Caustic Esophagitis

Published on 05/08/2015 by admin

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[level-membership-for-radiology-category] Causes mild to severe injury to upper GI tract

– Esophagus > stomach > duodenum

IMAGING

• Imaging evaluation: CECT for acute injury; barium esophagram for chronic

image If esophagram done in acute phase, use nonionic, water-soluble agent (e.g., Omnipaque)
• Fluoroscopic: Esophagram

image Stage 1: Acute severe phase (1-4 days)

– Narrowed lumen with irregular contour/ulcerations
– May have signs of perforation (extraluminal gas and contrast medium)
image Stage 2: Ulcer granulation phase (5-28 days)

– More defined ulcers; spasm
image Stage 3: Cicatrization and scarring (3-4 weeks)

– Strictures, usually long and smooth, can be  irregular and eccentric
– Sacculations, pseudodiverticula
– Stomach is often pulled up into chest by esophageal shortening
• CT Findings

image Acute phase

– Target sign: Mucosal enhancement and hypodense submucosa
– Esophageal perforation: Pneumomediastinum, pleural effusion
image Chronic phase: Luminal irregularity and narrowing

– Similar findings in stomach ± duodenum

CLINICAL ISSUES

• Complications: Perforation, mediastinitis, peritonitis, fistulas, shock
image
(Left) Graphic shows a long stricture of the esophagus and ulceration of the mucosa. The stomach is pulled up into the chest due to foreshortening of the esophagus by fibrosis &/or spasm.

image
(Right) Spot film from a barium esophagram in a patient with chronic stricture image from caustic ingestion shows a shortened and strictured esophagus, with the proximal stomach image pulled into the chest. This stricture has been treated repeatedly by balloon dilation, and the patient has not required surgery.
image
(Left) Axial CECT of a patient 2 hours after caustic ingestion shows marked thickening of the esophageal wall image and bilateral aspiration pneumonitis.

image
(Right) Axial CECT in the same patient shows marked thickening of the gastric wall with submucosal edema image, indicating corrosive gastritis.

TERMINOLOGY

Synonyms

• Corrosive esophagitis

Definitions

• Esophageal injury due to ingestion of strong alkali or acid

IMAGING

General Features

• Best diagnostic clue

image Long stricture ± diffuse ulceration of esophagus
• Location

image  
• Morphology

image  

Radiographic Findings

• Chest PA and lateral views (acute)

image Dilated, gas-filled esophagus
image May show aspiration pneumonitis
image Esophageal perforation

– Pneumomediastinum, pleural effusion
• Fluoroscopic: Esophagram

image Stage 1: Acute severe phase (1-4 days)

– Narrowed lumen with irregular contour/ulcerations
– May have signs of perforation

image Gas, fluid, or oral contrast medium in mediastinum ± pleural space
image Stage 2: Ulcer granulation phase (5-28 days)

– More defined ulcers; spasm
image Stage 3: Cicatrization and scarring (3-4 weeks)

– Strictures, usually long and smooth, can be  irregular and eccentric
– Sacculations, pseudodiverticula
– Stomach is often pulled up into chest by esophageal shortening

CT Findings

• Circumferential esophageal wall thickening (≥ 5 mm)
• Acute phase

image Target sign: Mucosal enhancement and hypodense submucosa
image Esophageal perforation: Pneumomediastinum, pleural effusion
• Chronic phase: Luminal irregularity and narrowing
• Similar findings in stomach ± duodenum

Imaging Recommendations

• Best imaging tool

image CECT for acute injury; barium esophagram for chronic
image Acute phase esophagram (if needed): Water-soluble, nonionic contrast agent

DIFFERENTIAL DIAGNOSIS

Radiation Esophagitis

• Stricture: Usually smooth, tapered narrowing within area of radiation

Reflux Esophagitis

• Short, distal esophageal stricture ± hiatal hernia and reflux

Esophageal Carcinoma

• Asymmetric contour with abrupt proximal borders of narrowed distal segment
• Patients with caustic injury may develop carcinoma later

Iatrogenic Injury: Feeding Tubes

• Usually seen in patients with longstanding intubation
• Long, smooth stricture of esophagus seen

PATHOLOGY

General Features

• Etiology

image Strong alkaline agents: Liquid lye (sodium hydroxide)

– Most common agent in USA; used as liquid drain cleaner
image Strong acids: Hydrochloric, sulfuric, acetic, oxalic, carbolic/nitric
image Ammonium chloride, phenols, silver nitrate, formaldehyde
• Associated abnormalities

image Associated gastroduodenal injuries seen in most on CT, fewer on esophagram and upper GI series

Staging, Grading, & Classification

•  

Gross Pathologic & Surgical Features

•  

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Pain, drooling, vomiting, hematemesis
image Odynophagia, fever, shock
• Clinical profile

image Patient with history of caustic ingestion and painful swallowing

Demographics

• Age

image Adults: Usually intentional (suicide attempt)
image Children: Accidental
• Epidemiology

image Most common cause of caustic esophagitis in USA: Ingestion of liquid lye drain cleaner

Natural History & Prognosis

• Complications

image Perforation, mediastinitis, peritonitis, fistulas, shock
image Increased risk of cancer after 20-40 years
• Prognosis

image Acute mild phase with early treatment: Good
image Acute severe and chronic phases: Poor

Treatment

• Medical

image Steroids, antibiotics, parenteral feedings
image Esophageal bougienage for strictures
• Surgical

image Esophageal (± gastric) bypass with jejunal or colonic interposition

– Usually anastomosed to Roux limb in upper abdomen

DIAGNOSTIC CHECKLIST

Consider

•  

Image Interpretation Pearls

• History of caustic ingestion and imaging findings are usually diagnostic
image
Spot film from a barium esophagram in this patient with chronic caustic stricture shows a long, smooth stricture image of the distal half of the esophagus.

image
Esophagram in a 24-year-old woman with subacute caustic esophagitis (lye) shows a stricture image and shortening of the distal esophagus with the stomach image pulled into the lower chest.
image
Axial CECT in the same patient shows similar submucosal edema of the stomach image. The patient subsequently developed esophageal perforation, respiratory failure, and sepsis before dying.
image
Axial CECT in a 67-year-old woman with acute caustic esophagitis (lye) shows nasogastric and endotracheal tubes in place along with acute airspace consolidation. The wall of the esophagus is massively thickened and edematous image.
image
Lateral esophagram hours after caustic ingestion shows complete obstruction of the mid distal esophagus.
image
Esophagram one week following lye ingestion shows a long stricture with deep ulcerations image.
image
Esophagram one month after caustic ingestion shows a short esophagus, long stricture image, and a hiatal hernia image. Reflux esophagitis may have a similar appearance.

SELECTED REFERENCES

1. Youn, BJ, et al. Balloon dilatation for corrosive esophageal strictures in children: radiologic and clinical outcomes. Korean J Radiol. 2010; 11(2):203–210.

 

Doo, EY, et al. Oesophageal strictures caused by the ingestion of corrosive agents: effectiveness of balloon dilatation in children. Clin Radiol. 2009; 64(3):265–271.

Abaskharoun, RD, et al. Nonsurgical management of severe esophageal and gastric injury following alkali ingestion. Can J Gastroenterol. 2007; 21(11):757–760.

Berkovich, GY, et al. CT findings in patients with esophagitis. AJR Am J Roentgenol. 2000; 175(5):1431–1434.

Levine, MS. Radiology of esophagitis: a pattern approach. Radiology. 1991; 179(1):1–7.

Levine, MS, et al. Update on esophageal radiology. AJR Am J Roentgenol. 1990; 155(5):933–941.

Goldman, LP, et al. Corrosive substance ingestion: a review. Am J Gastroenterol. 1984; 79(2):85–90.

Creteur, V, et al. Drug-induced esophagitis detected by double-contrast radiography. Radiology. 1983; 147(2):365–368.

Graziani, L, et al. Reflux esophagitis: radiologic-endoscopic correlation in 39 symptomatic cases. Gastrointest Radiol. 1983; 8(1):1–6.

[/level-membership-for-radiology-category][not-level-membership-for-radiology-category] Causes mild to severe injury to upper GI tract

– Esophagus > stomach > duodenum

IMAGING

• Imaging evaluation: CECT for acute injury; barium esophagram for chronic

image If esophagram done in acute phase, use nonionic, water-soluble agent (e.g., Omnipaque)
• Fluoroscopic: Esophagram

image Stage 1: Acute severe phase (1-4 days)

– Narrowed lumen with irregular contour/ulcerations
– May have signs of perforation (extraluminal gas and contrast medium)
image Stage 2: Ulcer granulation phase (5-28 days)

– More defined ulcers; spasm
image Stage 3: Cicatrization and scarring (3-4 weeks)

– Strictures, usually long and smooth, can be  irregular and eccentric
– Sacculations, pseudodiverticula
– Stomach is often pulled up into chest by esophageal shortening
• CT Findings

image Acute phase

– Target sign: Mucosal enhancement and hypodense submucosa
– Esophageal perforation: Pneumomediastinum, pleural effusion
image Chronic phase: Luminal irregularity and narrowing

– Similar findings in stomach ± duodenum

CLINICAL ISSUES

• Complications: Perforation, mediastinitis, peritonitis, fistulas, shock
image
(Left) Graphic shows a long stricture of the esophagus and ulceration of the mucosa. The stomach is pulled up into the chest due to foreshortening of the esophagus by fibrosis &/or spasm.

image
(Right) Spot film from a barium esophagram in a patient with chronic stricture image from caustic ingestion shows a shortened and strictured esophagus, with the proximal stomach image pulled into the chest. This stricture has been treated repeatedly by balloon dilation, and the patient has not required surgery.
image
(Left) Axial CECT of a patient 2 hours after caustic ingestion shows marked thickening of the esophageal wall image and bilateral aspiration pneumonitis.

image
(Right) Axial CECT in the same patient shows marked thickening of the gastric wall with submucosal edema image, indicating corrosive gastritis.

TERMINOLOGY

Synonyms

• Corrosive esophagitis

Definitions

• Esophageal injury due to ingestion of strong alkali or acid

IMAGING

General Features

• Best diagnostic clue

image Long stricture ± diffuse ulceration of esophagus
• Location

image  
• Morphology

image  

Radiographic Findings

• Chest PA and lateral views (acute)

image Dilated, gas-filled esophagus
image May show aspiration pneumonitis
image Esophageal perforation

– Pneumomediastinum, pleural effusion
• Fluoroscopic: Esophagram

image Stage 1: Acute severe phase (1-4 days)

– 

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