The Value of the X-ray in the Diagnosis and Treatment of Diseases of the Esophagus

Abstract

Radiology occupies a position of well-deserved prominence in the diagnosis and treatment of diseases of the esophagus. In this discussion, however, I wish to present its limitations, as well as its valuable points. The most common lesion in the esophagus is cancer, and in cases of obstruction due to cancer the radiologic findings are usually quite characteristic. The moth-eaten, irregular outline of the obstruction is not seen in other esophageal lesions (Fig. 1). In many of these cases, especially in growths at the cardia, the obstruction is smooth, and not infrequently diagnosed as cardiospasm (Fig. 2). Unless the outline is irregular, the lesion should not be considered cancer. The extent of the malignant stricture usually cannot he determined by the X-ray (Fig. 3). In cases of malignancy at the introitus, examination by the X-ray may lead to confusion, because the barium mixture may overflow into the trachea and suggest the existence of an esophagotracheal fistula. Perforation of a malignant esophageal growth with the formation of an esophagotracheal or esophagobronchial fistula is easily demonstrated with the X-ray, and in such cases forcible dilatations of the growth should not be attempted (Fig. 4). It must be understood that, unless the malignant growth in the esophagus is sufficiently advanced to obstruct the barium meal, diagnosis by X-ray is impossible. In the treatment of esophageal cancer, the X-ray is of limited value; however, it may aid in the exact introduction of radium capsules or needles. In cases of cardiospasm, the chief value of the ray is to demonstrate the amount of dilatation of the esophagus above the spasm. The degree of pressure used in stretching the cardia varies with this dilatation. In several clinics, the dilator is introduced into the cardia guided by the fluoro-scope, but if a thread is used as a guide, manipulation under the fluoroscope is not only unnecessary but distinctly disadvantageous. In two cases seen at the Mayo Clinic, the X-ray demonstrated diverticula of the middle third of the esophagus, associated with cardiospasm (2). The differentiation of cardiospasm and diverticula of the lower end of the esophagus, congenital or acquired herniation of the stomach through the diaphragm, and diverticula of the cardia, can best be accomplished by careful fluoroscopic studies. In the examination of cicatricial strictures of the esophagus, if the etiology is definitely known, the X-ray is rarely used. There is usually a smooth obstruction (Fig. 5), and knowing the point of stricture before passing sounds is of no value. Benign strictures may obstruct the lumen of the esophagus sufficiently to produce considerable dysphagia, and yet not enough to give definite X-ray findings.