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Case study Esophagus

Case study Esophagus. Dr W.J. Conradie Department of D iagnostic Radiology March 2012. 93 year old Caucasian female. Housewife No previous major surgery Medical history: Hypertensive with mild CCF on medication. Irritable bowel syndrome Medication: Fosamax Disprin Adco Dol

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Case study Esophagus

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  1. Case studyEsophagus Dr W.J. Conradie Department of Diagnostic Radiology March 2012

  2. 93 year old Caucasian female • Housewife • No previous major surgery • Medical history: • Hypertensive with mild CCF on medication. • Irritable bowel syndrome • Medication: • Fosamax • Disprin • AdcoDol • Enalapril and Lasix • Family history: • Eldest son died of esophagealCa in 2007

  3. 2008: Presented with.. • Progressive dysphagia (solids/fluids) over couple of months. • Episodes of coughing while eating/drinking • Intermitted regurgitation of undigested food. • Feeling of “fullness” in neck • Weight loss ± 5kg

  4. Clinically: • Large para-tracheal mass on the left extending into/through thoracic inlet • Moved with swallowing • No features of thyrotoxicosis • No cervical lymphadenopathy • Severe kypho-scoliosis

  5. Special investigations: • CXR: • Degenerative spine • Clear lung fields • Bloods: • Normal • FBC, U&E, LFT • CRP and ESR • Thyroid functions • S-albumin

  6. Special investigations:CT chest (19-06-2008) • Large irregular mass from left thyroid lobe • Extends deep into superior mediastinum • Cyst with calcifications inferiorly • Nodule in superior aspect of lobe with central breakdown • No mediastinallympnodes • Lung fields clear • Incidental: Aorta arch anomaly

  7. Aorta arch anomaly: Main stem for right and left common carotid Left subclavian artery Aberrant right subclavian artery

  8. Special investigations:Barium swallow (AP)

  9. Barium swallow (lateral)

  10. Differential diagnosis for dysphagia Thyroid mass Zenker ‘s Diverticulem Aberant right subclavian artery (dysphagia lusoria) Achalasia

  11. Zenker ‘s Diverticulem • Named after Friedrich Albert von Zenker who was a German pathologist (1825 – 1898) • Definition: • Mucosal outpouching of posterior hypopharyngeal wall. • Proximal to upper esophagealsphincter (Cricopharyngeal muscle) • Pathophysiology: • Pulsion-pseudodiverticulum with herniation of mucosa and submucosa through Killian’s dehiscence. • Focal weakness in cleavage plane between the fibers of inferior pharyngeal constrictor and cricopharyngeusmuscles. • Due to cricopharyngeal dysfunction luminal pressure

  12. Zenker ‘s Diverticulem • Prevalence • <0.2% of general population • Elderly woman • >50% occur in 7th -8th decade • Clinically: • globus feeling • dysphagia • halitosis • regurgitation • Associated with: • Hiatus hernia • GER / Reflux oesophagitis • Achalasia • Complications • Aspiration • Perforation • Ulceration • Carcinoma • Differential diagnosis • Killian-Jamieson diverticulum (K-J) • Esophagealweb • Lateral pharyngeal pouch • Epidermolysisbullosadystrophica

  13. Zenker ‘s DiverticulemImaging findings • General features: • Location: Killian’s dehiscence • Posterior above cricopharyngeus • C5-6 • Size: 0.5-8cm (average 2.5cm) • Best diagnostic clue: Barium filled sac! • Radiographic findings: CXR/CT: • Air-fluid level in superior mediastinum

  14. Zenker ‘s DiverticulemImaging findings Barium swallow • AP: • Barium-filled sac below the level of hypopharynx • Lateral/oblique view: • Barium-filled sac posterior to cervical esophagus • Neck opening into posterior wall above cricopharyngeus m. • Prominent or thickened cricopharyngeal muscle • Luminal narrowing at upper pharyngoesophageal junction • ± Nasopharyngeal regurgitation

  15. Zenker ‘s DiverticulemClassification

  16. Dysphagia Lusoria • Dysphagia secondary to extrinsic esophagealcompression by an aberrant right subclavian artery • Described by Bayford in 1794 • lusoria- Greek phrase lususnaturae, meaning  “ freak or zest of nature”, which refers to the freaky course of the artery (lusoria artery)

  17. Dysphagia LusoriaAberrant Right Subclavian artery • Prevalence of 1.8% • 1/3 experience symptoms (90% = dysphagia) • Any age • Old age: atherosclerosis or aneurysmal dilatation of ARSA. • Associated: • Dyspnoea • Lower right arm BP/pulse volume • Diverticulum of Kommerell. • Management: • Conservative • Carotico-subclavianbypass

  18. Achalasia • Definition: • Primary motility disorder of esophageal smooth muscle • Failure of LES to relax • “Failure to relax” • Sir Thomas Willis in 1672. • 1929: Hurt and Rake • Discovered failure of LES to relax. • Pathophysiology • Degeneration of Auerbach’s plexus • Primary(classic) - idiopathic (number decrease, CNX – nucleus or nerve) • Secondary - metastases, adenocarcinoma, vagotomy, scleroderma • Infectious - Chagas disease(trypanosomacrucineurotoxin destroys ganglia)

  19. Achalasia • Prevalence • Primary: younger (20-50) • Secondary: older • Male=female • Clinically: • Dysphagia (solids and liquids) • Regurgitation • Weight loss in 90% • Diagnosis • Exclude malignancy • Exclude oesophageal spasm • Manometry • Complications: • Coughing • Aspiration • Pneumonia • Lung abscess • Esophagealcarcinoma (2-7%) • Management: • Aimed at improving esophageal emptying • Calcium channel blockers • Botulinumtoxin injection • Pneumatic dilatation • Heller myotomy

  20. AchalasiaImaging findings • General findings • 2 criteria: • Absent primary/secondary peristalsis • LES fails to relax when swallowing • Tertiary waves • "Bird-beak" deformity • Dilated esophaguswith smooth, symmetric, tapered narrowing at GEJ

  21. AchalasiaImaging findings CXR: • Mediastinal widening • Double contour • Anterior tracheal bowing • Air-fluid level in mediastinum • Small or absent gastric air bubble

  22. AchalasiaImaging findings Barium meal Classic Achalasia • Dilated esophagus (>4cm) • Absent peristalsis • Distal segment • "Bird-beak" deformity • Hurst phenomenon: • transit when hydrostatic pressure of barium column is above tonic LES pressure • Narrowed segment: <3.5 cm in length Secondary Achalasia • Less dilated (<4 cm) • Decreased or absent peristalsis • Distal segment: • Eccentric, nodular, shoulder • smooth, symmetric, tapered • Narrowed segment: >3.5 cm

  23. Achalasia Differential diagnosis • Scleroderma • Esophageal carcinoma • Gastric carcinoma • Esophagitis with stricture • Diffuse esophageal spasm

  24. Back to grandma.. • Cause for dysphagia: Thyroid mass • Surgicaly removed 16-07-2008 • Histology: Benign, Non toxic Nodular goitre • Outcome (2012): • Improved but still suffers from dysphagia!! • Zenker’sdivertikulem? • ARSA? • THANK YOU

  25. REFERENCES • Weissleder, Wittenberg, Harisinghani, Chen. Primer of Diagnostic Imaging. Fifth edition. 2011. • Federle, Jeffrey, Desser, Anne, Eraso. Diagnostic Imaging of the Abdomen. First edition. 2004. • (PPP) ZENKER’S DIVERTICULUM. N. D’Souza,Underbrink. 2010 • J. Dandelooy, J.P.M. Coveliers, P.E.Y. Van Schil, S.Anguille. Dysphagia lusoria. CMAJ • October 13, 2009 • 181(8) • P.D. Kent, T.H. Poterucha. Aberrant Right SubclavianArtery and Dysphagia Lusoria. N Engl J Med, Vol. 346, No. 21 May 23, 2002

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