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Comprehensive Insights into Esophageal Conditions and Related Cases

This directory explores various esophageal conditions, highlighting key findings from cases 1 to 25. Notable conditions include intramural pseudodiverticula characterized by small, contrast-filled cavities, and esophageal varices linked to portal venous hypertension. The document also discusses pharyngeal pouches and various types of diverticula including pulsing and traction diverticula, as well as hiatal hernias and gastric malignancies. A detailed differential diagnosis is provided for each condition, enhancing understanding of their clinical implications.

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Comprehensive Insights into Esophageal Conditions and Related Cases

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  1. GI Barium Cases 1-25

  2. Case directory

  3. Case 1

  4. Case directory Intramural pseudodiverticula • Case findings: • Multiple contrast-filled cavities, only 1 or 2 millimeter in diameter in the esophageal mucosa • Dilated excretory ducts of deep mucous glands in esophagus • Secondary to esophagitis: pseudodiverticula vanish when the esophagitis is treated (MC Candida) • Dilated submucosal glands and ducts, which are similar to Rokitansky-Aschoff sinuses of GB • DDX: • Moniliasis • Glycogen acanthosis

  5. Case 2

  6. Case directory Esophageal varices • Etiology: portal venous hypertension • Classification • Uphill varices: mid to distal esophagus, portal hypertension • Downhill varices: upper or mid esophagus, SVC obstruction • DDX: • Varicoid carcinoma: superficial spreading carcinoma, with thickened nodular tortuous longitudinal folds • Has a rigid, fixed, nodular folds that do NOT change configuration (unlike varices) • Esophagitis with thickened esophageal folds • Lymphoma • Squamous cell carcinoma

  7. Case 3

  8. Pharyngeal pouch • Case findings: • Contrast-filled cavity at the posterior wall of the esophagus • Arises between the superior and the middle pharyngeal constrictors (congenitally weak point of the pharyngeal wall) • Esophageal diverticula: • Pulsion diverticula: contain no muscle in their wall so they tend to stay filled with barium after the rest of the esophagus empties • Traction diverticula: contain muscle in their walls so they tend to empty with the rest of esophagus

  9. Esophageal diverticulum • Pharyngo-esophageal (Zenker): • Herniation of mucosa and submucosa through oblique and transverse muscle bundles of the cricopharyngeal muscle (pseudodiverticulum) • Increased intraluminal pressures and tic formation in midline of Killian dehiscence at level of C5-C6 • MC posterior • Traction diverticulum (interbronchial diverticulum): • Response to pull from fibrous adhesions following lymph node infection (MC TB) • MC right anterior esophageal wall • Distal (epiphrenic diverticulum): • Pulsion, associated with hiatal hernia • MC right • Related to long-standing peptic esophagitis and strictures

  10. Esophageal diverticulum • Killian-Jamieson diverticulum: • Lateral to the insertion of the longitudinal tendon of the esophagus on the cricoid cartilage • Diverticula are in the mid esophagus can congenital or traction: • Traction types develop by traction from contiguous mediastinal inflammation and adenopathy such as from TB or histoplasmosis • Other causes of mid and lower diverticula: • Iatrogenic • Ehlers-Danlos syndrome • Motility disorders such as achalasia and esophageal spasm

  11. Zenker’s diverticulum

  12. Large diverticulum (arrows) arising from the posterior wall of the distal esophagus Epiphrenic diverticulum

  13. Case directory Traction diverticulum • Traction diverticulum identified by black arrow • MC located in the mid-esophagus • Result from scarring and retraction of the esophageal wall due to granulomatous disease in adjacent subcarinal or hilar lymph nodes • Presence of calcification in subcarinal (white arrows), hilar, or paratracheal lymph nodes  TB

  14. Case 4

  15. Paraesophageal hernia • Case findings: • Gastroesophageal junction in normal position • Parts of the stomach slip through the esophageal hiatus • Hiatal hernia: • Sliding: MC (80%), GEJ slides superior into the chest through the esophageal hiatus • Paraesophageal: GEJ remains in its normal position, but parts of the stomach and peritoneum slip through the esophageal hiatus

  16. Paraesophageal hernia

  17. Case directory Sliding hiatal hernia

  18. Case 5

  19. Gastric carcinoma • Case findings: • Filling defect in the gastric body • Location: MC pylorus > lesser curve, GEJ, greater curvature • Types: • Polypoid • Ulcerating • Infiltrating or schirrous:linitis plastica • DDX: metastatic breast carcinoma • Superficial spreading: confined to mucosa and submucosa • Predisposing factors: • H. pylori, adenomatous polyps, pernicious anemia, atrophic gastritis

  20. DDX gastric mass • Malignant: • Carcinoma, lymphoma, leiomyosarcoma, metastases • Benign: • Leiomyoma, lipoma, neurofibroma • Polyps: • Hyperplastic • Adenomatous • Hamartomatous • Others: • Bezoar, Nissen fundoplication, ectopic pancreas

  21. Case directory Gastric polyps • Hyperplastic (MC) • Adenomatous: increased risk of malignancy • Familial adenomatous polyposis (FAP) • Gardner’s syndrome • Turcot syndrome: associated with CNS tumors (e.g., gliomas) • Hamartomatous: • Peutz-Jeghers syndrome • Cowden syndrome • Inflammatory: • Cronkhite-Canada syndrome

  22. Case 6

  23. Duodenal diverticulum • Case findings: • Large duodenal diverticulum with some small diverticula at the top • MC located near the ampulla

  24. Duodenal diverticulum

  25. Case directory Intraluminal duodenal diverticulum (2 cases)

  26. Case 7

  27. Celiac disease (sprue) • Case findings: • Proximal small bowel dilatation • Smudging and dilution of barium in LUQ • Moulage sign: produced by barium reaching such diluted, fluid-filled, hypotonic segments • Normal sized, but widely spaced, sparser folds in jejunum • Associated with transient intussusception • Risk of intestinal lymphoma • Features: • Small bowel dilatation • Moulage pattern: barium pooling • Flocculation: excessive mucus prevents an adequate coating of the mucosa by the barium (barium flocculates in the presence of mucus) • Jejunization of the ileum: increased number of folds in the ileum, with reversal of the normal jejuno-ileal fold pattern

  28. Celiac disease (sprue) Jejunization of the ileum

  29. Celiac disease (sprue) Flocculation

  30. Case directory Celiac disease (sprue) • Lymphoma arising in celiac disease as thick, slightly undulating folds (arrows) and smooth nodules (arrowheads)

  31. Case 8

  32. Crohn’s • Case findings: • Deep and superficial linear ulcerations and small bowel wall thickening near the terminal ileum • Fistula track • Features: • Deep and superficial linear ulcerations • Cobblestoning • Bowel wall thickening, strictures, skip lesions • Pseudopolyposis, fistula

  33. Crohn’s • DDX: • Yersinia colitis: fold thickening (early finding), aphthoid ulcers, coarsened mucosal surface and inflammatory nodules (indistinguishable from early Crohn’s) • Deeper ulceration and marked luminal narrowing is unlikely • Heals to a lymphoid hyperplasia pattern, resolves completely • Ileitis: due to Shigella, Salmonella, Campylobacter • Self-limited and will not reach a stenotic stage • Tuberculosis: identical to Crohn’s

  34. Cobblestoning: deep and superficial linear ulcerations in descending colon Crohn’s

  35. Crohn’s • Numerous barium-filled linear clefts are seen as straight, longitudinal and transaxial lines (arrows) • Cobblestones: between the fissures are residual islands of less inflamed mucosa

  36. Crohn’s • Confined to the mucosa and submucosa with thickened and curved folds • Long mesenteric border ulcer is seen as a thin barium-filled line (arrows)

  37. Case directory Crohn’s • Area of ulceration merging with marked narrowing (arrowhead) of the terminal ileum • Small ulcers are also seen in the ascending colon (arrow)

  38. Case 9

  39. Case directory Ulcerative colitis • Case findings: • Loss of haustra and mucosal distortion

  40. Case 10

  41. Diverticulitis • Case findings: • Irregular bowel wall thickening, with narrowing of the sigmoid lumen • Mucosal pattern preserved (implies a benign process)

  42. Case directory Diverticulitis

  43. Case 11

  44. Moniliasis • Case findings: • Diffuse nodular and plaque like mucosal defects • Plaque like defects are longitudinally oriented • Sharply defined plaques • DDX: • Glycogen acanthosis • Reflux esophagitis: ill-defined plaques

  45. With progression, esophagus may have a grossly irregular or shaggy contour (shaggy esophagus) Shaggy contour due to multiple plaques, pseudomembranes, and ulcers Case directory Moniliasis

  46. Case 12

  47. Herpes esophagitis • Multiple small discrete superficial ulcerations: appears as a small barium collection with a surrounding halo of lucency due to edema • No fold thickening, normal esophageal contour • Ulcers may be clustered, MC in mid-esophagus (relative sparing of distal esophagus)

  48. Herpes esophagitis

  49. Discrete ulcers surrounded by radiolucent halos of edematous mucosa Normal intervening mucosa Herpes esophagitis

  50. Case directory Herpes esophagitis

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