(E) proximal to the web is also indicative of obstruction.
Source: Reproduced from Rubesin [24], with permission.
Reflux esophagitis may also be manifested on barium studies by thickened longitudinal folds as a result of edema and inflammation that extend into the submucosa [73] (Figure 6.38). These folds may have a smooth or irregular contour, occasionally mimicking the appearance of esophageal varices [75]. In general, thickened folds should be recognized as a nonspecific finding of esophagitis as a result of a host of causes. Other patients with chronic reflux esophagitis may have a single prominent fold that arises in the region of the gastric cardia and extends upward into the distal esophagus as a smooth, polypoid protuberance, also known as an inflammatory esophagogastric polyp [76, 77] (Figure 6.39). Because these lesions have no malignant potential, endoscopy is not warranted when barium studies reveal typical findings of an inflammatory esophagogastric polyp in the distal esophagus.
In advanced reflux esophagitis, extensive ulceration, edema, and spasm may cause the esophagus to have a grossly irregular contour with serrated or spiculated margins and loss of distensibility [73]. Occasionally, the narrowing and deformity associated with severe esophagitis can mimic the appearance of an infiltrating esophageal carcinoma, so endoscopy and biopsy may be required for a definitive diagnosis.
Scarring and strictures
As esophageal ulcers heal, localized scarring may be manifested on barium studies by flattening, puckering, or sacculation of the adjacent esophageal wall, often associated with the development of radiating folds [73] (Figure 6.40).
Further scarring can lead to the development of circumferential strictures (also known as “peptic” strictures) in the distal esophagus, almost always above a hiatal hernia [73, 78] (Figure 6.41). These strictures often appear as concentric areas of smooth, tapered narrowing, but asymmetric scarring can lead to asymmetric narrowing with focal sacculation or ballooning of the esophageal wall between areas of fibrosis. When there is marked irregularity, flattening, or nodularity of one or more walls of the stricture, endoscopy and biopsy should be performed to rule out a malignant stricture as the cause of these findings.
Figure 6.25 Retention cyst in medial left hypopharynx. A smooth‐surfaced hemispheric line (arrow) protrudes into the left piriform sinus.
Source: Reproduced from Rubesin and Glick [23], with permission.
Figure 6.26 Polypoid squamous cell carcinoma of the base of the tongue. (A) Frontal view of the pharynx demonstrates that the barium pool in the left vallecula is replaced by a 1.5 cm nodular mass (arrows) with barium in its interstices. (B) Lateral view of the pharynx shows a 1.5 cm radiolucent filling defect (black arrows) in the barium pooling in the valleculae. Barium has entered the interstices of the tumor (white arrows) deep to the expected contour of the base of the tongue.
Source: Reproduced from Rubesin and Glick [23], with permission.
Scarring from reflux esophagitis can also lead to longitudinal shortening of the esophagus and the development of fixed transverse folds, producing a characteristic “stepladder ” appearance caused by pooling of barium between the folds [79] (Figure 6.40). These fixed transverse folds should be differentiated on barium studies from the thin transverse folds (also known as the “feline” esophagus) often seen in patients with gastroesophageal reflux as a transient finding resulting from contraction of the longitudinally oriented muscularis mucosae [80, 81] (Figure 6.42).
Barrett’s esophagus
Barrett’s esophagus is characterized by progressive columnar metaplasia of the distal esophagus caused by chronic gastroesophageal reflux and reflux esophagitis. The classic radiologic signs of Barrett’s esophagus consist of a mid‐esophageal stricture or ulcer occurring at a discrete distance from the GEJ [82] (Figure 6.43). In the presence of a hiatal hernia or gastroesophageal reflux, a mid‐esophageal stricture or ulcer is thought to be highly suggestive, if not pathognomonic, of Barrett’s esophagus. A distinctive reticular pattern of the mucosa has also been recognized as a relatively specific sign of Barrett’s esophagus, particularly if adjacent to the distal aspect of a mid‐esophageal stricture [83]. This reticular pattern is characterized by tiny barium‐filled grooves or crevices resembling the areae gastricae on double‐contrast studies of the stomach (Figure 6.44). However, the classic radiologic signs of Barrett’s esophagus (a mid‐esophageal stricture or ulcer, or a reticular mucosal pattern) are seen in only 5–10% of all patients with Barrett’s esophagus [83, 84]. Other more common findings in Barrett’s esophagus, such as reflux esophagitis and peptic strictures, are often present in patients with uncomplicated reflux disease who do not have Barrett’s esophagus. Thus, those radiographic findings that are more specific for Barrett’s esophagus are not sensitive, and those findings that are more sensitive are not specific. As a result, many investigators have traditionally believed that esophagography has limited value in diagnosing Barrett’s esophagus.
Figure 6.27 Infiltrative squamous cell carcinoma of right aryepiglottic fold. (A) Frontal view of the pharynx during drinking shows diminished epiglottic tilt on the right (arrow). (B) Spot radiograph after drinking demonstrates thickening of the right aryepiglottic fold (short arrows) and nodularity of the mucosa overlying the muscular process of the right arytenoid process (open arrows).
Source: Reproduced from Rubesin [10], with permission.
Figure 6.28 Ulcerative squamous cell carcinoma of the epiglottis. (A) Lateral view of the pharynx shows that the epiglottic tip is missing. Fine mucosal nodularity is seen on the superior anterior wall of the laryngeal vestibule