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Oesophagus


Hiatus Hernia and Reflux

Hiatus Hernia

Definition

  • Protrusion of part of the stomach through the diaphragmatic oesophageal opening

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      Type 1 – sliding hernia (the commonest type): the gastro-oesophageal junction (GOJ) slides proximally through the diaphragmatic hiatus to assume an intrathoracic position ▸ it is accompanied by reflux and oesophagitis

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        The squamocolumnar junction is seen at ≤38 cm (the normal is 40 cm) from the incisors at endoscopy

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      Type 2 – rolling hernia: the GOJ is in a normal position below the diaphragm – the proximal stomach (usually the fundus) herniates through the hiatus/focal defect ▸ this is more prone to incarceration and obstruction, and it may undergo torsion, resulting in strangulation, infarction or perforation

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        The squamocolumnar junction maintains its normal position

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      Type 3 – combined hernia: features of both are present

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      Type 4 – intrathoracic stomach (± organoaxial rotation)

Clinical presentation

  • Asymptomatic or gastro-oesophageal reflux (± reflux oesophagitis) ▸ symptoms are more commonly seen with a sliding hernia

Radiological features

Barium swallow

  • Sliding hiatus hernia: the Schatski or B ring is demonstrated above (>2 cm) the diaphragmatic hiatus ▸ gastric rugae traversing the diaphragm

  • Rolling hiatus hernia: a part of the stomach (usually the gastric fundus) is prolapsed into the chest anterior or lateral to the oesophagus

Pearls

  • Schatski or B ring: a ring of mucosal tissue at the lower border of the phrenic ampulla marking the junction between the squamous and columnar epithelium (the ‘Z line’)

  • The ‘A’ ring or inferior oesophageal sphincter: about 2-4 cm proximal to the B ring is a thicker ring produced by active muscular contraction

  • The Schatski ring is always associated with a small sliding hiatus hernia ▸ it can be congenital or secondary to gastro-oesophageal reflux (with associated inflammation and fibrosis)

  • The Schatski ring is usually no more than 2–3 mm in thickness ▸ despite being mucosal it can be symptomatic (requiring dilatation)

  • If the B ring is incomplete, part of it can sometimes be demonstrated as the incisural notch (which is inevitably seen on the greater curve aspect of the stomach)

Rolling (paraoesophageal) hiatus hernia. The gastric fundus (H) lies alongside the lower oesophagus (O). †

Contrast study demonstrating a combined-type hiatus hernia. Note the rolling component with a large portion of stomach above the diaphragm, but in addition the gastro-oesophageal junction has also migrated cranially. *

Inflammatory polyp (arrows) lying at end of gastric fold (asterisk). †

Gastro-Oesophageal Reflux Disease (GORD)

Definition

  • GORD follows lower oesophageal sphincter dysfunction ▸ this initially leads to reflux (with minor irritation and inflammation) but can then proceed to ulceration, fibrosis and stricture formation ▸ it may also be associated with a hiatus hernia

Clinical presentation

  • Heartburn or dysphagia ▸ the major long-term complications are peptic oesophagitis (± stricture formation or Barrett's oesophagus)

Radiological features

Barium swallow

  • Reflux: this may be demonstrated but alone is of questionable significance – minor amounts can occur in the normal population ▸ gross reflux (up to the level of the aortic knuckle or above and not cleared by a stripping wave passing down the oesophagus) is likely to be symptomatic

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      Associated features: a wide gastro-oesophageal junction (> ⅔ of the maximally distended thoracic oesophagus) ▸ an inflammatory gastro-oesophageal polyp (seen as a single linear polyp straddling the GOJ)

  • Reflux oesophagitis: this can demonstrate mucosal oedema, erosive disease or frank ulceration ▸ initially the collapsed oesophagus shows thickened longitudinal folds (>3 mm) ▸ multiple fine ulcers give the mucosa a punctate or granular appearance ▸ larger discrete punched-out ulcers can develop ▸ ulceration is most pronounced immediately above the GOJ and local circular muscle spasm may produce transverse folds ▸ scarring produces permanent folds that radiate from the ulcer margins

  • Long-term sequelae: stricture formation (typically a short stricture above a hiatus hernia with smooth tapered margins) ▸ the development of Barrett's oesophagus (in 10% of cases)

Radionuclide study

Reflux of 99m Tc-sulphur colloid labelled scrambled egg can demonstrate gastro-oesophageal reflux

Pearls

  • 24-hour pH measurement is the ‘gold standard’ in the assessment of reflux

  • There is no direct relationship between a hiatus hernia and GORD: many patients have a hiatus hernia but no GORD (but most patients with GORD will have a hiatus hernia)

Sliding hiatus hernia. (A) Barium swallow shows a hiatus hernia (H), more than 3-cm wide with at least 3 gastric folds seen extending across it ▸ S = stomach forming the hernia ▸ B = B ring, the gastro-oesophageal junction ▸ V = vestibule. The A ring is not visible. (B) CT scan showing the crura of the diaphragm (arrows) separated by 28 mm (normal is <15 mm). The fundus of the stomach is seen herniating through the diaphragmatic hiatus. †

The lower end of the oesophagus. (A) The B ring may normally be within 2 cm above (as shown here) or below the hiatus. Thus the oesophageal vestibule may normally be above, or straddle the diaphragmatic hiatus. (B) Small sliding hiatus hernia with normal B ring (between arrows). †

Oesophagitis and Benign Strictures

Oesophagitis and Benign Strictures

Definition

  • Oesophageal inflammation (± subsequent smooth benign stricture formation) can be caused by the following:

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      GORD (see separate section)

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      Infection: especially in the immunocompromised patient Candida albicans ▸ herpes simplex virus (HSV) ▸ cytomegalovirus (CMV) ▸ human immunodeficiency virus (HIV) ▸ tuberculosis

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      Drugs: potassium chloride tablets ▸ tetracycline ▸ clindamycin ▸ doxycycline ▸ NSAIDs

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      Radiation: this is often self-limiting

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      Crohn's disease: this is very rare and usually accompanied by extensive GI disease elsewhere

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      Iatrogenic: following prolonged placement of a nasogastric tube (NGT)

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      Caustic ingestion of strong acids or alkalis

Clinical Presentation

  • Odynophagia ▸ dysphagia ▸ haematemesis

Radiological Features

Barium swallow

  • Candidiasis: initially there is dysmotility and atony of the oesophagus ▸ eventually classic plaque-like filling defects with ulceration and pseudomembrane formation are seen (there are also irregular and thickened mucosal folds) ▸ occasionally pseudo-ulcerations may appear as aphthous ulcers

  • HSV: vesicles in the upper and mid-oesophagus appear as sessile filling defects ▸ when they burst they leave punched-out superficial ulcers on a background of normal mucosa ▸ in advanced disease there can be diffuse ulceration

  • CMV/HIV: presents with giant oesophageal ulcers

  • Drugs: potassium chloride causes deep ulceration leading to stricture formation ▸ NSAIDs can cause contact oesophagitis

  • Radiation: >20 Gy results in a transient oesophagitis with aperistalsis or tertiary contractions ▸ >45 Gy results in obliterative endarteritis after 6 months with severe oesophagitis and smooth strictures – deep ulcers can also form (which may fistulate to the trachea)

  • Crohn's disease: this can present with aphthoid ulcers or frank ulceration

  • Nasogastric tube: this renders the lower oesophageal sphincter incompetent, resulting in a reflux oesophagitis and a long tapered stricture within the lower oesophagus ▸ this may occur only 48 h post placement ▸ the strictures are often long and extensive

  • Caustic ingestion: this can lead to mucosal necrosis with ulceration and mucosal sloughing ▸ the oesophagus may perforate within the 1 st 2 weeks or result in fistulation to the pleural cavity or pericaridium ▸ it heals with fibrosis and stricture formation ▸ strictures occur at the normal sites of oesophageal compression (e.g. at the level of the aorta, left main bronchus or diaphragmatic hiatus)

Pearls

Epidermolysis bullosa dystrophica

  • A hereditary skin disease affecting children where minor trauma produces bullae formation ▸ the oesophagus may be involved (leading to stricture formation)

Pemphigoid

  • A benign mucous membrane disease of middle age, involving the conjunctiva and mucosa of the oral cavity and skin ▸ the upper oesophageal mucosa may be involved with ulcers, webs and stricture formation

Intramural pseudodiverticulosis

  • The excretory ducts of the oesophageal deep mucous glands dilate and fill with barium ▸ they are seen on barium studies as multiple, flask-shaped mucosal outpouchings ▸ this disease is usually diffuse, but may be localized if it is associated with peptic stricture formation or an oesophageal carcinoma

  • Fistulation may occur between these pseudodiverticula ▸ intramural abscesses may develop which can rarely perforate through the oesophageal wall ▸ long tapered strictures may arise

  • It is associated with oesophagitis (usually due to reflux) ▸ other underlying disorders include diabetes, candidiasis and alcoholism

An annular peptic stricture at the GOJ. (A) An area gastricae pattern is present below the stricture. (B) Benign peptic stricture above a hiatus hernia. The stricture has smooth tapered margins. (C) Benign peptic stricture. Asymmetric ulceration and scarring has produced a stricture with irregular and shoulder margins resembling a carcinoma. Erosions on the oesophageal folds give them a lobular margin resembling varices (arrows). †

Corrosive stricture. A long stricture extending up to the mid-oesophagus (resulting from swallowing lye as child). †

Intramural pseudodiverticulosis. (A) Multiple flask-shaped projections produced by barium entering dilated oesophageal glands. (B) Mid-oesophageal stricture with small flask-shaped projections. †

Candida oesophagitis (A) Mucosal plaques. (B) Extensive mucosal nodularity. †

Diagrammatic representation of oesophageal ulceration.

Benign and Malignant Oesophageal Tumours

Benign Tumours

Definition

  • Benign tumours arising from the oesophageal mucosa or submucosa:

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      Mucosal origin: papilloma

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      Submucosal origin: leiomyoma (the commonest type) ▸ neurofibroma ▸ lipoma ▸ fibrovascular polyp

Clinical presentation

  • These can be asymptomatic or present with dysphagia

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      Fibrovascular polyp: this may be regurgitated into the mouth and even, on occasion, aspirated (resulting in asphyxia)

Radiological features

Barium swallow

  • Papilloma: these are usually small (2–5 mm) ▸ larger papillomas may trap barium within the interlacing fronds that cover their surface

  • Leiomyoma: these are usually found within the lower ⅓ of the oesophagus ▸ they appear as a smooth submucosal wide-based filling defect covered by an intact mucosa ▸ they may calcify and can be multiple

  • Neurofibroma/lipoma: these may be difficult to distinguish from a leiomyoma and are extremely rare

  • Fibrovascular polyp: these are usually found within the proximal oesophagus ▸ they are pedunculated (the stalk forms due to repeated passage of food with peristalsis) ▸ they may expand the oesophageal lumen but rarely cause significant barium hold-up (due to their very pliable nature)

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