Download Case study Oesophagus

Dr W.J. Conradie
Department of Diagnostic Radiology
March 2012
 Housewife
 No previous major surgery
 Medical history:
 Hypertensive with mild CCF on medication.
 Irritable bowel syndrome
 Medication:




Fosamax
Disprin
Adco Dol
Enalapril and Lasix
 Family history:
 Eldest son died of esophageal Ca in 2007
 Progressive dysphagia (solids/fluids) over couple of months.
 Episodes of coughing while eating/drinking
 Intermitted regurgitation of undigested food.
 Feeling of “fullness” in neck
 Weight loss ± 5kg
 Large para-tracheal mass on the left extending
into/through thoracic inlet
 Moved with swallowing
 No features of thyrotoxicosis
 No cervical lymphadenopathy
 Severe kypho-scoliosis
 CXR:
 Degenerative spine
 Clear lung fields
 Bloods:
 Normal
 FBC, U&E, LFT
 CRP and ESR
 Thyroid functions
 S-albumin
 Large irregular mass from left thyroid lobe
 Extends deep into superior mediastinum
 Cyst with calcifications inferiorly
 Nodule in superior aspect of lobe with central
breakdown
 No mediastinal lympnodes
 Lung fields clear
 Incidental:
Aorta arch anomaly
Aorta arch anomaly:
1. Main stem for right and left common carotid
2. Left subclavian artery
3. Aberrant right subclavian artery
Differential diagnosis
for dysphagia
1.
Thyroid mass
2. Zenker ‘s Diverticulem
3. Aberant right subclavian
artery (dysphagia lusoria)
4. Achalasia
 Named after Friedrich Albert von Zenker who was a German pathologist
(1825 – 1898)
 Definition:
 Mucosal outpouching of posterior hypopharyngeal wall.
 Proximal to upper esophageal sphincter
(Cricopharyngeal muscle)
 Pathophysiology:
 Pulsion-pseudodiverticulum with herniation of
mucosa and submucosa through Killian’s dehiscence.
 Focal weakness in cleavage plane between the fibers of
inferior pharyngeal constrictor and cricopharyngeus muscles.
 Due to cricopharyngeal dysfunction
luminal pressure
 Prevalence
 <0.2% of general population
 Elderly woman
 >50% occur in 7th -8th decade
 Complications




Aspiration
Perforation
Ulceration
Carcinoma
 Clinically:




globus feeling
dysphagia
halitosis
regurgitation
 Associated with:
 Hiatus hernia
 GER / Reflux oesophagitis
 Achalasia
 Differential diagnosis
1.
Killian-Jamieson
diverticulum (K-J)
2.
Esophageal web
3.
Lateral pharyngeal pouch
4.
Epidermolysis bullosa
dystrophica
 General features:





Location: Killian’s dehiscence
Posterior above cricopharyngeus
C5-6
Size: 0.5-8cm
(average 2.5cm)
Best diagnostic clue:
Barium filled sac!
 Radiographic findings:
CXR/CT:
 Air-fluid level in superior mediastinum
Barium swallow
 AP:
 Barium-filled sac below the
level of hypopharynx
 Lateral/oblique view:
 Barium-filled sac posterior to
cervical esophagus
 Neck opening into posterior wall
above cricopharyngeus m.
 Prominent or thickened
cricopharyngeal muscle
 Luminal narrowing at upper
pharyngoesophageal junction
 ± Nasopharyngeal regurgitation
 Dysphagia secondary to extrinsic esophageal
compression by an aberrant right subclavian artery
 Described by Bayford in 1794
 lusoria - Greek phrase lusus naturae, meaning
“ freak or zest of nature”, which refers to the freaky
course of the artery (lusoria artery)
 Prevalence of 1.8%
 1/3 experience symptoms
(90% = dysphagia)
 Any age
 Old age: atherosclerosis or
aneurysmal dilatation of ARSA.
 Associated:
 Dyspnoea
 Lower right arm BP/pulse volume
 Diverticulum of Kommerell.
 Management:
 Conservative
 Carotico-subclavian bypass
 Definition:
 Primary motility disorder of
esophageal smooth muscle
 Failure of LES to relax
 “Failure to relax”
 Sir Thomas Willis in 1672.
 1929: Hurt and Rake
 Discovered failure of LES to relax.
 Pathophysiology
 Degeneration of Auerbach’s plexus
 Primary(classic)  Secondary
 Infectious
-
idiopathic (number decrease, CNX – nucleus or nerve)
metastases, adenocarcinoma, vagotomy, scleroderma
Chagas disease (trypanosoma cruci neurotoxin
destroys ganglia)
 Prevalence
 Primary: younger (20-50)
 Secondary: older
 Male=female
 Clinically:
 Dysphagia (solids and liquids)
 Regurgitation
 Weight loss in 90%
 Diagnosis
 Exclude malignancy
 Exclude oesophageal spasm
 Manometry
 Complications:





Coughing
Aspiration
Pneumonia
Lung abscess
Esophageal carcinoma (2-7%)
 Management:
 Aimed at improving
esophageal emptying




Calcium channel blockers
Botulinum toxin injection
Pneumatic dilatation
Heller myotomy
 General findings
 2 criteria:
 Absent primary/secondary peristalsis
 LES fails to relax when swallowing
 Tertiary waves
 "Bird-beak" deformity
 Dilated esophagus with smooth, symmetric, tapered
narrowing at GEJ
CXR:
 Mediastinal widening
 Double contour
 Anterior tracheal
bowing
 Air-fluid level in
mediastinum
 Small or absent
gastric air bubble
Classic Achalasia
Secondary Achalasia
 Dilated esophagus (>4cm)
 Less dilated (<4 cm)
 Absent peristalsis
 Decreased or absent peristalsis
 Distal segment
 "Bird-beak" deformity
 Distal segment:
 Eccentric, nodular, shoulder
 smooth, symmetric, tapered
 Hurst phenomenon:
 transit when hydrostatic
pressure of barium column is
above tonic LES pressure
 Narrowed segment: <3.5 cm in
length
 Narrowed segment: >3.5
cm
Differential diagnosis
1.
Scleroderma
2.
Esophageal carcinoma
3.
Gastric carcinoma
4. Esophagitis with stricture
5.
Diffuse esophageal spasm
 Cause for dysphagia: Thyroid mass
 Surgicaly removed 16-07-2008
 Histology: Benign, Non toxic Nodular goitre
 Outcome (2012):
 Improved but still suffers from dysphagia!!
 Zenker’s divertikulem?
 ARSA?
THANK YOU
1.
Weissleder, Wittenberg, Harisinghani, Chen. Primer of Diagnostic
Imaging. Fifth edition. 2011.
2.
Federle, Jeffrey, Desser, Anne, Eraso. Diagnostic Imaging of the
Abdomen. First edition. 2004.
3.
(PPP) ZENKER’S DIVERTICULUM. N. D’Souza,Underbrink. 2010
4.
J. Dandelooy, J.P.M. Coveliers, P.E.Y. Van Schil, S.Anguille. Dysphagia
lusoria. CMAJ • October 13, 2009 • 181(8)
5.
P.D. Kent, T.H. Poterucha. Aberrant Right Subclavian Artery and
Dysphagia Lusoria. N Engl J Med, Vol. 346, No. 21 May 23, 2002