Food-stimulated gastro-oesophageal reflux demonstrated by barium examination

A prospective investigation on gastro-oesophageal reflux in 97 consecutive patients has been carried out by means of a barium examination employing the conventional method and after food stimulation. Gastro-oesophageal reflux was observed in 38 patients with and 15 patients without oesophageal symptoms. Gastro-oesophageal reflux was induced by two mechanisms, an active component after food stimulation and a passive component after the conventional method including respiratory manoeuvres and leg raising. In 32 patients, only the active component could be demonstrated and in 6 patients only the passive component. In the remaining 15 patients both active and passive components occurred. The clinical significance of the active and passive components in gastro-oesophageal reflux needs further investigation.

Radiologic diagnosis of Barrett's esophagus: critical analysis of 65 cases

A recent increase in the number of Barrett's esophagus being diagnosed is probably directly related to a proportional increase in endoscopic biopsies of the esophagus and awareness of premalignant potential of Barrett's mucosa. While the endoscopist can detect Barrett's mucosa with fair degree of accuracy, the radiologic diagnosis of Barrett's esophagus still remains a diagnostic challenge despite several well established radiologic features. We reviewed 65 patients with pathologically proven Barrett's esophagus and found a wide spectrum of radiologic features. These include hiatus hernia in 49, gastroesophageal reflux in 38, strictures in 32, esophagitis in 20, and characteristic Barrett's ulcer in 12. In addition ascending or migrating strictures were found in 10, mucosal pattern simulating areae gastricae in 5, cricopharyngeal dysfunction in 4, and fixed spiral folds in 3 patients. This constellation of radiologic features, some of which have not been previously emphasized, should further assist radiologists in suggesting the diagnosis of Barrett's esophagus.

Multiphasic examination of the esophagogastric region for strictures, rings, and hiatal hernia: evaluation of the individual techniques

Three hundred multiphasic examinations of the lower esophagus and esophagogastric region were assessed to determine the individual sensitivities of the full-column, mucosal relief, and double-contrast techniques in the detection of common structural abnormalities, such as hiatal hernia, lower esophageal rings, and peptic strictures. In 159 patients, there were 211 structural abnormalities including 153 hiatal hernias, 35 mucosal rings, 20 peptic strictures, and 3 esophageal diverticula. The overall sensitivity of the full-column technique in detecting these abnormalities was 100% compared to 52% and 34% for the mucosal relief and double-contrast techniques, respectively. We conclude that the prone full-column technique must be incorporated into any examination of the esophagogastric region if these common abnormalities are to be demonstrated reliably.

Radiological assessment of dysphagia with endoscopic correlation

Four hundred fifty consecutive patients with dysphagia were evaluated radiologically over a 14-month period; 127 of these (28.2%) were also examined endoscopically. The most common abnormality seen was dysmotility (34%), followed by hiatal hernia, benign stricture, and esophagitis. Correlation with endoscopy was generally good. Radiologic study demonstrated all cases of esophageal malignancy; radiologic/endoscopic correlation was also strong in patients with moderate or severe esophagitis, though the radiologist had some difficulty detecting mild inflammation. Endoscopy failed to demonstrate some benign strictures. Radiologic study was relatively accurate in detecting significant organic disease; most motility disorders were not detected by endoscopy. For these reasons, as well as lower cost, increased convenience, and patient comfort, radiologic assessment is recommended as the primary method of evaluating patients with dysphagia.

[Changes in the esophageal wall following sclerotherapy of varices--roentgen morphology and therapy]

Endoscopic sclerotherapy of esophageal varices is a widely used procedure. It reduces the frequency of rebleeding and improves the survival of cirrhotics with portal hypertension. The intravariceal or paravariceal injection of sclerosing agents causes structural changes of the esophageal wall recognisable radiologically. Stricture is a late complication which occurs in about 10 percent. In residual dysphagia balloon dilatation is recommended.

[Transluminal esophagoplasty (TE)]

The authors analyze their experience on 9 cases of esophageal stenosis dilated by "Grüntzig" type balloon catheter under fluoroscopic examination (transluminal esophagus plastica: TE). This procedure also allows dilatation of severe narrowing, offering distinct advantages represented by: low risk, easy performance, good tolerance, reduction or disappearance of disphagia. Esophageal perforation is possible, though it never appeared in author's experience.

Complications of colonic interposition

The roentgenographic and surgical experience with 44 patients treated with colon interpositions was examined. Forty-two of these patients had carcinoma of the esophagus. Staged therapy consisted of mediastinal irradiation, colonic interposition, and total esophagectomy. The more common complications related to luminal patency and conduit integrity. A total of 29.5% developed anastomotic narrowing due to postoperative edema. Anastomotic leaks arose only at the proximal anastomosis and had an incidence rate of 31.8%. Thirty-four percent had fistulous tracts originating in the reconstructed upper gastrointestinal tract. In eighty percent of the patients with leaks or fistulae, their defects healed spontaneously or with simple drainage. Strictures were encountered in 59.1%, and there were 5 instances of colonic graft ischemia. The mortality directly related to surgery was 6.8%. Ischemia, particularly at the cervical anastomosis, is probably the most common cause of complications. Radiographic evaluation is recommended using a single contrast barium examination unless gross extravasation is expected.

Transverse esophageal folds: association with corrosive injury

Two cases are presented in which transverse esophageal folds were observed in children following ingestion of corrosive material. Strictures developed at the sites that initially manifested this serrated mucosal appearance. These findings lend additional credence to the concept that transverse folds, reflecting contractions of the muscularis mucosae, represent a pattern of pathologic motility rather than merely a variant of normal mucosal anatomy.

[Effectiveness of the conservative treatment of patients with cicatricial stricture of the esophagus of different durations]

High efficiency and safety of bougieurage of the oesophagus with a metallic cord is shown. Conservative treatment of the postburn narrowing of the oesophagus associated with preventive bougieurage proved to be highly effective in patients admitted to the hospital with an early stage of the disease. There were no lethal outcomes. The continuous purposeful complex treatment of patients with cicatrical narrowing of the oesophagus is recommended during 1,5-2 years after burn.

Congenital oesophageal stenosis

Clinical and radiographic observations in 34 infants and children with congenital stenosis of the oesophagus are reported. (1) Congenital stenosis of the oesophagus occurs more frequently than the previous literature suggests. (2) A congenital stenosis most commonly affects the lower oesophagus at the junction of its middle and distal thirds. (3) High oesophageal stenosis is less common, usually producing respiratory distress. Low oesophageal stenosis is more frequent, usually producing vomiting and oesophageal obstruction at the time the patients begin eating solid foods. (4) Oesophageal stenosis persists into adult life although its clinical course is benign. (5) An infant who vomits undigested food should have an oesophagram for evaluation of possible congenital oesophageal stenosis. (6) A child who impacts a foreign body in the oesophagus, particularly in the distal half of the oesophagus, should have a follow-up oesophagram after removal of the foreign body to assess the possibility of congenital oesophageal stenosis.

Esophageal involvement in Zollinger-Ellison syndrome

Review of 18 patients with Zollinger-Ellison syndrome (ZES) revealed pathologic evidence of esophageal disease in six (33%). Four patients manifested varying degrees of esophagitis, ranging from mild to severe ulcerations and stricture formation. In two patients, symptomatic Barrett esophagus was detected 4 and 6 months after total gastrectomy, respectively. It is postulated that due to longstanding gastroesophageal reflux, Barrett esophagus was present in these two patients before total gastrectomy, and esophageal symptoms became only apparent after more compelling symptoms of gastric peptic ulceration were controlled by definitive surgery. Esophageal involvement occurs with greater frequency in patients with ZES; the previously held notion that esophageal disease due to gastroesophageal reflux in ZES patients is uncommon is contrary to the results of this study. It is recommended that all patients with ZES irrespective of symptom-complex should be routinely evaluated for the presence or absence of esophageal disease because of its important bearings on adequate surgical management.

Endoscopic sensitivity in the detection of esophageal strictures

Endoscopy was compared in 90 patients with a radiographic diagnosis of peptic esophageal stricture. Retrospectively, 78 strictures were classified as valid diagnoses giving a positive radiographic predictive value of 87%. Endoscopy diagnosed 74 (95%) of the 78 peptic strictures, detecting all 45 strictures under 10 mm in caliber, but failing to detect four (12%) of 33 broader strictures. Nine (75%) of the 12 radiographic false-positive errors involved misinterpretation of muscular or mucosal rings of the lower esophagus. We conclude that endoscopy and radiology are equally effective and complementary methods for evaluating patients with suspected peptic stricture.

[Clinical and radiological diagnosis considerations on 2 cases of achalasia]

Two cases of achalasia of the lower third of the oesophagus are presented. Leucoplakia was encountered in one of the cases. The clinical, aetiopathogenic and x-ray diagnostic aspects of achalasia are described in relation to the possibility that it may be associated with neoplasia or pre-cancerous alterations. In both the above cases, early dysphagia was encountered.

The emergency management of caustic ingestions

Controversial therapeutic issues in patients with caustic ingestions concern the reliability of symptoms and signs in predicting esophageal injury, the appropriate use of endoscopy in evaluating esophageal damage, and the use of steroids in preventing late strictures. The conclusions of this review are: The majority of pediatric caustic ingestions involve a "lick and taste" whereas adolescents and adults often ingest substantial quantities. Oral burns and dysphagia are sensitive predictors of esophageal injury; however, esophageal injury may occur in the absence of the findings. Household bleach and nonphosphate detergents represent a low risk of injury whereas button batteries greater than 20 mm in diameter and Clinitest tablets represent high risk. Endoscopy should be an elective rather than emergency procedure and should be undertaken in all symptomatic patients, and in asymptomatic patients when history indicates substantial ingestion. Steroid therapy should be considered only for patients who have deep or circumferential esophageal burns.

Steerable catheter fluoroscopy in total esophageal obstruction

We describe a patient with malignant esophageal obstruction in whom the lumen of the esophagus could not be identified at endoscopy. Contrast fluoroscopy using a steerable catheter allowed safe placement of a nasoduodenal feeding tube.

Esophageal stenosis: treatment with balloon catheters

We have performed 84 balloon dilatations in 40 patients who had esophageal strictures. Of these patients, 31 who had benign diseases improved, and the procedure proved to be safe, reliable, and easy to perform; in 77% of these patients, only one or two dilatations were necessary. In 10 patients who had previously undergone treatment with bougienage, the symptom-free interval of 9.3 months following balloon dilatation is four times longer than that experienced following bougienage. In patients who have malignant disease, though the symptom-free intervals are short, the procedure can be repeated easily and is accepted well by patients so that palliation can be achieved. Since only readily controlled transverse forces act in the balloon therapy, rupture is virtually eliminated, while the use of a flexible angiographic guidewire to traverse the strictures practically excludes perforation. Balloon dilatation offers distinct advantages compared with bougienage for the treatment of esophageal strictures.