X-ray signs of diseases of the esophagus

Indications for X-ray examination (X-ray of the esophagus) of the esophagus are dysphagia and any unpleasant sensations in the esophagus. The study is performed on an empty stomach.

Diverticula. Diverticulum is a saccular bulging of the mucous membrane and the submucosal layer of the esophagus wall through the slits of the muscular layer. Most diverticulums are located in the region of the pharyngeal esophagus, at the level of the aortic arch and in the bifurcation of the trachea, in the supra-diaphragm segment. The pharyngeal-esophageal (borderline, or Center) diverticulum is formed between the lower fibers of the lower pharyngeal constrictor and the cricoid-pharyngeal muscle on the back wall of the esophagus at the level of CVIII. This is a congenital diverticulum. The remaining diverticula usually develop during a person's life, especially often in old age, under the influence of the passage (propulsion) of food, and they are called pulsatile. Under the pressure of contrast mass, the diverticulum increases and gives an image in the form of a rounded formation with smooth contours. It can have a wide entrance or it communicates with the cavity of the esophagus by a narrow channel (neck). The folds of the mucosa are not changed and enter through the cervix into the diverticulum. As the evacuation diverticulum decreases. As a rule, diverticula are a random finding, which has no clinical significance. However, in rare cases, they develop an inflammatory process (diverticulitis). Cases of perforation of the esophagus diverticulum into the mediastinum are described.

When the scar process in the esophagus surrounding the cellulose, local deformities of the esophagus, in particular, protrusion of its wall, may occur. These bulges have an elongated or triangular shape and are devoid of a neck. Sometimes they are wrongly called tractional diverticula, although they are not true diverticula.

Dyskinesia of the esophagus. Dyskinesia of the esophagus is manifested in its hypertension or hypotension, hyperkinesia or hypokinesia, in spasms or insufficiency of sphincters. All these disorders are recognized by X-ray examination in the form of acceleration or slowing of the progress of contrast mass, the appearance of spastic constrictions, etc. Of the functional disorders most often observed failure of the lower esophageal sphincter with gastroesophageal reflux, i.e. Throwing the contents of the stomach into the esophagus. As a result, inflammatory phenomena develop in the esophagus, surface, and then deep esophagitis develops. The wrinkling of the esophagus wall promotes the formation of a hernia of the esophageal aperture of the diaphragm.

The best way to identify gastroesophageal reflux is scintigraphy. A patient standing drinking 150 ml of water with a labeled colloid. After 10-15 minutes, it assumes a horizontal position. Light pressure on the anterior abdominal wall is provoked by the manifestation of reflux (for this it is convenient to use an inflatable cuff, increasing the pressure in it every 30 seconds). The transition of even a small amount of fluid from the stomach into the esophagus is documented in a series of scintigrams.

Another functional disorder is the violation of secondary and tertiary cuts of the esophageal wall. The increase in secondary contractions is expressed in the spasm of the retrocardial segment of the esophagus. Spasm is removed by sublingual application of nitroglycerin. Strengthening of tertiary contractions causes numerous unstable pulls on the contours of the middle and lower sections of the thoracic part of the esophagus. Sometimes the esophagus resembles a rosary or a corkscrew (corkscrew gullet).

Hernia of the esophageal opening of the diaphragm. There are two main types of hiatal hernias: axial and para-esophageal.

In the axial hernia, the intra- and sub-diaphragm segments of the esophagus and part of the stomach are displaced into the thoracic cavity, the cardial opening is located above the diaphragm. In the paraeophageal hernia, the sub-diaphragm segment of the esophagus and the cardial opening are located in the abdominal cavity, and part of the stomach leaves the esophageal opening of the diaphragm into the thoracic cavity next to the esophagus.

Large fixed hernias are recognized by X-ray examination without difficulty, since barium fills a part of the stomach localized in the posterior mediastinum, above the diaphragm. Small sliding hernia is detected mainly in the horizontal position of the patient on the abdomen. It is necessary to distinguish between hernia and ampulla of the esophagus. In contrast to the ampoule, there is no sub-diaphragmal segment of the esophagus with a hernia. In addition, the folded part of the folds of the mucous membrane of the stomach, and it, in contrast to the ampoule, retains its shape upon exhalation.

Esophagitis and ulcers of the esophagus.

Acute esophagitis is observed after a burn of the esophagus. In the early days, edema of the mucous membrane of the esophagus and marked violations of its tone and motor skills are noted. The folds of the mucous membrane are swollen or not visible at all. Then, the unevenness of the esophagus contours and the spotted nature of its internal surface can be detected due to erosion and flat ulceration. Within 1-2 months, cicatricial narrowing develops, in the region of which there is no peristalsis. The passage of the esophagus depends on the degree of stenosis. If necessary, balloon dilatation of the esophagus is performed under fluoroscopy control.

Chronic esophagitis is most often associated with gastroesophageal reflux. The esophagus is moderately expanded, its tone is lowered. The peristalsis is weakened, the contours of the esophagus slightly uneven. Often its secondary and tertiary reductions are reinforced. Areas of the esophagus, in which the folds of the mucous membrane are tortuous and thickened, alternate with areas of lack of folding, where it is replaced by a kind of granularity and flocculent clusters of contrast mass. Similar changes are observed in viral and fungal lesions of the esophagus.

In the area of the ulcer, a contrast agent accumulates. At this point on the contour of the esophagus appears a rounded or triangular protuberance - a niche. If the ulcer can not be taken out to the contour, it gives an image in the form of a cluster of contrast medium of round shape that does not disappear after one or two sips of water.

Achalasia of the esophagus. Akhalasia - the absence of a normal opening of the cardial opening - a relatively often observed pathological condition. At the stage of the disease, the radiologist notes the conical narrowing of the sub-diaphragmatic segment of the esophagus and the delay in it of the contrast mass for several minutes. Then the cardial opening suddenly opens, and barium quickly enters the stomach. In contrast to cancer of the cardial department, the contours of the subdiaphragm segment and the upper part of the stomach are even; in these departments, there are clear longitudinal folds of the mucosa. With prolonged delay of contrast mass in the esophagus resort to a pharmacological test. Taking nitroglycerin or intramuscular injection of 0.1 g of acetylcholine promotes the opening of the cardial opening.

In the second stage of the disease, the thoracic part of the esophagus is enlarged, fluid accumulates in it. The peristalsis is weakened, and the folds of the mucosa are thickened. Subdiaphragmal segment of the esophagus before the cardiac opening is narrowed, often curved in the form of a beak, but with deep breathing and straining its shape changes, which is not the case with cancer lesions. Barium does not enter the stomach for 2-3 hours or more. The gas bubble in the stomach is sharply reduced or absent.

In stage III - the stages of decompensation - the esophagus is sharply expanded, contains liquid, and sometimes remains of food. This leads to an increase in the shadow of the mediastinum, in which the esophagus is different even before the contrast mass is received. Barium drowns in the contents of the esophagus. The latter forms bends. Air in the stomach is usually absent. Emptying the esophagus is delayed for many hours, and sometimes several days.

Control X-ray studies are performed to test the efficacy of conservative or surgical treatment, in particular after the application of esophageal-gastric anastomosis.

Tumors of the esophagus. Benign epithelial tumors (papillomas and adenomas) of the esophagus have the appearance of a polyp. They cause the defect of filling in the shade of the contrast medium. The contours of the defect are sharp, sometimes shallow, the folds of the mucous membrane are not destroyed, but the tumor is circumscribed. Benign non-epithelial tumors (leiomyomas, fibromas, etc.) grow submucous, so the folds of the mucous membrane are preserved or flattened. The tumor gives an edge filling defect with even outlines.

Exophytic cancer grows in the lumen of the organ and causes a defect of filling in the shadow of contrast medium in the form of rounded, oblong or mushroom-like enlightenment (polypoid, or mushroom-like, cancer). If the decay occurs at the center of the tumor, then a so-called cup-like cancer is formed. It looks like a large niche with uneven and elevated edges, like a roller. Endophytic cancer infiltrates the wall of the esophagus, causing a flat defect in filling and a gradual narrowing of the lumen of the esophagus.

Both exophytic and endophytic cancer destroys the folds of the mucosa and turns the wall of the esophagus into a dense, non-polymerizing mass. As the esophagus narrows, the barium moves along it. The contours of the stenosed area are uneven, suprastenotic expansion of the esophagus is defined above it.

Introduction to the esophagus ultrasound sensor allows you to determine the depth of tumor invasion of the esophageal wall and the state of regional lymph nodes. Before a surgical operation, it is necessary to establish whether there is invasion of the tracheobronchial tree and the aorta. For this purpose, CT or MRI is performed. Penetration of tumor tissue beyond the esophagus causes an increase in the density of mediastinal fiber. Radiation studies must be repeated after preoperative chemotherapy or radiotherapy and in the postoperative period.

Dysphagia

The term "dysphagia" refers to all the types of difficulty swallowing. This is a syndrome that can be caused by various pathological processes: neuromuscular disorders, inflammatory and neoplastic lesions of the esophagus, systemic connective tissue diseases, scar strict strictures, etc. The main method of examining patients with dysphagia is radiographic. It allows you to get an idea of the morphology of the pharynx and all parts of the esophagus and to detect compression of the esophagus from the outside. In unclear situations, with negative results of radiography, and also with the need for biopsy, esophagoscopy is indicated. In patients with functional impairment, established by X-ray examination, esophageal manometry may be necessary (in particular, in the case of achalasia of esophagus, scleroderma, diffuse esophageal spasm). The general scheme of the complex study for dysphagia is presented below.