DOI: 10.1148/rg.234025717
Radiologic Diagnosis of Benign Esophageal Strictures: A Pattern Approach1
Pia Luedtke, BA,
Marc S. Levine, MD,
Stephen E. Rubesin, MD,
Donald S. Weinstein, MD and
Igor Laufer, MD
1 From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (P.L., M.S.L., S.E.R., I.L.), and the Department of Radiology, Pennsylvania Hospital, Philadelphia, Pa (D.S.W.). Received October 14, 2002; revision requested November 22 and received December 9; accepted December 12. M.S.L. and S.E.R. are consultants with E-Z-Em Co, Inc, Westbury, NY. Address correspondence to M.S.L. (e-mail: levine@oasis.rad.upenn.edu).
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Figure 1. Peptic stricture with esophageal intramural pseudodiverticula. Double-contrast esophagogram shows a smooth, tapered area of concentric narrowing in the distal esophagus (large arrow) above a hiatal hernia. This is the classic appearance of a peptic stricture. Note also the tiny esophageal intramural pseudodiverticula in the region of the stricture (small arrows). Some of the pseudodiverticula seem to be "floating" outside the wall of the esophagus without direct communication with the lumen, a characteristic radiographic feature of these structures.
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Figure 2. Peptic stricture. Double-contrast esophagogram shows an eccentric area of narrowing in the distal esophagus (arrow), a finding that resulted from asymmetric scarring from reflux esophagitis.
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Figure 3. Peptic stricture with sacculations. Double-contrast esophagogram shows an eccentric area of narrowing in the distal esophagus (black arrow) above a hiatal hernia. Note the associated sacculations (white arrows) that resulted from outward ballooning of the esophageal wall between areas of fibrosis.
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Figure 4. Peptic stricture with fixed transverse folds. Double-contrast esophagogram shows a mild peptic stricture in the distal esophagus (white arrow) with barium collections between fixed transverse folds (black arrows), findings that produce a characteristic "stepladder" appearance. Note that the folds are wider than the delicate transverse striations in feline esophagus and do not extend more than halfway across the esophagus.
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Figure 5. Ringlike peptic stricture. Double-contrast esophagogram shows an area of ringlike narrowing in the distal esophagus (arrows) above a hiatal hernia. Note the resemblance to a Schatzki ring (cf Fig 6). However, this ringlike stricture is more asymmetric and has more tapered borders and a greater length than do most Schatzki rings.
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Figure 6. Schatzki ring. Prone single-contrast esophagogram shows a classic Schatzki ring (arrows), which appears as a smooth, symmetric, ringlike constriction at the gastroesophageal junction above a hiatal hernia. Note that the ring has a length of only 2 mm and has more abrupt borders than does a ringlike peptic stricture (cf Fig 5).
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Figure 7. Infiltrating esophageal carcinoma. Double-contrast esophagogram shows a malignant stricture with the typical features: a markedly irregular contour and abrupt, shelflike proximal and distal margins (arrows).
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Figure 8. Scleroderma with a peptic stricture. Double-contrast esophagogram shows a relatively long segment of tapered narrowing in the distal esophagus (arrows) that resulted from marked peptic scarring in a patient with esophageal involvement by scleroderma.
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Figure 9. Nasogastric intubation stricture. Prone single-contrast esophagogram shows a relatively long segment of narrowing in the distal esophagus (arrows). This stricture developed 3 months after prolonged nasogastric intubation.
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Figure 10. Barrett esophagus with a midesophageal stricture and a reticular pattern. Double-contrast esophagogram shows a focal area of mild narrowing in the midesophagus (black arrow). Note also the distinctive reticular pattern that extends distally a considerable distance from the stricture (approximately to the level indicated by the white arrow). This reticular pattern is thought to result from intestinal metaplasia in Barrett mucosa. (Reprinted, with permission, from reference 20.)
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Figure 11. Barrett esophagus with a midesophageal stricture. Double-contrast esophagogram shows a relatively long segment of tapered narrowing in the midesophagus (arrows). A hiatal hernia and gastroesophageal reflux were seen at fluoroscopy.
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Figure 12. Radiation stricture. Double-contrast esophagogram shows a smooth, tapered segment of concentric narrowing in the midesophagus (arrows). The stricture was caused by prior mediastinal irradiation.
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Figure 13. Caustic stricture. Double-contrast esophagogram shows a long stricture involving most of the thoracic esophagus. The stricture resulted from ingestion of a caustic substance many years earlier.
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Figure 14. Drug-induced stricture in a patient who developed dysphagia 6 months after taking potassium chloride for hypokalemia. Double-contrast esophagogram shows a slightly asymmetric focal area of narrowing in the upper thoracic esophagus (arrow) above the level of the aortic arch.
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Figure 15. Congenital esophageal stenosis in a young man with long-standing dysphagia and occasional superimposed food impactions. Double-contrast esophagogram shows an area of mild narrowing in the midesophagus with distinctive ringlike indentations ("ringed esophagus") (arrows) in the region of the stricture. Endoscopic findings confirmed the presence of a mild stricture in the midesophagus with indentations that resembled tracheal rings.
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Figure 16. Benign mucous membrane pemphigoid. Single-contrast esophagogram shows a focal stricture in the upper esophagus (arrow) near the thoracic inlet. The stricture resulted from esophageal involvement by benign mucous membrane pemphigoid. Other skin diseases such as epidermolysis bullosa dystrophica may produce similar strictures.
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Figure 17. Esophageal intramural pseudodiverticulosis. Double-contrast esophagogram shows a moderately long stricture in the upper thoracic esophagus (straight solid arrows). Note the tiny esophageal intramural pseudodiverticula (curved solid arrows) at and below the level of the stricture. Note also the intramural tracking of barium between adjacent pseudodiverticula (open arrows). Despite the dramatic radiographic findings in such cases, a localized cluster of pseudodiverticula in the distal esophagus in the region of a peptic stricture is actually more common (cf Fig 1).
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Figure 18. Esophageal stricture caused by endoscopic sclerotherapy. Single-contrast esophagogram shows a long, irregular stricture in the distal esophagus (straight white arrows) that resulted from scarring caused by prior endoscopic sclerotherapy for esophageal varices. Note also the flat ulcer in the region of the stricture (curved white arrow). Black arrows indicate a transjugular intrahepatic portosystemic shunt.
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Figure 19. Glutaraldehyde-induced stricture in a patient who developed dysphagia several months after undergoing endoscopy. Double-contrast esophagogram shows a long stricture that involves the middle and distal esophagus (arrows). There were no other predisposing factors for the development of this stricture, which was presumed to be caused by toxicity from residual glutaraldehyde at endoscopy.
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Copyright © 2003 by the Radiological Society of North America.
