Diagnostic imaging in mediastinal thyroid tumor

Various diagnostic imagings in nine patients with mediastinal goiters were presented. The clinical manifestations of these patients were various, from totally asymptomatic to severe dyspnea. Six of the nine patients underwent surgical intervention, three were follicular adenomas and three were nodular goiters. A chest radiograph (positive in seven out of nine patients) provided the most valuable initial localization of a goiter mass to the anterior, middle, or posterior compartment. Esophagograms (performed in four patients) showed compression of esophagus by the mediastinal mass. I-131 scintigraphy (performed in seven patients) was capable of detection of functional (in three patients) vs nonfunctional status of thyroid status (in four patients). Angiography (performed in five patients), characterized by anatomic continuity with cervical thyroid gland, calcifications, well-defined border of masses and/or contrast enhancement, offered important roles to direct a diagnosis of intrathoracic goiter. The computed tomography becomes increasingly important because all mediastinal goiters are not radioiodine avid.

Cold barium suspensions in the clinical evaluation of the esophagus

Cold barium suspensions have been shown to reduce primary esophageal peristalsis and improve distention of the lower esophagus and esophagogastric region. Cold barium is a useful adjunct to the standard radiographic examination when adequate distention of the esophagus has not initially been achieved. It is particularly applicable to evaluation of reflux esophagitis and esophageal strictures and rings.

Severe esophageal strictures: indications for balloon catheter dilatation

Bougienage of esophageal strictures is a traditional method of therapy for patients who present with a stricture sufficiently large to permit passage of a mercury-weighted rubber bougie. However, when the residual lumen is smaller than 12 mm diameter, bougie dilatation acquires a prohibitively high risk of esophageal perforation. Twenty patients who had severe esophageal strictures have undergone surgical repair or Eder-Puestow dilatation assisted by guidewire. Fluoroscopic balloon catheter dilatation obviated surgery and allowed subsequent standard bougienage both in hospital and at home performed by the patient. We discuss indications, technique, results, and complications.

Esophageal strictures in children: treatment by serial balloon catheter dilatation

Grüntzig balloon catheters were used to dilate ten esophageal strictures in eight infants and children. Five infants who had anastomotic strictures following esophageal atresia repair gained complete resolution of their strictures, usually after one or two dilatations. Three older children who had strictures following esophageal re-operation or reconstruction required longer courses of dilatations to achieve consistent esophageal patency. The technique failed in two chronic strictures of two and one-half and nine years' duration. Balloon catheter dilatation, begun in the early postoperative period, is a safe, effective method for dilating esophageal strictures.

Surgical treatment of congenital esophageal atresia

Severe gastroesophageal reflux was found in 9 out of 18 infants with congenital esophageal atresia studied radiographically shortly after primary reconstruction. Pulmonary complications were recorded in 18 out of 32 similar patients in long-term follow-up. Strictures at the level of the anastomosis were detectable in 18 out of 32 patients; eleven strictures were severe enough to require dilation or surgical revision. These findings suggest that early evaluation for gastroesophageal reflux may be useful in management of infants with esophageal atresia. The precautions taken preoperatively to prevent complications of gastroesophageal reflux should be continued in the postoperative interval unless a competent lower esophageal sphincter is demonstrated.

Esophageal radionuclide transit tests. Potential false-positive results

Esophageal radionuclide transit testing is a sensitive technique for assessing esophageal clearance. Experience with the technique in 150 patients has led to an awareness of several pitfalls which might lead to false-positive results. Potential problems may be grouped into technical factors, clinical aspects, and misinterpretations. Examples of these are presented and techniques to minimize such problems are discussed.

Proximal strictures of the esophagus

Proximal esophageal strictures have received little attention in the gastroenterologic literature. Of 238 esophageal strictures endoscopically recognized at the Phoenix V.A. Medical Center over the past 7 1/2 years, 20 lesions were in the upper or mid and upper esophagus (8.4%). Sixty percent of these lesions were benign, mostly as the result of total laryngectomy and postoperative irradiation. In contrast to more distal lesions, proximal esophageal strictures often required initial rigid bougienage with Peustow dilators and frequent dilation thereafter.

Candidiasis-induced esophageal strictures

Candidiasis of the esophagus progressing to hard fibrosed strictures of the esophagus in 2 patients is reported. Both patients had deficient immunologic systems and received extended courses of broad-spectrum antibiotic therapy for control of sepsis. The strictures were progressive despite adequate antifungal therapy and several attempts at dilatations and necessitated visceral esophageal substitution as definitive surgical therapy.

Fixed transverse folds in the esophagus: a sign of reflux esophagitis

Scarring from reflux esophagitis is usually manifested by circumferential stricture formation. This article reports 17 cases in which double-contrast esophagography demonstrated fixed transverse folds in the esophagus, presumably secondary to longitudinal scarring from reflux esophagitis. In all cases, pooling of contrast material between the folds produced a series of horizontal, relatively parallel collections of barium in a "stepladder" arrangement. This appearance should be distinguished from linear ulcerations, tertiary esophageal contractions, and the delicate transverse striations that are occasionally observed as a transient phenomenon on the double-contrast examination.

[Intramural pseudodiverticulosis of the esophagus]

Description of a case of rare endoluminal pseudodiverticulosis--only 49 cases have been reported to date--presenting the characteristic x-ray morphology and clinical course. Aetiological factors and the pathogenesis of the dilatation of the submucous oesophageal gland as a morphological substrate of pseudodiverticulosis are discussed.

Barrett's esophagus: radiological and clinical considerations

We reviewed the radiographic findings in thirty patients with columnar-lined (Barrett's) esophageal mucosa. Gastroesophageal reflux was observed in 90%, hiatal hernia in 83%, stricture in 80% and esophageal ulceration in 33%. Superficial nodular mucosal changes were detected on 50% of the air contrast esophagrams. Prominence of this pattern may be associated with dysplastic or early malignant change. In addition, four conditions associated with secondary lower esophageal sphincter incompetence were identified in our patient group. These were scleroderma, previous myotomy for achalasia, previous gastric surgery and long-term indwelling nasogastric tubes.

Balloon catheter dilatation of malignant esophageal stricture

In tight esophageal strictures, the surgical methods of dilatation occasionally become difficult or impossible. This case report illustrates the use of a guidewire and balloon catheter in traversing and dilating a narrowed esophageal lumen under fluoroscopic control. The channel of the stricture was off-center and so did not permit endoscopic placement for dilatation. This technique enabled subsequent passage of an Eder-Puestow guidewire with redilatation and insertion of an Atkinson feeding tube.

Multiple benign strictures of the oesophagus in the paediatric age-group--modified technique of antegrade dilatation

Accidental ingestion of strong acids and alkalines still remains the commonest cause of benign strictures of the oesophagus in our country, particularly in children from the poor socio-economic strata, who are left alone to fend for themselves. Once the stricture is well-formed, repeated antegrade dilatations are required in order to dilate the lumen gradually. The procedure is done with the utmost care and gentleness in order to avoid rupture of the cicatricial wall of the oesophagus. The present series consisting of 10 cases of multiple, benign, mostly permeable, strictures of the oesophagus were successfully managed with Jackson's antegrade dilatation technique. During one of the dilatation sessions we observed that instead of pushing the bougie gently, it seemed to be sucked down entirely on its own, a few millimeters at a time (described in case 3) and traversed the entire stricture. This procedure appears safer for the patient and has now become routine with us. There was no mortality in our series. In all, a total of 168 dilatations have been done. The average lumen achieved in all our cases was 6 mm (Jackson's bougie No. 18) which was well maintained in all our cases on a permanent basis.

Colonic interposition: radiographic evaluation

This report reviews the clinical and radiographic features of 40 patients who underwent visceral esophageal substitution with colon for benign or malignant lesions of the esophagus. The incidence and radiographic identification of complications are discussed. All patients were routinely examined with barium esophagrams on postoperative day 10. If an anastomotic leak was suspected clinically before this time, studies were performed using water-soluble iodinated contrast material. Follow-up barium esophagrams were obtained 1-96 months after operation (average, 60 months) in 24 patients. Eight patients (21%) demonstrated asymptomatic "jejunization" of the colonic mucosa with no attributable clinical manifestations; this finding resolved in 1-3 months, without sequelae, and has not been reported before. The spectrum of ischemic changes in the colonic segment included mucosal edema, spasm, ulceration, loss of haustration, and frank necrosis. Radiographically detectable early postoperative complications included anastomotic leak in six (three pharyngocolic, three cervical esophagocolic) and aspiration of barium into the tracheobronchial tree due to incoordinated swallowing in eight. Late postoperative complications included anastomotic narrowing (12) malfunctioning of the colon due to impaired emptying (five), recurrent aspiration pneumonia (three), small bowel obstruction (three), transhiatal herniation of small bowel through the diaphragmatic hiatus (one), and reflux into the retained bypassed esophagus (one).

Oesophageal involvement in benign mucous membrane pemphigoid

Benign mucous membrane pemphigoid is a relatively rare disease characterised by the presence of bullous lesions and erosions of the mucous membranes leading to scarring. Oral and conjunctival mucosae are most frequently affected. Occasionally, the oesophagus is involved and two radiological patterns, webs and smooth strictures, are seen.

[Roentgen morphology of intramural pseudodiverticulosis of the esophagus]

Two cases of oesophageal intramural pseudodiverticulosis are described. They presented with typical numerous pseudodiverticula, each one or several millimetres in size, within the mucosa. One patient had a fibrous stenosis. In both cases CT showed localised thickening of the wall of the oesophagus. The few reports in the literature concerning histology, clinical findings and aetiology are reviewed.

Intramural pseudodiverticulosis of the esophagus

Two cases of esophageal intramural pseudodiverticulosis are presented. A brief review is made of previously published reports. This entity, first described in 1960, is still rarely diagnosed. Its etiology is still debatable. However, as more cases are published, it becomes more apparent that esophageal intramural pseudodiverticula can be found as part of a distinct syndrome with diffuse intramural pseudodiverticulosis, as originally described by Mendl, or localized in a limited extension of the esophagus as a response to esophageal obstruction.

[Dilatation of esophageal strictures using a balloon catheter]

The technique of balloon catheter dilatation of benign esophageal strictures is presented. A general anesthetic is unnecessary which is an advantage in older patients. Moreover, the encouraging results and the absence of complications support the opinion that balloon catheter dilatation is an excellent alternative in the treatment of esophageal strictures.

Esophageal stricture secondary to drug-induced toxic epidermal necrolysis

Toxic epidermal necrolysis is a cutaneous disorder with high morbidity and mortality. Esophageal stricture has rarely been reported following recovery from this abnormality. A case is presented demonstrating the occurrence of an esophageal stricture following successful therapy. New methods of treatment are changing the mortality and morbidity such that esophageal stricture will be observed more frequently.

Esophageal strictures in children. Treatment by balloon dilatation

The authors describe a new technique for dilatation of an esophageal stricture in a child. Under fluoroscopic control, a small guide wire is passed through the narrowed area. Dilation is accomplished with the Grüntzig balloon catheter.