CT Findings of the Esophagus in Patients With Excessive Central Airway Collapse and Gastroesophageal Reflux

Abstract

SESSION TITLE: Medical Imaging: New Approaches to Old Technologies SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Gastroesophageal reflux (GER) is increasingly recognized as an exacerbating or causal factor in patients with excessive central airway collapse (ECAC). Esophageal air of ≥10 mm and thickened esophageal wall (≥5 mm) on computed tomography of the chest might suggest esophageal pathology such as GER.1,2 The aim of this study was to evaluate the frequency of these and other CT findings of the esophagus in patients with GER and ECAC. METHODS: This was a retrospective review of patients with confirmed positive GER testing (acid and nonacid reflux) and ECAC on dynamic CT chest. We measured the largest internal lumen diameter and thickness of the esophagus at the level of the cricoid, sternal notch, and carina and in between the ventricles and distal esophageal sphincter at end inspiration on dynamic chest CT. We also recorded presence of GER-specific symptoms, presence of diaphragmatic hernia, signs of aspiration, and bronchial changes. RESULTS: Twenty-nine patients (median age 58[IQR 45-65]), 21(72%) women were included. Median BMI was 34 (IQR 29-39). Twenty-one patients (79%) have tracheobronchomalacia and 7 patients (21%) have excessive dynamic airway collapse. Frequent comorbidities included obesity in 72% (n=21), asthma in 48% (n=14), obstructive sleep apnea in 31 % (n=9) and cystic fibrosis in 3% (n=1). Seventeen of the 29 patients (58%) did not have clinical symptoms of GER. The median DeMeester score was 29.5 (IQR 23.9-45.9); impedance (non-acid reflux) was abnormal in 9 patients. The median of the maximal air-containing esophageal lumen and wall thickness were 9 mm (IQR 5.5-13) and 4mm (IQR 3-5) respectively. 12 patients (41%) had esophageal lumen of ≥ 10mm, 11 patients (38%) had wall thickness of ≥ 5mm, eight patients (27%) had sign of possible aspiration and 12 patients (41%) had hiatal hernia. Twenty of the 29 patients (69%) had at least one of the previous abnormalities. Nine patients (31%) had a complete normal esophagus on CT scan. CONCLUSIONS: Abnormal esophageal findings on CT have low sensitivity for GER. In patients with ECAC, normal esophagus on chest CT scan or absence of symptoms should not rule out GER. CLINICAL IMPLICATIONS: In ECAC patients, the decision to pursue a formal GER evaluation should not be based on the presence of typical GER symptoms (heartburn or reflux sensation) or esophageal abnormalities on chest CT scan.