6.45). A much more fulminant form of candidiasis has been encountered in patients with AIDS, who may present with a grossly irregular or “shaggy” esophagus caused by innumerable coalescent plaques and pseudomembranes with trapping of barium between the lesions [90] (Figure 6.46). Some of these plaques may eventually slough, producing one or more deep ulcers superimposed on a background of diffuse plaque formation (Figure 6.46). However, this type of advanced Candida esophagitis is rarely encountered in modern medical practice because of better antiviral therapy of HIV‐positive patients and the infrequent development of AIDS. Patients with typical findings of Candida esophagitis on double‐contrast studies can be treated with antifungal agents such as fluconazole without need for endoscopy.
Figure 6.35 Normal esophagus and cardia. (A) Double‐contrast view of the esophagus shows how it normally has a smooth, featureless appearance en face. (B) Mucosal relief view shows thin, straight longitudinal folds as a normal finding in the collapsed esophagus. (C) Recumbent right lateral view of the gastric fundus shows stellate folds radiating to a central point (arrow) at the gastroesophageal junction, also known as the cardiac “rosette.”
Herpes esophagitis
The herpes simplex virus is another frequent cause of infectious esophagitis. Most patients with this condition are immunocompromised, but herpes esophagitis may occasionally develop as an acute, self‐limited disease in otherwise healthy patients who have no underlying immunologic problems [91]. Herpes esophagitis is initially manifested by small esophageal vesicles that subsequently rupture to form discrete, punched‐out ulcers on the mucosa. Although some patients have associated herpetic lesions in the oropharynx, most do not have oropharyngeal disease, and others with herpetic infection of the oropharynx have Candida esophagitis.
Herpes esophagitis may be manifested on double‐contrast studies by small, discrete ulcers on a normal background mucosa [92, 93]. The ulcers can have a punctate, stellate, or volcano‐like appearance and are often surrounded by radiolucent mounds of edema (Figure 6.47). Multiple discrete ulcers are found on double‐contrast esophagography in about 50% of patients with herpes esophagitis [93]. In the appropriate clinical setting, the presence of small, discrete ulcers without plaques should be highly suggestive of herpes esophagitis because ulceration in candidiasis almost always occurs on a background of diffuse plaque formation. As the disease progresses, however, herpes esophagitis may be manifested by a combination of ulcers and plaques, mimicking the appearance of Candida esophagitis. Occasionally, herpes esophagitis in otherwise healthy patients may be manifested by innumerable tiny ulcers that tend to be clustered together in the mid esophagus below the level of the left main bronchus [91] (Figure 6.48). The ulcers are even smaller than those in immunocompromised patients with herpes esophagitis, presumably because these individuals have an intact immune system that can prevent the ulcers from enlarging.
Figure 6.36 Reflex esophagitis with granular mucosa. Double‐contrast view shows fine nodularity or granularity of the distal esophagus caused by edema and inflammation of the mucosa. Compare this image to the smooth, featureless appearance of the normal esophagus in Figure 6.35A.
Cytomegalovirus esophagitis
Cytomegalovirus (CMV) is another cause of infectious esophagitis that occurs primarily in patients with AIDS or organ transplants or in those who are severely immunocompromised. CMV esophagitis may be manifested on double‐contrast studies by the development of one or more giant, flat ulcers that are several centimeters or more in length [94] (Figure 6.49). The ulcers may have an ovoid or diamond‐shaped configuration and are often surrounded by a thin radiolucent rim of edema. Because herpetic ulcers rarely become this large, the presence of one or more giant ulcers should suggest the possibility of CMV esophagitis in the appropriate clinical setting. However, the differential diagnosis also includes giant human immunodeficiency virus (HIV) ulcers in the esophagus (see next section). Less commonly, CMV esophagitis may be manifested by small, superficial ulcers indistinguishable from those in herpes esophagitis [94]. Because CMV esophagitis is treated with relatively potent antiviral agents such as ganciclovir, which has associated bone marrow toxicity, endoscopy (with biopsy specimens, brushings, or cultures from the esophagus) is required to confirm the presence of CMV infection before treating these patients.
Human immunodeficiency virus esophagitis
HIV infection of the esophagus can lead to the development of giant esophageal ulcers indistinguishable from those caused by CMV esophagitis. Double‐contrast esophagrams typically reveal one or more large, ovoid or diamond‐shaped ulcers surrounded by a radiolucent rim of edema, sometimes associated with a cluster of small satellite ulcers [95, 96] (Figure 6.50). The diagnosis is established by obtaining endoscopic biopsy specimens, brushings, or cultures from the esophagus to rule out CMV esophagitis as the cause of the ulcers. Unlike CMV ulcers, HIV‐related esophageal ulcers usually heal markedly on treatment with oral steroids [95, 96]. Thus, endoscopy is required in HIV‐positive patients with giant esophageal ulcers to differentiate esophagitis caused by HIV and CMV, so appropriate therapy can be instituted.
Drug‐induced esophagitis
Tetracycline and its derivative, doxycycline, are two of the agents most commonly responsible for drug‐induced esophagitis in the United States, but other offending medications include potassium chloride, quinidine, aspirin or other non‐steroidal anti‐inflammatory drugs (NSAIDs), and alendronate [97]. Affected individuals typically ingest the medications with little or no water immediately before going to bed. The pills or capsules tend to become lodged in the upper or mid esophagus, which is compressed by the adjacent aortic arch or left main bronchus. Prolonged contact of the esophageal mucosa with the pills presumably causes a focal contact esophagitis. These patients may present with severe odynophagia, but there is often marked clinical improvement after withdrawal of the offending agent.
The radiographic findings in drug‐induced esophagitis depend on the nature of the offending medication. Tetracycline and doxycycline are associated with the development of small, superficial ulcers in the upper or mid esophagus indistinguishable from those in herpes esophagitis [98, 99] (Figure 6.51). Because of the superficial nature of the disease, these ulcers almost always heal without associated scarring or stricture formation. In contrast, potassium chloride, quinidine, and NSAIDs may cause more severe esophageal injury, sometimes leading to the development of much larger ulcers and subsequent strictures [100] (Figure 6.52). Alendronate may also cause a severe form of esophagitis