Reflux Esophagitis

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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Probably result and not cause of reflux

• Peptic stricture (1-4 cm length): Concentric, smooth, tapered narrowing of distal esophagus

TOP DIFFERENTIAL DIAGNOSES

• Scleroderma

• Drug-induced esophagitis

• Viral esophagitis

• Candida esophagitis

• Caustic esophagitis

PATHOLOGY

• Lower esophageal sphincter (LES): Decreased tone leads to increased reflux

• Hydrochloric acid (HCl) and pepsin: Synergistic effect

CLINICAL ISSUES

• 15-20% of Americans have heartburn due to reflux

Prevalence of GERD has increased sharply with obesity epidemic

• Symptoms: Heartburn, regurgitation, angina-like pain

Dysphagia, odynophagia

• Confirmatory testing: Manometric/ambulatory pH-monitoring techniques

Endoscopy, biopsy, and histological studies

(Left) Graphic shows a small type 1 (sliding) hiatal hernia, associated with foreshortening of the esophagus, ulceration of the mucosa, and tapered stricture of the distal esophagus.

(Right) Film from an air-contrast esophagram demonstrates a small hiatal hernia , foreshortening of the esophagus, and a mild stricture at the gastroesophageal (GE) junction. There are several subtle esophageal ulcers at the level of the stricture.

(Right) Film from an air-contrast esophagram demonstrates a small hiatal hernia , foreshortening of the esophagus, and a mild stricture at the gastroesophageal (GE) junction. There are several subtle esophageal ulcers at the level of the stricture.

(Left) Spot film from a barium esophagram shows a small hiatal hernia. Note the gastric folds extending above the diaphragm. The esophagus appears shortened, presumably due to spasm of the longitudinal muscles within its wall. A stricture is present at the GE junction, and persistent collections of barium indicate mucosal ulceration .

(Left) Spot film from a barium esophagram shows a small hiatal hernia. Note the gastric folds extending above the diaphragm. The esophagus appears shortened, presumably due to spasm of the longitudinal muscles within its wall. A stricture is present at the GE junction, and persistent collections of barium indicate mucosal ulceration .

(Right) An esophagram in the same patient shows that a 13 mm barium-impregnated pill cannot pass through the peptic stricture.

(Right) An esophagram in the same patient shows that a 13 mm barium-impregnated pill cannot pass through the peptic stricture.

TERMINOLOGY

Definitions

• Inflammation of esophageal mucosa due to gastroesophageal (GE) reflux

IMAGING

General Features

• Best diagnostic clue

Irregular ulcerated mucosa of distal esophagus on barium esophagram

Most common sign

– Finely nodular or granular appearance with poorly defined radiolucencies that fade peripherally due to edema and inflammation of mucosa

• Location

Distal 1/3 or 1/2 of esophagus

• Other general features

Complication of gastroesophageal reflux disease (GERD)

Based on onset, classified clinically and radiologically

– Acute or chronic reflux esophagitis

Severity of reflux esophagitis

– Depends on intrinsic resistance of mucosa

Radiographic Findings

• Double-contrast esophagography

Acute reflux esophagitis

– Decreased primary wave of peristalsis with increased tertiary contractions

– Mucosal nodularity

Fine nodular, granular, or discrete plaque-like defects (pseudomembranes)

– Foreshortening of esophagus

Due to spasm of longitudinal muscles

Not necessarily fibrotic stricture

– Ulcers

Single or multiple tiny collections of barium with surrounding mounds of edematous mucosa

Radiating and puckering of folds

Usually at or near GE junction

– Thickened vertical or transverse folds (> 3 mm)

Chronic or advanced reflux esophagitis

– Decreased distal esophageal distensibility with irregular, serrated contour (due to ulceration/edema/spasm)

Due to ulceration, edema, or spasm

– Sacculations and pseudodiverticula may be seen

– Peptic stricture (1-4 cm length/0.2-2 cm width)

Concentric smooth-tapered narrowing of distal esophagus with proximal (upstream) dilatation

Some may resemble Schatzki rings, but are generally thicker

– “Stepladder” appearance

Transverse folds due to vertical scarring

– Hiatal hernia

Seen in > 95% of patients with peptic stricture

Probably result and not cause of reflux

– Inflammatory pseudopolyp

Single enlarged fold arising at GE junction

No malignant potential but may need endoscopy with biopsy to rule out cancer

CT Findings

• CECT

Target sign: Combination of esophageal mucosal enhancement and surrounding hypodense submucosa

Hiatal hernia usually evident

Imaging Recommendations

• Videofluoroscopic double-contrast esophagram

En face and profile views

90% sensitivity

• Biphasic examination with upright double-contrast and prone single-contrast views of esophagus

• Include provocative maneuvers to test for reflux

Not always evident on esophagram in spite of other evidence of reflux esophagitis

Perform with fluoroscopy table horizontal

Roll patient back and forth

DIFFERENTIAL DIAGNOSIS

Scleroderma

• Also results in decreased peristalsis, distal esophageal stricture

• Diminished peristalsis is earlier and more prominent feature in scleroderma

• Correlation with skin changes of scleroderma usually allows diagnosis

Drug-Induced Esophagitis

• Usually abrupt onset of odynophagia

• Ulceration &/or stricture in upper esophagus at sites of narrowing

e.g., at aortic arch indentation

• Usually not associated with hiatal hernia or foreshortened esophagus

Viral Esophagitis

• Usually in immunocompromised patients

• Small or large shallow ulcers on background of normal mucosa

• Usually no hiatal hernia, reflux, or stricture

Candida

• Usually in immunocompromised patients

• Usually more raised plaques than ulceration

• No associated hiatal hernia, reflux, or stricture

Caustic Esophagitis

• History of caustic ingestion is key

• Strictures are usually more severe and longer than with peptic strictures

PATHOLOGY

General Features

• Etiology

GERD

– Irritants: Drugs, alcohol, smoking

– Obesity and tight clothing provoke reflux

Pathogenesis of reflux esophagitis

– Lower esophageal sphincter (LES)

Decreased tone leads to increased reflux

– Hydrochloric acid (HCl) and pepsin

Synergistic effect producing more injury than HCl alone

Staging, Grading, & Classification

• Double-contrast esophagrams can classify risk for Barrett esophagus

Low risk: No structural abnormalities (regardless of presence/absence of reflux or hiatal hernia)

– Can treat empirically without endoscopy

Moderate risk: Esophagitis or short peptic strictures in distal esophagus

– Endoscopy based on severity of symptoms, age, and health of patient

High risk: Midesophageal, long (> 3 cm) stricture, ulcer, or reticular pattern of mucosa

– Endoscopy with biopsy for possible Barrett esophagus

Gross Pathologic & Surgical Features

• Hyperemia, inflammation

• Superficial ulceration, necrosis, white plaques, strictures

Microscopic Features

• Thinning of stratified squamous epithelium

• Superficial necrosis and ulceration

• Basal cell hyperplasia, edema

• Submucosal polymorphonuclear leukocyte infiltrate

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

Heartburn, regurgitation, angina-like pain

Dysphagia, odynophagia

• Lab data

Manometric/ambulatory pH-monitoring techniques

– Reveal increased presence of acid in esophagus

– Often decreased esophageal peristalsis

• Diagnosis

Endoscopy, biopsy, and histological studies

Demographics

• Age

Usually middle-aged adults

• Gender

M = F

• Epidemiology

15-20% of Americans have heartburn due to reflux

Prevalence of GERD has increased sharply with obesity epidemic

Natural History & Prognosis

• Some degree of GE reflux is considered normal

GERD implies damage to esophagus or symptoms that interfere with quality of life

• Complications

Ulceration, bleeding, stenosis

Sliding hiatal hernia due to

– Inflammation of mucosa

– Longitudinal esophageal shortening (muscle spasm, not fibrosis)

– Disruption of ligaments surrounding GE junction

Pulls gastric fundus into thorax

Barrett esophagus/adenocarcinoma

• Prognosis

Acute reflux esophagitis: Good

Chronic reflux esophagitis: Poor without treatment

Treatment

• H2 receptor antagonists, proton-pump inhibitors

• Antacids, cessation of irritants

• Weight loss for obese patients

• Metoclopramide: Increases LES tone

• Surgery (fundoplication)

DIAGNOSTIC CHECKLIST

Consider

• Differentiate from other types of esophagitis

Image Interpretation Pearls

• Smooth, tapered, concentric narrowing in distal esophagus above hiatal hernia is diagnostic of peptic stricture due to reflux esophagitis

(Left) Supine spot film from a barium esophagram demonstrates free and repeated reflux and a stricture at the GE junction. Tertiary contractions and diminished primary peristalsis were also noted during fluoroscopy.

(Left) Supine spot film from a barium esophagram demonstrates free and repeated reflux and a stricture at the GE junction. Tertiary contractions and diminished primary peristalsis were also noted during fluoroscopy.

(Right) The stricture at the GE junction is again noted on this prone film from the esophagram. Tertiary contractions are also seen.

(Right) The stricture at the GE junction is again noted on this prone film from the esophagram. Tertiary contractions are also seen.

(Left) Two views from a barium esophagram demonstrate a small hiatal hernia and a stricture at the GE junction. Endoscopic biopsy of the strictured lesion was performed to rule out Barrett metaplasia.

(Left) Two views from a barium esophagram demonstrate a small hiatal hernia and a stricture at the GE junction. Endoscopic biopsy of the strictured lesion was performed to rule out Barrett metaplasia.

(Right) Following biopsy, a repeat esophagram (with water-soluble contrast medium) shows a contained leak from the biopsy site. Leaks such as this can also result from balloon dilation of strictures.

(Right) Following biopsy, a repeat esophagram (with water-soluble contrast medium) shows a contained leak from the biopsy site. Leaks such as this can also result from balloon dilation of strictures.

(Left) Prone film from an esophagram shows a tight stricture just above the GE junction with upstream dilation of the esophagus. The herniated stomach is pulled taut as a result of the foreshortening of the esophagus, a common and important sign of reflux esophagitis.

(Left) Prone film from an esophagram shows a tight stricture just above the GE junction with upstream dilation of the esophagus. The herniated stomach is pulled taut as a result of the foreshortening of the esophagus, a common and important sign of reflux esophagitis.

(Right) Endoscopic image of the distal esophagus in the same patient demonstrates pseudomembranes , mucosal ulceration , nodularity, and stricture.

(Right) Endoscopic image of the distal esophagus in the same patient demonstrates pseudomembranes , mucosal ulceration , nodularity, and stricture.

Double-contrast esophagram shows a small hiatal hernia with shallow round and linear esophageal ulcers.

Double-contrast esophagram shows a small hiatal hernia with shallow round and linear esophageal ulcers.

Double-contrast esophagram shows a small hiatal hernia, distal stricture, and nodular, granular esophageal mucosa that simulates Barrett esophagus.

Esophagram shows a sliding hiatal hernia and multiple esophageal ulcers .

Esophagram shows a sliding hiatal hernia and multiple esophageal ulcers .

Esophagram shows thickened, irregular, longitudinal folds and a large ulcer .

Esophagram shows thickened, irregular, longitudinal folds and a large ulcer .

Esophagram shows a hiatal hernia, stricture at the GE junction, and obstructed passage of food (walnuts) within lumen .

Esophagram shows a hiatal hernia, stricture at the GE junction, and obstructed passage of food (walnuts) within lumen .

Diagnostic Imaging_ Gastrointes - Michael P Federle