rel="nofollow" href="#ulink_84678561-5bf9-5e0c-80bc-e158e7d2d42c">Figure 6.56B). Fistula formation is another uncommon complication of chronic radiation injury to the esophagus.
Figure 6.43 Barrett’s esophagus with mid‐esophageal stricture. Prone single‐contrast view shows a large hiatal hernia (straight arrow) and a moderately long stricture (curved arrow) in the mid esophagus a considerable distance from the hernia. In the proper clinical setting, the presence of a mid‐esophageal stricture should be highly suggestive of Barrett’s esophagus, but this finding is seen on barium studies in only a small percentage of patients with this condition.
Caustic esophagitis
Whether accidental or intentional, ingestion of lye or other caustic agents can lead to a severe form of esophageal injury characterized by marked esophagitis and stricture formation. When esophagography is performed after a patient ingests a caustic agent, water‐soluble contrast media should be used because of the risk of esophageal perforation. Such studies may reveal marked edema, spasm, and ulceration of the affected esophagus, and in some cases, esophageal disruption [112]. As the esophagitis heals, follow‐up studies may reveal marked stricture formation, typically involving a long segment of the thoracic esophagus [112] (Figure 6.57). Patients with chronic lye strictures have an increased risk of developing squamous cell carcinoma of the esophagus [113], so a new area of mucosal irregularity or nodularity within a pre‐existing lye stricture on barium studies should raise concern about the possibility of a superimposed carcinoma.
Figure 6.44 Barrett’s esophagus with reticular pattern. Double‐contrast view shows the earliest stage of a stricture in the mid esophagus with slight flattening of one wall (white arrow). Also note a distinctive reticular pattern of the mucosa (black arrows) just below the level of the stricture. This radiographic finding is thought to be highly suggestive of Barrett’s esophagus.
Source: Reproduced from Levine et al. [83], with permission.
Other esophagitides
Alkaline reflux esophagitis is caused by reflux of bile or pancreatic secretions into the esophagus after partial or total gastrectomy [114]. The esophagitis is characterized on barium studies by mucosal nodularity or ulceration, or, in severe disease, by the development of distal esophageal strictures that may progress rapidly in length and severity over a short period of time [114]. The risk of developing alkaline reflux esophagitis can be decreased by performing a Roux‐en‐Y type of reconstruction to prevent or minimize reflux of bile or pancreatic secretions into the esophagus after partial or total gastrectomy.
Figure 6.45 Candida esophagitis with plaques. Double‐contrast view shows multiple discrete plaque‐like lesions in the esophagus. Note how the plaques have a linear configuration and are separated by segments of normal intervening mucosa. This appearance is characteristic of Candida esophagitis.
Source: Reproduced from Levine et al. [88], with permission.
Nasogastric intubation is an uncommon cause of esophagitis and stricture formation in the distal esophagus [112]. Most strictures develop after prolonged nasogastric intubation, but some patients have developed strictures from nasogastric tubes that were in place for as little as 48 h [112]. It has been postulated that these strictures result from severe reflux esophagitis caused by constant reflux of acid around the tube into the distal esophagus. Such strictures may progress rapidly in length and severity on follow‐up barium studies [112].
Other uncommon causes of esophagitis include Crohn’s disease, acute alcohol‐induced esophagitis, chronic graft‐versus‐host disease, Behçet’s disease, and, rarely, skin disorders involving the esophagus, such as epidermolysis bullosa dystrophica and benign mucous membrane pemphigoid [112].
Figure 6.46 Advanced Candida esophagitis with “shaggy” esophagus. Double‐contrast view shows a grossly irregular or shaggy esophagus caused by innumerable coalescent plaques and pseudomembranes with trapping of barium between the lesions. Also note a superimposed ulcer (arrow) due to sloughing of diseased mucosa. This patient had acquired immunodeficiency syndrome.
Source: Reproduced from Levine et al. [90], with permission.
Benign tumors
Papilloma
Squamous papillomas are uncommon benign mucosal tumors in the esophagus. These lesions consist histologically of a central fibrovascular core with multiple digit‐like projections covered by hyperplastic squamous epithelium. Papillomas usually appear on double‐contrast esophagography as small, sessile polyps with a smooth or slightly lobulated contour [115]. Occasionally, papillomas are difficult to distinguish from small esophageal cancers on the basis of the radiographic findings (Figure 6.58), so biopsy or resection of the lesions may be required. Some patients can have innumerable papillomas in the esophagus, a rare entity known as esophageal papillomatosis [116].
Adenoma
Esophageal adenomas are rare, benign lesions that usually arise in metaplastic columnar epithelium associated with Barrett’s esophagus [116]. Because these lesions have the same potential for malignant degeneration as colonic adenomas, endoscopic or surgical resection is warranted. Adenomas typically appear on barium studies as sessile or pedunculated polyps in the distal esophagus at or near the GEJ [116]. Adenomatous polyps should be differentiated from inflammatory esophagogastric polyps, benign lesions in the distal esophagus that have no malignant potential (see above).
Figure 6.47 Herpes esophagitis. Double‐contrast view shows multiple tiny ulcers (arrows) with surrounding mounds of edema in the mid esophagus. In an immunocompromised patient with odynophagia, this finding should be highly suggestive of herpes esophagitis.
Source: Reproduced from Levine MS, Rubesin SE, Laufer I, eds. Double contrast gastrointestinal radiology, 3rd ed.Philadelphia: WB Saunders; 2000, with permission.
Glycogenic acanthosis