focal spot-film distance inherent in the use of under-table tubes; (c) insufficiently fine stationary grid to clean up adequately the scattered secondary radiation from adjacent soft tissues; and (d) improper exposure factors (kilovoltage, milli* Radiologist to the,Woodlawn Hospital, Chicago. 21
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LILIAN DONALDSON
amperage, exposure time). If these are corrected, spot-films of consistently fine quality are relatively easy to obtain. In the postwar years considerable improvement has been made in the spot-film devices commercially available, so that all the necessary aids can be obtained by those who wish to do such work. The filming fluoroscope which we are using at Woodlawn Hospital was built for us by Mr. Raymond Angrabright and is a modification of the one designed by Dr. Paul C. Hodges more than a decade ago for use at the University of Chicago. The device can be built into any good motor-driven commercial tilt table, and for all but large institutions it is more economical of machinery to combine this unit with the presence of an overhead tube running on floor or ceiling rail and a Potter-Bucky grid suspended beneath the table top, so that the machine can be used for other types of special examination during that part of the day when it is not needed for fluoroscopy. In our machine the kilovoltage used for fluoroscopy and filming are independent of each other. We routinely fluoroscope. all adults at 70 kvp and 3 ma., and take spot-films at 90 kvp and 100 mao Exposure time is controlled by a photoelectric cell so that the examiner is free to de':ote himself to the patient and his lesion. While the examiner asks the patient to stop breathing, he locks the machine in position with one movement of the left hand, while his right hand brings the film into place, thereby automatically transferring the active circuit to filming and causing the photocell to fall into reading position over the screen. Immediately on completion of these movements, the foot initiates the filming exposure, which is terminated automatically by the photoelectric cell as soon as suffici{lnt radiation has passed through the patient's body and the film to reach the fluorescent screen. With rare exceptions all films taken are made with the fluoroscopic tube which has a rotating anode with twin 1.5 mm. focal spots. A focal spot of this size makes for fine definition of the film image, and the fact that the anode rotates allows prolonged use of the tube without overheating of the anode in spite of the small focal spot. We use a B-2 Patterson fluoroscopic screen backed by a very finegrain magnesium-dipped Lysholm grid, the lines of which are set transversely across the field. By reducing the number of scattered rays which reach the examiner's eye or the film, sharper definition is obtained. A fine cross-hatch or honeycomb type of grid has also recently become commercially available should one prefer it. It is a grave mistake to purchase an elaborately designed filming fluoroscope into the screen of which no grid or only a relatively coarse one has been incorporated, for really fine delineation of detail can never be obtained with it. We fluoroscope and film through a screen aperture nearly 7 inches
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
23
. long by a little over 4 inches wide. It is possible, when occasion requires, to open the aperture to twice this width for a large spot view, but this is not needed for work on the esophagus. It is also possible to incorporate electrically driven shutters which will. enable one to reduce the field to a tiny fraction of its usual size, but this device is seldom needed for work on the upper alimentary tract. A vertical length of 7 inches is practical for spot-filming of the esophagus, since it is long enough to .enable one to record the entire length of most localized lesions with some adjacent normal portion above and below the lesion, together with the shadow of an easily identifiable adjacent structure, such as clavicle, aortic knob or diaphragm, so that the lesion can be localized accurately within the thorax for the benefit of the surgeon. Four views of this size can be obtained in rapid succession without change of the 7 by 17 inch film used, and this is of particular value in some of the technics used for lesions of the esophagus where a rapid series of views may be needed to show satisfactorily the nature of the lesion, as described later. RADIOPAQUE MATERIAL
We'begin by giving the patient a mouthful of a watery suspension of barium sulfate, made with equal parts by volume of barium and water, flavored with chocolate syrup. If th~s mixture does not adhere sufficiently well to the esophageal mucosa to give satisfactory views of the rugal pattern, we resort to use oia. smooth barium and water paste. Gelatinbarium bougies can also b~;ised, but we are of the opinion that most of the information needed can be obtained quite as well or better by the use of the first two types of mixture. Some examiners find a thin bariumacacia suspension of value in coating the mucosa. With these mixtures the esophagus is examined with the patient first in the erect position and then in the horizontal. HYPOP~ARYNX
AND CERVICAL ESOPHAGUS
Of great' aid to the radiologist in enabling him to state whether or not a lesion is present is a thorough knowledge of the roentgen appearance of the normal. In the frontal plane the hypopharynx and cervical esophagus, when filled with the passing bolus of barium, present the appearance of slightly flared funnel with a wide stem. When the bolus has passed, the valleculae and pyriform sinuses are frequently seen delicately outlined by barium. All these structures are quite symmetrical. However, if the patient is allowed to turn the head even slightly from the true frontal position during swallowing, the bolus will travel in much greater quantity down the side of the hypopharynx from which the head is turned, causing the region to assume an asymmetric appear-
24
LILIAN DONALDSON
ance and giving rise to a false impression of the asymmetry which may be encountered in this region as a result of unilateral bulbar palsy.
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
25
many months 'in whom laryngoscopy and esophagoscopy had at first shown nothing. On
10. Posterior pharyngeal diverticulum . . a, In active phase of deglutition. b, After the bolus has passed the hypopharynx leaving the diverticulum still barium filled. c, During performance of the Valsalva test.
after the bolus has passed, leaving the lumen delineated by air-barium contrast, it is easy to demarcate the hypopharynx from the cervical esophagus by asking the patient to perform a modified Valsalva test. To do this, the patient is asked to take a deep breath, close his lips, pinch his nose and then blow against these closed openings so that his cheeks become roundly puffed. During this effort the contracting mass of the cricopharyngeus muscle invaginates the posterior wall of the passageway so markedly as practically to obliterate the lumen at the point where hypopharynx joins' cervical esophagus, just anterior to the sixth
26
LILIAN DONA"4DSON
cervical vertebra (Fig. 9, b). This muscle mass may be so prominent that competent radiologists have been known to mistake it for a tumor mass when recorded in tracheal films made while a patient was spontaneously performing the Valsalva test. It is at this level that Zenker's diverticulum is found as a pouch of mucosa protruding from the posterior pharyngeal wall at a weak point in the crossing of fibers of the cricopharyngeus, and therefore the latera] projection is the more useful one in search for an early stage of develop-
Fig. 11. Webs in a case of Plummer-Vinson syndrome. This case is unusual in that the webs can be seen posteriorly as well as anteriorly and laterally in this anemic woman of 62 who had developed rather marked dysphagia . .a, Frontal view. b, Lateral view at a phase of deglutition corresponding to that shown in (a). The indentation of a thickened fold is seen in the hypopharynx just above the level of the cricopharyngeus. Shadow of shoulder girdle obscures the condition of cervical esophagus. c, Lateral view during the Valsalva test. The bolus has passed the hypopharynx and the web there is no longer visualized, but another one can be seen in the barium filled cervical esophagus just below the cricopharyngeus.
ment of this diverticulum. A large diverticulum assumes a dependent position and commonly displaces the adjacent esophagus anteriorly compressing its lumen; a position of slight obliquity as compared with the true lateral may be necessary to bring out this relationship fully (Fig. 10). Another important though relatively rare condition best shown by lateral views of the hypopharynx and cervical esophagus is the web formation found in the Plummer-Vinson syndrome, in which dysphagia is associated with a microcytic hypochromic anemia. Chronic thickening of the mucosa throws it into weblike folds (Fig. 11) which in lateral
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
27
roentgenograms may be seen indenting the anterior surface of the gullet just above or below the level of the cricopharyngeus. Webs are seen only when the region concerned is well filled with barium, and are relatively difficult to record because of the rapid passage of barium across this region. However, if the fluoroscopist first observes the interval required by the erect patient to initiate the act of swallowing, and then places the film in position for exposure, again asks the patient to swallow a large bolus of barium, and initiates the exposure at the previously ascertained interval, good views may be obtained. Another methodl is to place the examiner's finger lightly over the thyroid cartilage, and as the cartilage begins to rise with initiation of the act of swallowing, the finger is quickly removed and the exposure immediately made. INTRATHORACIC ESOPHAGUS
Immediately after the patient has swallowed a mouthful of barium the pharynx contracts, forcing the bolus into the esophagus and initiating the primary peristaltic wave which carries the opaque material downward in a rapid stream so that the intrathoracic esophagus becomes visualized as a smooth-walled relatively straight distensible tube (Fig. 12), which quickly collapses after passage of the main stream of contrast material to a narroW tube identified by the presence of three or four thin radiopaque longitudinal lines of barium caught in valleys between the thin rugal folds. If the patient is standing, the rate of progress is greatly enhanced by the action of gravity; hence, although the vertical position is of major value in the early evaluation of an obstruction, particularly in the region at or just above the cardia, the study of fine detail is better carried out with the patient horizontal or in slight Trendelenburg position. Several angles should be viewed, but of special value is the left posterior oblique position (a designation which refers to that portion of the body nearest the fluoroscopic screen) in which the intrathoracic esophagus is thrown into relief against the radiolucent pulmonary tissue, free of the denser shadows of spine and heart. The primary peristaltic wave usually carries the contrast all the way down the relatively straight esophageal lumen to the cardia, but if the patient is asked to take a deep breath during its passage, hold the breath against the closed glottis and then bear down as though his bowels were about to move (the Valsalva test), the wave will cease about 3 cm. above the diaphragmatic hiatus, and the distal end of the intrathoracic esophagus assumes a relaxed bulbous form. After several seconds the bulbous portion will gradually contract, causing the barium to be regurgitated upward along the intrathoracic esophagus. When the patient exhales
28
LILIAN DONALDSON
after this Valsalva test, it is seen that the fold pattern of the distalmost portion of the intrathoracic esophagus is of the same delicate linear type as that of the rest of the tube. This fleetingly bulbous portion of the esophagus is known as the phrenic ampulla,t and can be demonstrated in a high proportion of subjects if the Valsalva test is carefully carried out with the patient preferably in the horizontal left oblique position. It -is to be sharply differentiated from the supradiaphragmatic pouches formed by small gastric diaphragmatic hernias. When these are of the
Fig. 12. Normal intrathoracic esophagus. a, Upper half, in left posterior oblique position. The long smooth indentation of the anterior wall is caused by the arch of the aorta. The oblique radiolucent shadow just below it is that of left main stem bronchus. b, Distal half. Note the delicate linear fold pattern of the intra-abdominal esophagus.
eccentric type,2 showing the cardioesophageal junction on medial aspect of the pouch, there is no difficulty in identification. Further, in those concentric diaphragmatic hernias where the herniated portion is not under any great tension and so retains its usual cerebriform fold pattern, the diagnosis is obvious (Fig. 13), but small concentric hernias in which the rugal fold pattern is of a linear type (such as may be seen particularly in short esophagus of whatever origin) require more careful evaluation to avoid confusion with normal phrenic ampulla. The Valsalva test is of value here, for in the case of hernia the barium often flows
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
29
down from the pouch through the widened hiatus during the test, instead of being regurgitated up the esophagus as in phrenic ampulla; and the folds in the pouch and those passing through the hiatus are coarser and more multiple than in phrenic ampulla. The Short Esophagus. We have had little experience with true congenital short esophagus, but have examined subjects whose esophagus has been shortened secondary to some disease process. The prime ex-
Fig. 13. Concentric gastric diaphragmatic hernia in hiatus insufficiency, showing the cerebriform fold pattern commonly found in the gastric fundus. Numerous coarse gastric folds across the widened hiatal area; compare this region with the corresponding one in Figure 12, b. a, Frontal view with patient supine. b, Left posterior ob.lique projection with patient in a slight Trendelenburg position.
ample of this in our experience has been scleroderma in which the esophageal shortening results from diffuse fibrous connective tissue changes in the esophagus. 3 To compensate for this loss of length, a small amount of stomach may be pulled up through the diaphragmatic hiatus. On fluoroscopic examination the coarse gastric rugae are seen stretched taut by the shortened esophagus, causing the pouch in some instances to have a rather triangular shape with the apElf{ at the concentrically placed . cardioesophageal junction (Fig. 14). Just above this point it is not uncommon to find a sharply bordered ulcer niche, and, as this heals, a
30
LILIAN DONALDSON
stricture may form, involving only a short segment and usually not of marked degree, but sufficient to cause some obstruction in an esophagus which even relatively early in the disease process may be observed not to clean itself of barium as readily as the normal does. This lack of cleansing power is ascribable to the enfeebled peristalsis observed in such cases. The change in muscular function is also reflected in the diffi-
Fig. 14. Esophageal scleroderma. a, The .shortened' esophagus has pulled a small nubbin of stomach above the I;liaphragmatic hiatus and stretched it taut (endoscopic confirmation). i~b, The small niche seen protruding anteriorly just above the cardioesophageal junction was identified as a shallow ulcer on endoscopic examination. c, The midesophagus is slightly dilated, shows two persistent linear flecks along its anterior margin, which probably represent very shallow ulcerations, The esophagus showed impaired peristalsis, failed to clean itself well, Good esophageal rugal pattern could not be obtained, but gastric fold pattern was not difficult to visualize.
culty in deglutition which these patients manifest. This may be. sufficiently marked so that barium is repeatedly regurgitated up the nasopharynx. Another change is diffuse loss of normal linear rugal fold pattern. In some advanced instances of this disease in which superficial ulcerations are present in the furrows between large hyperkeratotic plaques, several of the shallow ulcerations may penetrate sufficiently to be recognizable roentgenologically as shallow linear ulcers scattered anywhere along the course of the intrathoracic esophagus.
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
31
Malignant Neoplasms. The most important lesion of the esophagus demonstrable by x-ray is, of course, maligant neoplasm, and the typical advanced ragged ulcerating, constricting, and polypoid lesion is usually obvious when the first mouthful of barium flows down the esophagus. Neoplasm may be found anywhere in the esophagus, but as a primary lesion it is surely commoner in the intrathoracic portion. The typical advanced lesion offers at least moderate obstruction to passage of barium, so that that portion of the esophagus proximal to it usually be-
•
Fig. 15. Three cases of malignant neoplasm of intrathoracic esophagus.
a, Ragged ulcerating type. b, Infiltrating annular constricting type with conspicuous mushrooming of the tumor mass into adjacent normal lumen. c, Diffuse type which .spread widely along the mucosa, but was found to have infiltrated submucosa only at the point where slight irregularity of luminal width is shown above.
comes somewhat dilated. The tumor tissue which encroaches on the lumen is often visualized fluoroscopically as an irregular luminal filling defect so that the luminal margins appear ragged. When the main bolus of barium has passed the lesion, the rugal pattern there is seen to have been destroyed and an oval pool of barium may persist within one of the tumor masses, indicative of ulceration (Fig. 15, a). While little effort is necessary on the part of the radiologist to demonstrate the nature of such a spectacular lesion, it is necessary that he record on film, for the information of the surgeon, the preci~e location of the lesion in relation
32
LILIAN DONALDSON
tQ other mediastinal structures such as the aortic arch, the carina, or the diaphragm, and to adjacent bony landmarks, and that he determine how long a segment of esophagus is involved and whether any barium seen spilling into the bronchial tree arrives there through aspiration of material regurgitated from a severely obstructed esophagus or through a fistula at the site of the lesion. Neoplasms such as these are unlikely to be confused with any other disease process.
Fig. 16. Benign midesophageal stricture showing the typical hour-glass deformity, in a young adult male who had ingested carbolic acid twelve days before. At this time only a threadlike stream of barium traversed the most severely involved region.
Other primary carcinomas may cause smooth annular constrictions. usually narrow the esophageal lumen abruptly both at the proximal and distal end of the lesion, and the tumor mass around the remaining narrowed lumen tends to invaginate the adjacent normal portions of the esophagus (Fig. 15, b). These features serve to distinguish this type of neoplasm from benign stricture, which narrows the esophagus gradually in concentric fashion, so that the lesion has an hour-glass shape in which the constricted area gradually and smoothly widens both proximally and distally until normal or, in the proximal portion, dilated luminal width is reached. Long strictures of this type are usually the Th~se
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
33
result of ingestion of corrosive of some type (Fig. 16). Where these are fresh there is a complete loss of rugal pattern of the esophagus, but after healing has taken place the linear pattern may be partially reconstituted. Stricture resulting from the scarring of benign esophageal ulcer usually involves only a short segment of the esophagus, and the degree of·constriction is frequently not marked. The ulcer which causes it is usually small, sharply bordered, and best seen protruding from the margin of the esophageal lumen as a small barium-filled niche bordered by a narrow collar of radiolucency representing a little adjacent inflammatory edema. Such craters most often occur in the distal third of the esophagus as a result of regurgitation of acid gastric content, particularly when this regurgitation is made easy by the presence of a gastric diaphragmatic hernia, or in association with repeated vomiting, and they may be a'3so:)iated with an esophagitis. This last condition, if severe, is identifiable roentgenologically by fine, diffuse marginal serration in an esophagus that tends to remain slightly contracted. While the two types of neoplasm which have been described are easily identifiable, there are neoplasms which are difficult to differentiate either from other types of lesion or from the normal. The small tumor is of course always apt to be a difficulty, and there is a diffuse type of neoplasm which one can be certain of only after meticulous observation. An example of this is the case shown in Figure 15, c. This patient was complaining of mild dysphagia. Within a week he had been esophagoscoped twice and examined roentgenologically once, and no lesion had been seen. When he was re-fluoroscoped at the end of the week, however, it was noted that the slight indentation of the anterior wall of the esophagus in its distal third persisted during all phases of filling of the esophagus, and during both cardiac systole and diastole. When the esophagoscopist then biopsied this area, carcinoma cells were found. The' distal half of the esophagus was resected, and histologic examination showed that this neoplasm was spreading along the mucosa extensively, although at only one point, that identified in the film, was there even minimal invasion of the submucosa. Since cardiac impression is common in this region in older persons with moderate cardiac enlargement, it is solely by repeated and discriminating observation that the fluoroscopist should venture to label such an appearance as intrinsically abnormal. When neoplasm is found affecting only the intra-abdominal portion of the esophagus, the lesion is not usually primary in the esophagus, \ but in the stomach and has involved the esophagus by direct extension. Such an involvement may be polypoid in type, in which case differentiation must be made from varices, or it may be of the annular constricting tyPe which requires differentiation from cardiospasm. Of course if the neoplasm of the gastric fundus or corpus is readily identifiable and
34
LILIAN DONALDSON
extending toward the cardia, then any distortion of intra-abdominal esophagus may usually be ascribed with confidence to direct neoplastic extension. However, some gastric neoplasms begin to infiltrate the cardia and intra-abdominal esophagus before any sizable mass is readily identifiable at the primary site. The most useful p~ints in recognizing the nature of the small rounded filling defects that occur in the extension of polypoid neoplasm into intra-abdominal and distal intrathoracic esophagus are that these defects tend to cause obstruction, are constant, and tend to distort the fold pattern of the esophagus in an irregular fashion. The polypoid filling defects of varices, on the other hand, are inconstant during certain phases of esophageal observation (unless they are thrombosed) and tend to impinge upon the rugal fold pattern in regular rows, forming a lacelike pattern. When neoplasm extends from the gastric cardia through intra-abdominal esophagus, narrowing, with resultant partial obstruction of the affected portion of the esophagus, is usually an outstanding finding. The normal esophagus above it will be slightly or moderately dilated. If the fold pattern of the intra-abdominal segment can be shown to be distorted instead of lying in normal delicate linear pattern, it speaks for neoplasm, but in cases in which the tumor cells have invaded the outer coats of the distalmost esophagus, but have not yet involved the muscularis mucosa, the rugal pattern may appear normal. This then necessitates a nice differentiation from cardiospasm in those occasional cases in which one is not certain of the presence of a primary gastric cancer. Esophageal Varices. Roentgen proof of esophageal varices is obtained by a three-phase observation. When the distal esophagus is well filled with barium, it expands widely and smoothly and appears normal, and no obstruction is offered to the progress of the barium. If the barium is allowed to pass downward into the stomach, leaving the folds of the intrathoracic esophagus lightly coated with barium as the patient rests in horizontal or Trendelenburg left posterior oblique position, the rugal pattern appears essentially regular and normal; but if the patient is asked to take a deep breath and perform the Valsalva test, small regular rounded filling defects appear in rows along the rugal folds of the esophagus, indenting in regular fashion the barium-filled fold valleys. When the patient is allowed to exhale, these rounded areas of radiolucency disappear. Cardiospasm. Examinations for cardiospasm are best done with the patient in the vertical position facing the examiner. With the esophagus about half filled with barium, some degree of esophageal dilatation is seen down to the funnel-like tapering of the esophagus which occurs just above the diaphragmatic hiatus, together with the persistent narrowing of the intra-abdominal portion. Except in the mildest form of
ROENTGENOLOGIC EXAMINATION OF ESOPHAGUS
35
this condition, the narrowing is usually sufficient to restrict sharply the rate of barium flow into the stomach (Fig. 17). When this picture has been recorded on spot films, the patient is then asked to inhale the vapor from a crushed ampule of amyl nitrite while the narrowed area is kept under fluoroscopic observation. As the affected region widens under influence of the drug, it is rapidly filmed. In all but very advanced cases
Fig. 17. Cardiospasm, with typical funnel-like tapering of the esophagus just above the level of the diaphragmatic hiatus, and persistent narrowing down to the cardia. A little barium has escaped through it to coat the adjacent gastric rugae. This view was taken with the patient standing. Under the influence of amyl nitrite the narrowed portion attained a width three times as great as that shown here with resultant good momentary drainage of the esophagus by gravity.
the widening is usually sufficient to empty the esophagus fairly well. An esophagus markedly stiffened by neoplastic infiltration, on the other hand, does not show this good response. The success of the procedure depends on keeping the patient erect so that advantage is taken of the force of gravity, and in continuing the inhalation of amyl nitrite until the patient becomes a little faint or dizzy. This can be done without accident, provided the tilt control on the filming fluoroscope is so 10-
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LILIAN DONALDSON
cated as to make it possible to start lowering the table immediately if the patient seems about to faint. We have seen only one case of cardiospasm in which amyl nitrite used in this manner was not effective in substantially widening the narrowed lumen. This occurred in a woman with a history of marked cardiospasm for many years resulting in gross esophageal dilatation, in whom had recently developed, as shown at exploration, a superimposed napkin-ring carcinoma of the intra-abdominal esophagus. In long-standing cardiospasm causing great esophageal dilatation there is usually loss of an effective primary peristaltic wave; tertiary contractions are prominent, and the esophageal margins therefore appear coarsely irregular, with the location of the irregularities changing as the contractions come and go. Metastatic Neoplasm. The esophagus may be narrowed anywhere along its course by direct extension of neoplasm arising elsewhere in the mediastinum, but metastasis to the esophagus from a distant primary tumor is rare. It may be suspected if multiple tumor nodules are seen scattered along a segment of the esophagus. In one such case the primary site was a melanosarcoma of the skin. Benign Esophageal Tumors. Benign esophageal tumors 4 are rare j the writer has seen only two, both leiomyomas. This type tends to cause smooth displacement of the lumen of the involved esophageal segment rather than to narrow it significantly. Benign tumors arising in mucosa or submucosa may become pedunculated and are more apt to cause obstruction. If one encounters a smooth oval mass causing a filling defect in one wall of the esophagus, but not affecting the flexibility of the surrounding wall, the possibility of benignity may be considered, but it is more likely that further investigation will prove the lesion to be malignant. Esophageal Diverticula. Intrathoracic esophageal diverticula should be mentioned, but whether of the traction or pulsion type they are seldom of clinical importance, and radiologically they present few problems in recognition and recording. Occasionally, however, they do give rise to symptoms of importance. We recently examined a middle-aged woman who was suspected clinically of having a carcinoma of the esophagus. For two months she had noted mild midsubsternal distress after deglutition, associated with a tendency to regurgitation, Because of this she had reduced her food intake. At fluoroscopy, with the patient in supine position, a moderately large wide-mouthed diverticulum of the midintrathoracic esophagus was seen which filled promptly as a bolus of barium was driven downward by the primary peristaltic wave. Only occasionally, however, did the wave carry barium further down the esophagus; instead, as the bolus distended the diverticulum, a reverse
ROENTGENOLOGIC EXAMINATION OF ElSOPlIAGtJS
37
peristaltic wave appeared to be initiated there, which caused much of the barium to be regurgitated up to the cervical esophagus (Fig. 18).
Fig. 18. Diverticulum of the intrathoracic esophagus, causing dysphagia and regurgitation. . a, Shows only the diverticulum and proximal esophagus filled with barium. This view was made just as the primary peristaltic wave had caused filling of the diverticulum and then had become reversed, forcing the stream of barium back up the esophagus. b, In this view a little barium makes visible the distal esophagus, but onlv very occasionally did enough barium traverse this portion at anyone time to distend it widely. The small pouch just above the diaphragm when examined carefully fulfilled the criteria for phrenic ampulla rather than small hiatus hernia.
CLINICAL HISTORY
Since the examples given are only an introduction to the lesions which the radiologist may encounter when asked to examine the upper alimentary tract, it becomes obvious that before he begins his search he should be sufficiently informed of the patient's complaints, either by the referring physician or by questioning the patient himself, to form some idea of the location and possible nature of the lesion for whi~h search is to be made. Such information enables the examiner, after brief survey of the whole region, to concentrate his efforts first in that area and on those technics most likely to yield information of value. Such an approach reduces the amount of time, radiation and expense necessary to answer the clinical question in the majority of patients, while
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LILIAN DONALDSON
in no sense hampering the investigation of areas less likely to be involved. REFERENCES 1. Templeton, F. E.: X-Ray Examination of the Stomach. A Description of the
Roentgenologic Anatomy, Physiology, and Pathology of the Esophagus, Stomach, and Duodenum. Chicago, The University of Chicago Press, 1944, pp. 70-119. 2. Harrington, S. W.: Diagnosis and Treatment of Various Types of Diaphragmatic Hernia. Am. J. Surg. 50:381-446, 1940. 3. Lindsay, J. R.: Esophageal Lesions in Diffuse Scleroderma. Laryngoscope. 59:82-112, 1949. 4. Harper, R. A. K., and Tiscenco, E.: Benign Tumor of the Esophagus and Its Differential Diagnosis. Bl·it. J. Radio!. 18:99-107, 1945.
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