caustic esophagitis

CAUSTIC ESOPHAGITIS

TERMINOLOGY

• CORROSIVE ESOPHAGITIS• INJURY DUE TO INGESTION OF STRONG ALKALI

OR ACID• LIQUID LYLE CAUSES MOST SEVERE FORM OF

CAUSTIC INJURY TO THE ESOPHAGUS.– INCREASED RISK OF DEVELOPING SQUAMOUS CELL

CARCINOMA OF THE ESOPHAGUS, SO NEW AREA OF MUCOSAL IRREGULARITY OR NODULARITY WITHIN A PREEXISTING LYLE STRICTURE ON A BARIUM STUDY SHOULD RAISE CONCERN ABOUT THE POSSIBILITY OF A SUPERIMPOSED CARCINOMA

IMAGING

NONDISTENDIBLE, RIGID SEGMENT (STRICTURE) OF ESOPHAGUS WITH ULCERATED MUCOSA

ACCIDENTAL OR INTENTIONAL INGESTION OF CAUSTIC AGENTS

CAUSES MILD TO SEVERE INJURY TO UPPER GI TRACT: ESOPHAGUS>STOMACH>DUODENUM

PHASE

ACUTE MILD PHASE

ATONIC DILATED, APERSITALTIC ESOPHAGUS

STAGE 1: ACUTE NECROTIC PHASE (1-4 DAYS0

EXTENSIVE ULCERATION AND NARROWED LUMEN WITH IRREGULAR CONTOUR

MAY HAVE SIGNS OF PERFORATION (GAS, FLUID IN MEDIASTINUM)

STAGE 2: ULCERATION-GRANULATION PHASE ( 5-28 DAYS)

MORE DEFINED ULCERS SPASM

STAGE 3: CICATRIZATION AND SCARRING (3-4 WEEKS)

LONG OR SHORT SEGMENTAL STRICTURES

SMOOTH, CONCENTRIC, AND SYMMETRIC OR IRREGULAR, ECCENTRIC

PROXIMAL PART OF STOMACH IS PULLED INTO CHEST BY SHORTENING

OF ESOPHAGUS

IMAGING EVALUATION

• BEST IMAGING TOOL: CT FOR ACUTE INJURY. BARIUM ESOPHAGRAM FOR CRONIC.

• ACUTE PHASE ESOPHAGRAM (IF NEEDED): WATER – SOLUBLE , NONIONIC CONTRAST AGENT

CLINICAL ISSUES

• COMPLICATIONS: PERFORATION, MEDIASTINITIS, PERITONITIS, FISTULAS, SHOCK

RADIOGRAPHIC FINDINGS

CHEST PA AND LAREAL VIEWS (ACUTE)

• DILATED, GAS AND LATERAL VIEWS (ACUTE)

• DILATED GAS FILLED ESOPHAGUS

• ASPIRATION PNEUMONITIS

• ESOPHAGEAL PERFORATION

– MEDIASTINAL WIDENING , PNEUMOMEDISATRINUM, PLEURAL EFFUSION

FLUORSCOPIC-GUIDED WATER-SOLUBLE OR BARIUM ESOPHAGRAM

• aCUTE MILD PHASE– ATONIC DILATED, APERISTALTIC ESOPHAGUS– MULTIPLE SHALLOW, IRREGULAR ULCER

• ACUTE SEVERE PHASEEXTENSIVE ULCERATIONDIFFUSELY NARROWED OSPHAGUS WITH IRREGULAR CONTOURDOUBLE-BARRELED APPEARANCE:LINEAR OR STREAK COLLECTION OF BARIUM IN ESOPHAGEAL WALL

MAY HAVE SIGNS OF PERFORATION

FLUORSCOPIC-GUIDED WATER-SOLUBLE OR BARIUM ESOPHAGRAM

(CONT)CHRONIC PHASE

SACCULATION, PSEUDODIVERTICULALONG OR SHORT SEGMENTAL STRICTURES: SMOOTH, CONCENTRIC AND SYMMETRIC OR IRREGULAR, ECCENTRI AND ASYMETRIC

DIFFUSE LONG STRICTURE: THREAD-LIKE OR FILIFORM APPEARANCE OF ENTIRE THORACIC ESOPHAGUS (DUE TO EXTENSIVE SCARRING AND FIBROSIS)

PROXIMAL PART OF STOMACH IS PULLED INTO CHEST BY SHORTENING OF ESOPHAGUS

CT FINDINGS

• CIRCUMFERENTIAL ESOPHAGEAL WALL THICKENING (>5MM)

• ACUTE PHASE– TARGET SIGN MUCOSAL ENHANCEMENT AND

HYPODENSE SUBMUCOSA– ESOPHAGEAL

PERFORATION:PNEUMOMEDIASTINUM,PLEURAL EFFUSION

CHRONIC PHASE:LUMINAL IRREGULARITY AND NARROWING

SIMILAR FINDINGS IN STOMACH