Oesophagus
HIATUS HERNIA AND REFLUX
HIATUS HERNIA
DEFINITION
• Protrusion of part of the stomach through the diaphragmatic oesophageal opening
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
Rolling hernia: the GOJ is in a normal position below the diaphragm – the proximal stomach (usually the fundus) herniates through the hiatus 
this is more prone to incarceration and obstruction, and it may undergo torsion, resulting in strangulation, infarction or perforation
symptoms are more commonly seen with a sliding herniaPEARLS
• 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 2-4cm 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)
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
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
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 (>3mm) 
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)
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 28mm (normal is <15mm). The fundus of the stomach is seen herniating through the diaphragmatic hiatus.†
OESOPHAGITIS AND BENIGN STRICTURES
OESOPHAGITIS AND BENIGN STRICTURES
DEFINITION
• Oesophageal inflammation (± subsequent smooth benign stricture formation) can be caused by the following:
Infection: especially in the immunocompromised patient Candida albicans 
herpes simplex virus (HSV) 
cytomegalovirus (CMV) 
human immunodeficiency virus (HIV) 
tuberculosis
Drugs: potassium chloride tablets 
tetracycline 
clindamycin 
doxycycline 
NSAIDs
Radiation: this is often self-limiting
Crohn’s disease: this is very rare and usually accompanied by extensive GI disease elsewhere
Iatrogenic: following prolonged placement of a nasogastric tube (NGT)
dysphagia 
haematemesisRADIOLOGICAL 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 1st 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
the oesophagus may be involved (leading to stricture formation)
the upper oesophageal mucosa may be involved with ulcers, webs and stricture formationIntramural 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
BENIGN AND MALIGNANT OESOPHAGEAL TUMOURS
BENIGN TUMOURS
DEFINITION
neurofibroma 
lipoma 
fibrovascular polyp
RADIOLOGICAL FEATURES
Barium swallow
• Papilloma: these are usually small (2–5mm) 
larger papillomas may trap barium within the interlacing fronds that cover their surface
• Leiomyoma: these are usually found within the lower 1/3 of the oesophagus 
they appear as a smooth 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)
its aetiology is unclear (but possibly age related) 
it demonstrates no malignant potential
MALIGNANT TUMOURS
DEFINITION
• Malignant tumours arising from the oesophageal mucosa or submucosa
Oesophageal carcinoma: the commonest malignant tumour (see separate section)
Leiomyosarcoma (1%): these arise from the smooth muscle within the oesophageal wall – therefore they are found only within the distal oesophagus (striated muscle is found within the proximal 1/3 of the oesophagus) 
they can grow to an extraordinary size before symptoms present due to their failure to cause obstruction 
they are relatively indolent and metastasize late
Melanoma (1%): these are rare tumours (melanoblasts are uncommon within the oesophagus) 
they metastasize early with a very poor prognosis
Lymphoma (1%): oesophageal involvement is very rare 
it is usually of the non-Hodgkin’s type and is usually associated with lymphomatous disease elsewhere
– It begins as a submucosal lesion (usually in the distal 1/3 of the oesophagus) resulting in a smooth luminal narrowing with an intact overlying mucosa 
later ulceration can develop
– Secondary involvement by contiguous spread from adjacent nodal disease is more common but rarely results in dysphagia
Spindle cell carcinoma: a rare tumour containing both carcinomatous and spindle cell elements
Metastases: these are usually due to direct extension from tumours within the thoracic cavity (notably carcinoma of the bronchus) 
involved nodes may also infiltrate the oesophagus causing displacement and occasionally fistula formation between the oesophageal lumen and the adjacent bronchus 
carcinoma of the pancreas (particularly the tail) may involve the distal oesophagus or gastro-oesophageal junction
there can be a large exophytic component which may be seen on a CXR as a mediastinal mass
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