OESOPHAGEAL ANATOMY AND PATHOLOGIES (2) [Autosaved].pptx

OESOPHAGEAL ANATOMY AND PATHOLOGIES (2) [Autosaved].pptx

1. OESOPHAGEAL ANATOMY AND PATHOLOGIES MODERATOR – DR. PRASANTHI MDRD PRESENTOR – DR. SWETHA

2. Gross anatomy The esophagus is 23-37 cm long with a diameter of 1-2 cm and is divided into three parts: Cervical :  continuous with the  hypopharynx , commences at the lower border of  cricoid cartilage  (at level of C5/6) Thoracic :  from  superior thoracic aperture  (T1) to the  esophageal hiatus  (T10) in the diaphragm Abdominal:  from esophageal hiatus and to the cardia of the  stomach  at the  gastro-esophageal junction

3. There are three normal esophageal constrictions cervical constriction (narrowest point): due to the cricoid cartilage at the level of C5/6 thoracic constriction: due to the aortic arch at the level of T4/5 abdominal constriction: at the esophageal hiatus at the level of T10/11

4. RELATIONS Posteriorly : vertebral column, pre-vertebral fascia, descending aorta,  thoracic duct  (at thoracic plane) Anteriorly :  trachea  (to T4/5),  recurrent laryngeal nerves  (in tracheo-esophageal groove), left main bronchus,  left atrium Left lateral :  lung ,  pleura , aorta , left  subclavian artery , thoracic duct Right lateral : lung; pleura, azygos vein

5. BLOOD SUPPLY Arterial supply upper third: Inferior thyroid artery middle third: esophageal branches of the  thoracic aorta  and by the bronchial arteries lower third: esophageal branches of the  left gastric artery

6. Venous drainage upper third:  inferior thyroid veins  to  brachiocephalic veins middle third:  azygos vein  to  SVC lower third:  left gastric vein  to  portal vein  (site of  portal-systemic collateral pathway

7. Radiographic appearance Fluoroscopy Barium swallow  is the main radiological method of assessing the esophagus Double contrast esophagogram using CO2 gas-forming crystals and barium contrast are used to distend the esophagus and coat the mucosa

8. Ultrasound first hyperechoic layer represents the interface between the balloon and the superficial mucosa second hypoechoic layer represents the lamina propria and muscularis mucosae a third hyperechoic layer represents the submucosa fourth hypoechoic layer represents the muscularis propria fifth layer represents the interface between the adventitia and surrounding tissues

9. CT 80% will contain gas allowing for appreciation of the wall if there is enough surrounding mediastinal fat if collapsed will appear as round or ovoid MRI T1: isointense to muscle T2: hyperintense to muscle

10. Related pathology OESOPHAGEAL STRICTURE OESOPHAGEAL WEBS SCHTAZKI RING GERD ACHALAISIA CARDIA OESOPHAGEAL PERFORATION OESOPHAGEAL CARCINOMA

11. OESOPHAGEAL BRONCHUS Esophageal bronchus, - . communicating bronchopulmonary foregut malformation Esophageal bronchi may be the main bronchus, which gives rise to esophageal lung, or may be a lobar bronchus, most commonly a lower lobe bronchus unilateral  alveolar opacity  and  air bronchogram  as a result of aspiration  mediastinal shift to the affected side

12. OESOPHAGEAL ATRESIA Esophageal atresia refers to an absence in the continuity of the esophagus due to an inappropriate division of the primitive foregut into the  trachea  and  esophagus if an esophagogastric (feeding) tube insertion may show the tube blind looping and turning back at the upper thoracic part of the esophagus or heading into the trachea and/or bronchial tree Contrast swallow may show contrast blindly ending and pooling in an esophageal stump

13. Esophageal stricture Esophageal strictures are often associated with a  hiatal hernia . The most common causes are fibrosis induced by inflammatory and neoplastic processes. Because radiographic findings are not reliable in differentiating benign from malignant strictures, all should be evaluated endoscopically. 

14. Radiographic features BENINGN STRICTURE smoothly tapering typically concentric narrowing, but may affect only one side of the esophagus (asymmetric wall rigidity) MALIGNANT STRICTURE abrupt asymmetric eccentric with irregular, nodular mucosa Tapered margins may occur with malignant lesions because of the ease of submucosal spread of a tumor.

15. Esophageal web Esophageal webs refer to an esophageal constriction caused by a thin mucosal membrane projecting into the lumen.  Barium swallow a "jet effect" of contrast passing distal to the web may be seen

16. Schatzki ring symptomatic, narrow esophageal    occurring in the distal  esophagus  and usually associated with a  hiatus hernia . Barium swallow Circumferential narrowing at the gastro-esophageal junction, often a few centimeters above the diaphragmatic hiatus thin smooth ring, 1-3 mm

17. Esophageal perforation Esophageal rupture is iatrogenic from instrumentation and surgery in ~80% of cases Possible clues on chest radiographs include: Pneumomediastinum abnormal  cardiomediastinal contour pneumothorax   and  pleural effusion widening of the mediastinal shadow

18. Fluoroscopy Most sensitive within the first 24 hours  A low-osmolar water-soluble agent should be used initially as barium can cause  mediastinitis   Esophageal perforation may be represented as mucosal irregularity or extraluminal oral contrast leak

19. CT Extraluminal gas locules in the mediastinum or abdominal cavity, adjacent to the esophagus Pleural or mediastinal fluid pneumomediastinum  or  pneumothorax pericardial  or  pleural effusions   can be seen

20. Gastro- esophageal reflux disease Barium swallow Gastroesophageal reflux (demonstrated with provocative maneuvers ) Hiatal hernia (associated with presence of reflux esophagitis) Reflux  esophagitis in more advanced cases, stricturing and/or esophageal shortening may be present

21. HIATUS HERNIA type 1: sliding hiatal hernia (~95%) type 2: paraesophageal hiatal hernia with the gastro- esophageal junction in a normal position type 3: paraesophageal hiatal hernia with displaced gastro- esophageal junction type 4: mixed or compound type hiatal hernia with additional herniation of viscera

22. Plain radiograph retrocardiac opacity with gas-fluid level Fluoroscopy numerous coarse thick gastric folds within the suprahiatal pouch tortuous esophagus with an eccentric gastro- esophageal junction

23. CT focal fat collection in the middle mediastinum paraesophageal hernia through a widened esophageal hiatus herniated contents lie adjacent to the esophagus widening of esophageal hiatus dehiscence of  diaphragmatic crura   (>15 mm): increased distance between crura and esophageal wall

24. Feline esophagus Feline esophagus also known as esophageal shiver, refers to the transient transverse bands seen in the mid and lower  esophagus  on a double-contrast  barium swallow . The folds are 1-2 mm thick and run horizontally around the entire circumference of the esophageal lumen. The appearance is confined to the distal two-thirds of the thoracic esophagus.

25. Achalasia Achalasia (primary achalasia) is a failure of organized esophageal peristalsis that causes impaired relaxation of the  lower esophageal sphincter , resulting in food stasis and often marked dilatation of the  esophagus . 

26. Plain radiograph Convex opacity overlapping the right mediastinum. Air-fluid level due to stasis in a thoracic esophagus filled with retained secretions and food Small or absent  gastric bubble Anterior displacement and bowing of the trachea on the lateral view

27. Barium swallow : bird beak sign  or  rat tail sign Esophageal dilatation Tram track appearance: central longitudinal lucency bounded by barium on both sides  Pooling or stasis of barium in the esophagus when the esophagus has become atonic or non-contractile (a late feature in the disease) Uncoordinated, non-propulsive,   tertiary contractions

28. Oesophageal leiomyoma Esophageal leiomyoma is a benign smooth muscle neoplasm of the  esophagus . It is the most common  benign tumor of the esophagus . Fluoroscopy On barium swallow, may be seen as a discrete ovoid mass that is well outlined by barium. Its borders form slightly obtuse angles with the esophageal wall

29. Esophageal carcinoma Chest radiograph Widened  azygos- esophageal recess  with convexity toward the right lung. Thickening of posterior tracheal stripe and  right paratracheal stripe   >4 mm (if tumor located in the upper third of esophagus ) lobulated mass extending into a  gastric bubble  ( Kirklin sign ) repeated aspiration pneumonia (with   tracheo-esophageal fistula )

30. Contrast swallow Irregular stricture Prestricture dilatation with 'hold up’ Shouldering of the stricture

31. Endoscopic ultrasound The most accurate imaging modality for the T staging of esophageal cancer. It defines the layers of the esophageal wall hence can differentiate T1, T2, and T3 tumors.

32. CT Eccentric or circumferential wall thickening >5 mm Periesophageal soft tissue and fat stranding Dilated fluid- and debris-filled esophageal lumen is proximal to an obstructing lesion Tracheobronchial invasion appears as a displacement of the airway (usually the trachea or left mainstem bronchus) as a result of the mass effect by the esophageal tumor Aortic invasion

33. THANK YOU