Atlas of Gastrointestinal Imaging Sunitha Lingareddy
Chapter Notes

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1GI Tract and Abdominal Cavity

EsophagusChapter One

  • Smooth, thin, delicate membrane covered with normal mucosa.
  • B-ring
  • Idiopathic
  • Epidermolysis bullosa
  • Plummer-Vinson syndrome
Signs and Symptoms
  • Majority are seen in the cervical esophagus within 2 cm of the pharyngoesophageal junction.
Imaging Findings
Barium Swallow
  • Transverse web arises from the anterior wall forming a right angle and protruding into the lumen
  • Rarer circumferential type of web appears as a symmetric annular radiolucent band that concentrically narrows the barium filled esophagus
  • Visualized during maximal distension
  • Uniform thickness of < 3 mm.
  • Carcinoma
Differential Diagnosis
  • Stricture3
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Fig. 1.1A: Frontal view of esophagogram shows filling defect in the anterior wall of cervical esophagus
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Fig. 1.1B: Lateral view of barium esophagogram shows thin shelf like indentation anteriorly
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Fig. 1.2: Upper GI endoscopy showing the web in the cervical esophagus
  • Esophageal inflammation secondary to reflux of acidpeptic contents of the stomach.
  • Gastroesophageal reflux disease
    • Drugs
    • Alcohol
    • Smoking
    • Corrosive chemicals
    • Radiation
Signs and Symptoms
  • Heart burn
  • Regurgitation
  • Angina like pain
  • Lower 1/3rd of esophagus.
Imaging Findings
Barium Swallow
  • Acute
    • Granular or finely nodular appearance of thickened mucosal folds
    • Single marginal ulcer or erosion at/adjacent to GE junction
    • Multiple tiny ulcers seen as collections of barium with surrounding mucosal edema
    • Non peristaltic waves in distal esophagus (85%)
    • Incomplete relaxation of lower esophageal sphincter (75%), incompetent sphincter (33%)
  • Chronic
    • Decreased distal esophageal distensibility
    • Peptic stricture—concentric smooth tapered narrowing of distal esophagus
    • “Step ladder” appearance—Transverse folds due to vertical scarring.
  • NECT
    • Diffuse/focal circumferential wall thickening (≥ 5 mm)
  • CECT
    • “Target sign” – Mucosal enhancement with surrounding hypodense submucosa.
Reflux Tests
  1. Reflux of barium in RPO position, elicited by coughing/deep respiratory movements
  2. Water siphon test
  3. Tuttle test
  4. Radionuclide gastroesophageal reflux test.5
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Figs 1.3A and B: Frontal and lateral projections of barium swallow shows irregularity in the margins of lower esophagus with hiatal hernia and small ulcer posteriorly. Significant reflux was noted on water siphon test
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Fig. 1.4: Upper GI endoscopy shows ulcer in the lower esophagus with luminal narrowing
  • Injury to the esophagus caused by acid/alcohol.
  • Alcohol
  • Acids - HCl, H2SO4
  • Ammonium chloride, nitrate
  • Initially there is hyperemia of the mucosa followed by inflammation, which may progress to stricture formation.
Signs and Symptoms
  • Pain, vomiting, hematemesis.
Imaging Findings
Barium Swallow
  • Atonic, dilated esophagus with shallow ulcers in the acute phase
  • Narrowed esophagus with extensive ulceration if severe
  • Long segment stricture in the chronic phase.
  • Diffuse thickening of the wall
  • If there is perforation then pneumomediastinum and pleural effusion can be seen.
Differential Diagnosis
  • Reflux esophagitis
  • Infectious esophagitis
  • Esophageal carcinoma
  • Radiation esophagitis
  • Nasogastric intubation.
Key Imaging Points
  • Non distensible, rigid, narrowed segment of esophagus
  • Strictures are smooth and symmetric.7
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Figs 1.5A and B: Frontal and lateral projections of barium swallow showing long segment high grade stricture with smooth margins
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Fig. 1.6: Upper GI endoscopy shows dilated esophagus with smooth narrowing
  • Failure of the upper esophageal sphincter relaxation.
  • Improper cricopharyngeal muscle contraction
  • Presbyoesophagus
  • Neuromuscular dysfunction
  • Compensatory mechanism in GERD patients.
  • Hypertrophy of cricopharyngeal muscle.
Signs and Symptoms
  • Dysphagia
Imaging Findings
Barium Swallow
  • Lateral view: Persistent posterior extrinsic impression on the esophagus at C5-C6 level
  • AP view: Luminal narrowing at C5-C6 level.
Differential Diagnosis
  • Cervical osteophytes
  • Esophageal tumor: Benign/Malignant.
Key Imaging Points
  • Persistent smoothly obtained projection posteriorly at C5-C6 level.
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Figs 1.7 and 1.8: Lateral esophagogram showing hypertrophied cricopharyngeus causing posterior indentation
  • Motility disorder involving the smooth muscle.
  • Primary achalasia - Idiopathic, neurogenic disorder
  • Secondary achalasia – Neoplasm, scleroderma, chagas disease.
  • Reduction of the ganglion cells in mesenteric/Auerbachs plexus.
Signs and Symptoms
  • Dysphagia
Imaging Findings
Plain Film: Chest X-ray
  • Mediastinal widening more so to the right of midline
  • Mottled lucencies noted within this shadow +/- air fluid levels
  • Dilated esophagus causing anterior tracheal bowing on the lateral radiograph.
Barium Swallow
  • Grossly dilated esophagus with absent primary peristalsis
  • Smooth, conical, tapered narrowing of the distal esophagus giving rise to a “bird's beak” appearance
  • Length of the narrowed segment varies from 1 to 3 cms
  • Small spurts of barium noted entering the stomach in the erect posture.
  • Markedly dilated esophagus with diameter > 4 cms
  • +/- Air fluid level
  • Abrupt narrowing of distal esophageal segment
Differential Diagnosis
  • Scleroderma—patulous GE junction
  • Esophageal carcinoma—Asymmetric contour, mucosal irregularity and shouldering
  • Gastric carcinoma extending into distal esophagus
  • Diffuse esophageal spasm
Key Imaging Points
  • Dilated esophagus with absence of primary peristalsis
  • Smooth, symmetric tapering
  • Bird beak deformity
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Figs 1.9 and 1.10: Frontal and lateral projection of esophagogram shows dilated esophagus with conical, smooth, tapered narrowing of distal end giving rise to bird's beak appearance
  • Dilated submucosal veins
  • Venous collaterals carrying a disproportionately greater quantity of blood than the corresponding arterial supply
Table 1.1   Differentiating features of Uphill and Down hill varices
Uphill varices
Downhill varices
Portal HTN mainly cirrhosis
SVC obstruction
Portal vein thrombosis
Tumor invasion
Splenic vein thrombosis
Mediastinal fibrosis
Lower 2/3rds of esophagus
Upper and middle esophagus/entire esophagus
Portal vein blood is conveyed to azygos vein
Systemic venous blood is conveyed bypassing SVC through azygos/IVC
If obstruction of SVC proximal to Azygos – varices only in upper esophagus
If obstruction distal to azygos -
Varices in proximal 2/3rd of esophagus
Barium Swallow
  • Best achieved by using anticholinergic agents (Buscopan 20 mg IV)
  • Small amount of high density barium
  • Administration of gas producing agent is optional
  • Multiple films in various projections in different phases of respiration should be taken
  • Round/oval filling defects giving rise to rosary beaded appearance
  • Serpiginous thickening of folds (Resemble earth worms lying in the lumen of esophagus)
  • Translucent
In Profile
  • Line of nodular/scalloped filling defects
  • Thickening of mucosal folds
  • Irregularity of esophageal outline
  • Worm eaten appearance
Differential Diagnosis
  • Peptic esophagitis
  • Infectious esophagitis
  • Verrucoid carcinoma
  • Thickened folds
  • Mucosal abnormality
  • Sliding hiatus hernia with GE reflux
  • Fixed, thickened mucosal folds
  • Rigidity and loss of peristalsis of affected area
  • Submucosal tumor
  • Thickened nodular folds
  • Evidence of lymphnodes elsewhere in body usually present
  • Primary diagnosis is not enhanced
  • But possible to demonstrate deeper periesophageal collaterals which may be larger than submucosal varices
  • Communication with a collateral circuit below diaphragm seen in 25 %
  • EUS demonstrates not only perigastric varices and collaterals but varices within gastric submucosa
  • Scanning after sclerotherapy shows disappearance with preservation of deeper collaterals
  • May detect those at risk of rebleeding13
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Fig. 1.10A: Axial NECT shows cirrhotic liver
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Fig. 1.10B: Axial CECT shows multiple enhancing vessels in the periesophageal region
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Fig. 1.11: Endoscopy shows grade 3 varices
  • Herniation of the stomach through the diaphragmatic hiatus into the thorax
  • Type I: GE junction and gastric cardia are intrathoracic (sliding hiatal hernia)
  • Type II: GE junction is intraabdominal gastric fundus intrathoracic (paraesophageal hernia)
  • Type III: Both GE junction and fundus are in chest (paraesophageal hernia)
  • Type IV: GE junction and all of stomach in chest (paraesophageal hernia)
  • Sliding
  • Paraesophageal/rolling
  • Mixed
Sliding Hiatal Hernia
  • Stretching/rupture of phrenicoesophageal membrane
Imaging Findings
Barium Swallow
  • ‘B’ ring above the hiatus
  • Small hernia appears as a pouch of stomach protruding above the hiatus by more than 2 cms
  • Three or more gastric folds within the suprahiatal pouch
  • The hiatus is wide, measuring more than 3 cm in diameter
  • Large hernia often become fixed with part of the stomach remaining permanently in the thorax
  • Diaphragmatic crura are separated by more than 15 mm
  • Soft tissue density mass above the hiatus
  • Increase in the fat surrounding distal esophagus due to herniation of omentum through phrenicoesophageal ligament.
Paraesophageal Hernia
  • Widened esophageal hiatus/gap in the diaphragm
Imaging Findings
Barium Swallow
  • Cardia/esophagogastric junction situated below the diaphragm
  • Herniation of portion of stomach anterior to esophagus
  • Usually not reducible
  • May be associated with gastric ulcer of lesser curvature at the level of diaphragmatic hiatus
Mixed Hernia
  • Hernia is demonstrated with both a sliding and paraesophageal component.15
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Fig. 1.12: Esophagogram shows a large Type I sliding hiatal hernia
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Fig. 1.13: Endoscopy showing the large hernia
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Fig. 1.14: Type II paraesophageal hernia - Esophagogram shows GE junction below the diaphragm and fundus in the thorax
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Fig. 1.15: Barium esophagogram shows type III paraesophageal hernia with fundus and GE junction above diaphragm
  • Outpouching from the esophageal lumen
  • Fibrous healing after infection of the mediastinal lymphnodes
Signs and Symptoms
  • Small diverticula—asymptomatic
  • Large diverticula—Dysphagia/regurgitation
  • Most commonly in the middle third of thoracic esophagus
Imaging Findings
Barium Swallow
  • Diverticular collection of contrast that may have a funnel, cone, tent or fusiform shape
  • Best visualized in the left anterior oblique projection
  • Calcified mediastinal nodes from healed granulomatous disease are often seen adjacent to the diverticulum.17
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Fig. 1.16A and B: Esophagogram showing barium filled outpouching from mid esophagus
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Fig. 1.17: Upper GI endoscopy showing the paraesophageal diverticulum
  • Saccular outpouching from the distal esophagus
  • Defect in the muscular wall of esophagus
  • Due to increased intraluminal pressure
Signs and Symptoms
  • Asymptomatic if small, dysphagia if large
Imaging Findings
Barium Swallow
  • Large barium filled outpouching in the epiphrenic region from the lateral wall
  • Right side is more common than left
  • Association with achalasia or hiatal hernia
Differential Diagnosis
Hiatal Hernia
  • GE junction above the diaphragmatic hiatus
  • Lower esophageal sphincter is identified by the ‘B’ ring/Schatzki's ring
  • Diagnosed when the ring is seen 2 cms/more above the hiatus, more than 3 gastric rugae passing through this and > 2 cms in width.
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Figs 1.18A and B: Frontal and lateral view of esophagogram showing large epiphrenic diverticulum with residue noted posteriorly
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Figs 1.19A and B: Upper GI endoscopy showing the large mouth of diverticulum
  • Transmural esophageal tear
  • Iatrogenic injury
  • Spontaneous rupture – Boerhaave's syndrome
  • Closed chest trauma
  • Esophageal carcinoma
  • Retained foreign body leading to perforation
  • Barrett ulcer
Signs and Symptoms
  • Pain, dysphagia, odynophagia
  • Rapid onset of overwhelming sepsis – fever, tachycardia, hypotension, shock
  • Upper esophageal perforation – at the level of cricopharyngeal muscle
  • Distal esophageal perforation near GE junction
  • Thoracic esophageal perforation
    • Areas of anatomic narrowing
    • At/above benign or malignant strictures
Imaging Findings
Plain Film
  • Cervical esophageal perforation
    • Subcutaneous emphysema
    • Widening of superior mediastinum
    • Widening of prevertebral space on lateral films
    • Pneumomediastinum due to dissection of air along fascial planes from neck into chest
    • Retropharyngeal abscess – mottled gas, air fluid level
    • Right sided hydrothorax
  • Thoracic and distal esophageal perforation
    • Pneumomediastinum identified as radiolucent streaks of gas along
      • Left lateral border of aortic arch
      • Descending aorta
      • Right lateral border of ascending aorta
      • Heart
    • Left pleural effusion
    • Atelectasis in left basal segment
    • Hydropneumothorax – 75% on left
Esophagography with Oral Contrast
  • Small esophageal perforation (EP)
    • Localized extravasation of contrast medium into neck or mediastinum
  • Distal EP
    • Extravasation of contrast from left lateral aspect of esophagus into adjacent mediastinum
  • Sealed off EP
    • Self contained extraluminal collection of contrast media
  • Large EP
    • Free extravasation of contrast medium into mediastinum
  • Extraluminal air (92%), most useful sign
  • Periesophageal/mediastinal fluid (92%)
  • Extravasation of oral contrast medium
  • Esophageal thickening
  • Esophagopleural fistula – site of communication may be seen
  • Pleural effusion (75%)
Differential Diagnosis
  • Esophageal diverticulum
  • Esophageal ulceration
  • Boerhaave syndrome
  • Postoperative
  • Tracheobronchial aspiration
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Figs 1.20 and 1.21: Water soluble esophagogram shows extravasation into mediastinum with communication to the lower lobe bronchus
  • Squamous cell carcinoma is malignant transformation of squamous epithelium
  • Adenocarcinoma is malignant dysplasia in columnar metaplasia
  • Barret's esophagus
  • Ethyl alcohol abuse
  • Lye stricture
  • Head and neck tumor
  • Smoking
  • Plummer-Vinson syndrome
  • Achalasia
  • Tylosis
  • Squamous cell carcinoma
  • Adenocarcinoma
  • Mucoepidermoid carcinoma, adenoid cystic carcinoma
  • Carcinosarcoma
  • Leiomyosarcoma, rhabdomyosarcoma, fibrosarcoma
  • Malignant lymphoma
  • Polypoid/fungating
  • Ulcerating
  • Infiltrating
  • Verrucoid
  • Upper 1/3rd – 15 to 20%
  • Middle 1/3rd – 35 to 45%
  • Lower 1/3rd – 35 to 45%
Signs and Symptoms
  • Dysphagia
  • Weight loss
  • Retrosternal pain
  • Regurgitation
Imaging Findings
Plain Film: Chest X-ray
  • Widened azygoesophageal recess
  • Thickening of posterior tracheal stripe and right paratracheal stripe
  • Widened mediastinum
  • Tracheal deviation
  • Posterior tracheal indentation
  • Retrocardiac mass
  • Esophageal air fluid level
  • Lobulated mass extending into gastric air bubble
Barium Swallow
  • Polypoidal filling defect with destruction of mucosal folds, overhanging margins and an abrupt transition to normal tissue
  • Ulcer crater surrounded by a bulging mass projecting into the esophageal lumen
  • Infiltrating carcinomas appears initially as a flat plaque like lesion. It progresses to cause luminal irregularities and advanced lesions encircle the lumen
  • Large, irregular thickening of the mucosal folds with wall irregularity arranged in a chaotic pattern. This appearance mimicks esophageal varices
  • Intraluminal mass
  • Esophageal wall thickening
  • Irregular/eccentric esophageal lumen
  • Dilated lumen with/without A/F level proximally.
  • Obliteration of fat between tumor and adjacent structures
  • Perforation/sinus tract into mediastinum
  • Fistula to tracheobronchial tree
  • Enlargement of lymphnodes – mediastinal/supraclavicular/retrocrural/left gastric/celiac
  • Metastasis to liver, lung
Tracheobronchial involvement
  • Thickening of tracheobronchial wall
  • Intraluminal mass in airway23
  • Extension between trachea and aortic arch or left main bronchi and descending aorta
  • Intimal contact between tumor and aorta, 90°/more of aortic circumference
  • Deformation of aortic lumen
  • Amputation/lack of opacification of pulmonary vein.
EUS Findings
  • It is the best tool available for preoperative staging and local invasion
  • If restricted to the mucosa then allows immediate surgical procedure or endoscopic resection
  • Confined to the gut wall – neoadjuvant chemoradiation
  • Invaded adjacent structures – unresectable
  • Provides an accurate assessment of celiac axis lymphadenopathy
  • Presence of celiac axis lymphnodes represents distant metastases and is associated with worse prognosis.
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Fig.1.22: Esophagogram shows irregular narrowing with ulceration
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Fig.1.23: CT axial and sagittal reconstruction shows irregular circumferential thickening of the wall with significant luminal narrowing
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Fig.1.24: Upper GI endoscopy shows ulceroproliferative growth in the lower esophagus