Double-contrast Esophagography Research Articles

Barrett's esophagus: clinical features, obesity, and imaging

The following includes commentaries on clinical features and imaging of Barrett's esophagus (BE); the clinical factors that influence the development of BE; the influence of body fat distribution and central obesity; the role of adipocytokines and proinflammatory markers in carcinogenesis; the role of body mass index (BMI) in healing of Barrett's epithelium; the role of surgery in prevention of carcinogenesis in BE; the importance of double-contrast esophagography and cross-sectional images of the esophagus; and the value of positron emission tomography/computed tomography.

Tumor Staging of Advanced Esophageal Cancer: Combination of Double-Contrast Esophagography and Contrast-Enhanced CT

Tumor Staging of Advanced Esophageal Cancer: Combination of Double-Contrast Esophagography and Contrast-Enhanced CT

Tumor Staging of Advanced Esophageal Cancer: Combination of Double-Contrast Esophagography and Contrast-Enhanced CT

The objective of this study was to compare the diagnostic accuracy of tumor staging in patients with advanced esophageal cancer based on contrast-enhanced CT findings alone with that based on a combination of CT and double-contrast esophagography and to evaluate the relevance of tumor stage to survival rate. In 94 patients who underwent surgery as the primary treatment for esophageal cancer and had a diagnosis of postoperative T stage 3 (pT3) or pT4 disease based on pathologic examination, T stage was evaluated using CT alone and using a combination of CT and double-contrast esophagography. The diagnostic criterion for T4 disease using CT alone was tumor strongly displacing or deforming adjacent organs. The diagnostic criterion for T4 disease using the combined method was tumor displacing or deforming adjacent organs in the direction that corresponded to the direction of the location of the tumor or the deepest ulcer as diagnosed by barium esophagography. Concordance of T staging based on imaging with postoperative T staging based on pathology results, the gold standard, and survival rate were assessed for CT alone and for the combined method. The concordance rate with postoperative T staging pathology results was 78% for CT alone and 84% for CT and double-contrast esophagography combined, with a significant difference between the two diagnostic methods. For patients with a diagnosis of T3 and those with a diagnosis of T4 using CT alone, the 3-year survival rate was 42% and 26%, respectively, with no significant difference between the two. For patients with a diagnosis of T3 and those with a diagnosis of T4 using the combined method, the 3-year survival rate was 42% and 21%, respectively, with a significant difference between the two. The diagnostic performance of contrast-enhanced CT and double-contrast esophagography combined in staging advanced esophageal tumors is better than that of CT alone and thus has potential for estimating prognosis.

Candida esophagitis in achalasia cardia: Case report and review of literature

Candida albicans is by far the most common cause of infectious esophagitis. In most patients, this infection is secondary to an immuno-compromised state. In nearly 25% of the cases, underlying causes of esophageal stasis, e.g., achalasia and scleroderma, facilitate fungal colonization of the esophagus. Double contrast esophagography is a highly sensitive tool for diagnosing candida esophagitis. This report discusses the uncommon association of Candida esophagitis with achalasia cardia, their radiographic features and a short review of the available literature.

Short-segment Barrett's esophagus: findings on double-contrast esophagography in 20 patients.

The purpose of this study was to determine the findings of short-segment Barrett's esophagus on double-contrast esophagography. A review of pathology and endoscopy data revealed 142 patients with short-segment Barrett's esophagus, which was defined as columnar epithelium in the distal esophagus extending 3 cm or less above the gastroesophageal junction at endoscopy with histopathologic confirmation of intestinal metaplasia. Twenty of these patients underwent double-contrast esophagography. These 20 patients comprised our study group. The original radiology reports and images were reviewed to determine the findings on double-contrast esophagography. Medical records were also reviewed to determine the clinical findings and treatment. Double-contrast esophagrams revealed hiatal hernias in 18 patients (90%), gastroesophageal reflux in 16 (80%), reflux esophagitis in seven (35%), peptic scarring or strictures in 11 (55%), and a reticular mucosal pattern in none. A total of 14 patients (70%) had morphologic findings of reflux disease with esophagitis alone (three patients), peptic scarring or strictures alone (seven patients), or both (four patients), but the remaining six (30%) had hiatal hernias or gastroesophageal reflux as the only radiographic finding. Double-contrast esophagography revealed morphologic findings of reflux disease with esophagitis, peptic scarring or strictures, or both in 70% of patients with short-segment Barrett's esophagus. Thus, the absence of esophagitis or peptic scarring or strictures on double-contrast esophagography does not exclude the possibility of short-segment Barrett's esophagus.

Congenital esophageal stenosis in adults: clinical and radiographic findings in seven patients.

The purpose of this study was to determine the clinical and radiographic findings in seven adults with congenital esophageal stenosis. In young or middle-aged individuals, particularly men with long-standing dysphagia, an upper or mid esophageal stricture with multiple ringlike constrictions is a characteristic appearance of congenital esophageal stenosis on double-contrast esophagography.

The "foamy" esophagus: a radiographic sign of Candida esophagitis.

The purpose of this study was to describe the radiographic features of the "foamy" esophagus, a new sign of Candida esophagitis seen on double-contrast esophagography, in six patients. The foamy esophagus was characterized by innumerable tiny (1-3 mm), round lucencies (bubbles) that intermingled with the barium suspension along the top of the barium column, producing a layer of foam. Candida esophagitis should be strongly suspected when a foamy esophagus is detected on double-contrast esophagography, particularly in patients with underlying esophageal involvement by scleroderma.

Diagnosis of Superficial Esophageal Cancer: Comparative Study of Double Contrast Esophagography and Endoscopy

Purpose: To assess the diagnostic accuracy and limitations of double contrast esophagography in patients with superficial esophageal cancer, as compared with endoscopic, gross and microscopic findings. Materials and Methods: In 43 patients with pathologically proven superficial esophageal cancer, the detection rate and diagnostic accuracy of double contrast esophagography and endoscopy were compared. The depth of invasion revealed by esophagography, and grossly and microscopically in resected specimens, was compared. Results: The detection rate and diagnostic accuracy were, respectively, 86.0% and 76.7% for esophagography, and 100% and 95.3% for endoscopy. In addition, very different detection rates (54.6% and 100%, respectively) were noted for epithelial and mucosal lesions. In flat-type cases (0-IIb), esophagography showed limited ability to detect lesions, but the accuracy of this modality in predicting the depth of tumor invasion was relatively high (94.6%). Conclusion: In cases of superficial esophageal cancer, double contrast esophagography showed a lower detection rate and lower diagnostic accuracy than endoscopy, and this was especially so for epithelial and mucosal lesions. The modality was able, however, to reliably predict the depth of tumor invasion.

The right inferior supraazygous recess: a cause of upper esophageal pseudomass on double-contrast esophagography.

Our purpose was to characterize the radiographic features of a pseudomass impression on the upper thoracic esophagus, to determine the frequency of such a pseudomass both on double-contrast esophagography and on CT, and to elucidate the anatomic basis for this finding. Our study group consisted of 135 patients whose double-contrast esophagograms were reviewed retrospectively for the presence or absence of an extrinsic indentation on the right posterolateral wall of the upper thoracic esophagus. In another patient group, 50 CT scans of the chest were also reviewed for the presence or absence of a prominent right inferior supraazygous recess and an associated indentation on the upper thoracic esophagus. Thirteen (9.6%) of the 135 barium studies revealed a smooth, gently sloping indentation on the right posterolateral wall of the upper thoracic esophagus. The indentations ranged from 5 to 10 cm in length and extended inferiorly from the thoracic inlet to or just below the aortic arch. Twenty-four (48%) of the 50 CT scans revealed a prominent right inferior supraazygous recess projecting behind the esophagus. In five cases (10%), this recess also caused a smooth indentation on the upper thoracic esophagus. A pseudomass impression was seen on double-contrast radiography as a smooth, gently sloping indentation on the right posterolateral wall of the upper thoracic esophagus in approximately 10% of patients. The indentation probably represents a normal anatomic variant (i.e., an unusually prominent right inferior supraazygous recess) that should not be mistaken for adenopathy or other masses in the mediastinum impinging on the esophagus.

Early esophageal carcinoma. Evaluation of the depth of invasion based on double-contrast esophagography.

The aim of this study was to assess the depth of invasion of early esophageal carcinoma (EEC) by means of double-contrast esophagography. The radiological findings of 46 EECs were retrospectively analyzed for the following factors that might be related to the depth of invasion: in depressed lesions (n = 30): maximum size, surface appearance, sharpness of contour, and wall rigidity; and in elevated lesions (n = 16): maximum size, height, shape, and wall rigidity. All lesions were surgically or endoscopically resected and the radiological findings were compared with the histological appearance. In depressed lesions, the size of the surface granules correlated very strongly with the depth of invasion (rs = 0.8147). In both depressed and elevated lesions, wall rigidity correlated strongly with the depth of invasion (rs = 0.7540 and rs = 0.6702 respectively). In depressed lesions, sharpness of contour also correlated strongly with the depth of invasion (rs = 0.6731). The other factors did not correlate with the depth of invasion. Double-contrast esophagography could provide useful information for assessing the depth of invasion of EECs.

Barrett's esophagus and esophageal adenocarcinoma: the scope of the problem.

Barrett's esophagus is probably a more common condition than previously recognized. Although the classic radiologic findings of Barrett's esophagus are present in only a small percentage of patients, this condition should be suspected whenever reflux esophagitis or peptic strictures are demonstrated on double-contrast esophagography. Recent literature also suggests that Barrett's carcinomas comprise up to 50% of all esophageal cancers. Because of the increased risk of developing adenocarcinoma in Barrett's esophagus, endoscopic surveillance has been advocated to detect dysplastic or carcinomatous changes at the earliest possible stage. When barium studies are performed on patients with known Barrett's esophagus, the radiographs should be carefully evaluated for signs of early adenocarcinoma, so these patients can be referred for appropriate management prior to the development of advanced, unresectable tumors.

Giant esophageal ulcer due to Clinoril.

Drug-induced esophagitis isanincreasingly frequent causeofacuteodynophagia inadults. Affected persons typicallyhaveahistory ofingesting theirmedication withlittleornowaterimmediately beforegoingtobed.Prolonged exposureoftheesophageal mucosa toavarietyofcapsules ortabletsisthought tocauseafocalcontact esophagitis, manifestedbyoneormoreareasofshallow ulceration intheupperormidesophagus. Inthepast,endoscopy hasbeenadvocatedastheprimarytechnique fordiagnosing thiscondition. Morerecently, double-contrast esophagography alsohasbeenrec-

Radiology of esophagitis: a pattern approach.

This article presents a pattern approach for diagnosing esophagitis at double-contrast esophagography. In patients with nodular elevations of the mucosa, discrete plaques should suggest Candida esophagitis, whereas poorly defined nodules should suggest reflux esophagitis and a distinctive reticular pattern of the mucosa should suggest Barrett esophagus, particularly if adjacent to the distal aspect of a high stricture. In patients with ulceration, one or more shallow ulcers at or near the gastroesophageal junction should suggest reflux esophagitis, whereas discrete, superficial ulcers in the midesophagus should suggest herpes or drug-induced esophagitis, depending on the clinical setting. In contrast, one or more giant, relatively flat ulcers should suggest cytomegalovirus esophagitis, particularly in patients with acquired immunodeficiency syndrome. Finally, thickened longitudinal folds may be caused by esophagitis, varices, or, rarely, "varicoid" carcinoma, but these conditions usually can be differentiated on radiologic grounds. By carefully analyzing the appearance and location of nodules, plaques, ulcers, or abnormal folds in the esophagus, one can usually suggest a cause of the disease.

Barrett's esophagus in scleroderma: increased prevalence and radiographic findings.

Ten of 27 patients (37%) with scleroderma who underwent endoscopy at our hospital between 1980 and 1984 for symptoms of reflux esophagitis had biopsy-proven Barrett's esophagus. Two of those 10 patients had esophageal adenocarcinomas. In a blinded review of esophagrams (all but 2 using double-contrast technique) from 16 of the 27 patients, only 1 patient was thought to be at high risk for Barrett's esophagus due to a high esophageal stricture with an adjacent reticular pattern of the mucosa. The latter patient had biopsy-proven Barrett's mucosa. Eight patients were thought to be at moderate risk for Barrett's esophagus due to reflux esophagitis and/or distal strictures in 6 and polypoid intraluminal masses in 2. Three of the 6 patients with esophagitis and/or strictures had Barrett's esophagus, and both patients with masses had adenocarcinomas arising in Barrett's mucosa. Finally, 7 patients who had no esophagitis or strictures were thought to be at low risk for Barrett's esophagus. None of those 7 had histologic evidence of Barrett's mucosa. Thus, the major value of double-contrast esophagography is its ability to classify patients into high-, moderate-, and low-risk for Barrett's esophagus to determine the relative need for endoscopy and biopsy in these patients.

Drinking cup for double-contrast esophagography.

A drinking cup was designed for high-quality double-contrast esophagography. The device comprises a holder for the barium, a feeding arrangement for the air, and a feed valve, which in part blocks the free discharge of barium from the cup. Upon continuous ingestion from the cup, an effective mixture of air and barium is formed without the use of any effervescent or other agents. The technique was evaluated in 72 patients, including children. The studies were successful in nearly all cases.

Barrett's esophagus: diagnosis by double-contrast esophagography.

A blinded, retrospective study was performed to determine the role of double-contrast esophagography in diagnosing Barrett's esophagus. The study group consisted of 200 patients who had double-contrast esophagrams and endoscopy because of severe reflux symptoms. The radiographs were reviewed by two gastrointestinal radiologists who had no knowledge of the endoscopic findings. Patients were classified as being at high risk for Barrett's esophagus if the radiographs revealed a high stricture or ulcer or a reticular mucosal pattern; at moderate risk if the radiographs revealed a distal peptic stricture and/or reflux esophagitis; and at low risk if none of the aforementioned findings were present. When these radiologic criteria were used, 10 patients (5%) were thought to be at high risk, 73 (37%) at moderate risk, and 117 (58%) at low risk for Barrett's esophagus. Endoscopic correlation revealed biopsy-proved Barrett's mucosa in nine (90%) of 10 patients at high risk, in 12 (16%) of 73 at moderate risk, and in only one (1%) of 117 at low risk for Barrett's esophagus. Thus, endoscopy is clearly indicated for patients in the high-risk group. Because of the lower prevalence of Barrett's esophagus in the moderate-risk group, clinical judgment should be used in deciding when to perform endoscopy in these patients. However, most patients were in the low-risk group, and the prevalence of Barrett's esophagus was so low in this group that endoscopy does not appear to be warranted. Thus, the major value of double-contrast esophagography is its ability to separate patients into high-, moderate-, and low-risk groups for Barrett's esophagus to determine the relative need for endoscopy and biopsy.

Opportunistic esophagitis in AIDS: radiographic diagnosis.

Thirty-five of 90 patients with acquired immunodeficiency syndrome (AIDS) seen between 1983 and 1986 underwent esophagography (double contrast in all but two) to rule out opportunistic esophagitis; 20 of the 35 were found to have fungal or viral esophagitis. A radiographic diagnosis of Candida esophagitis was made in 17 patients because of varying degrees of plaque formation. Seven of those patients had a grossly irregular or "shaggy" esophagus; in four, the diagnosis of AIDS was initially suspected from this finding. In the remaining three patients, a radiographic diagnosis of viral esophagitis (herpes simplex in two and cytomegalovirus in one) was made because of discrete ulcers on a normal background mucosa. Eighteen patients had endoscopic, clinical, or autopsy findings that corroborated the radiographic diagnosis; follow-up data were not available for two patients with Candida esophagitis. This experience suggests that fungal and viral esophagitis can often be differentiated with double-contrast esophagography, enabling appropriate antifungal or antiviral therapy to be instituted without endoscopic intervention.

Medication-induced esophagitis: diagnosis by double-contrast esophagography.

Although medication-induced esophagitis is recognized more frequently nowadays, reports of associated radiographic findings are limited. Nine cases of esophagitis associated with various medications were evaluated by using double-contrast esophagography. The usual features were several discrete focal ulcerations localized to a short segment of the proximal half of the esophagus. In seven of the cases, the offending medication was an antibiotic. Symptoms resolved in about 4 days after medication was discontinued. Finding characteristic radiologic abnormalities in the appropriate clinical setting may obviate endoscopy.

Esophageal intramural pseudodiverticulosis: a reevaluation

Esophageal intramural pseudodiverticulosis is an unusual condition manifested by tiny flask-shaped outpouchings in the wall of the esophagus. The condition was diagnosed in 21 (0.15%) of 14,350 patients undergoing radiologic examinations of the esophagus at our hospitals. The pseudodiverticula were detected only by single-contrast technique in five of 18 patients (28%) who underwent both single- and double-contrast examinations. Thus, thin, low-density barium seems to enter these structures more readily than the high-density barium used for double-contrast esophagography. While most patients reported in the literature have diffuse or segmental pseudodiverticulosis associated with high esophageal strictures, the majority of our patients (11 [52%] of 21) had isolated involvement of the distal esophagus with 10 or fewer pseudodiverticula in the region of a peptic stricture. Other associated conditions included Candida esophagitis, herpes esophagitis, and squamous cell carcinoma of the esophagus. Our experience suggests that pseudodiverticulosis usually represents a sequela of reflux esophagitis, although the reason that so few patients with esophagitis develop this condition is unclear.

An alternative technique for double-contrast esophagography (technical note).

Routine double-contrast esophagography using effervescent materials and high-density barium is well established as the most efficient way to evaluate the morphology of the esophageal mucosa [1]. Several investigators have attempted to obtain a double-contrast esophagram using negative contrast agents other than air. The use of water to distend the esophagus for a double-contrast effect was first described by Brombart [2] and later modified by Goldstein and Dodd [3]. Wiljasalo and Rissanen [4] were the first to describe the use of sodium methylcellulose and barium separately to achieve a double-contrast esophagram. In their technique [4], the patient was placed erect and given a spoonful of Microtrast followed by a spoonful of sodium methylcellulose, after which the esophagus was filmed in the anteroposterior and both oblique projections. The technique we describe is a modification of this technique.