Gastroesophageal Junction Narrowing with Proximal Esophageal Dilation: A Case-Based Illustrative Review

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Case Presentation

A 58-year-old woman presented with long-standing dysphagia without weight loss or hematemesis. She was subsequently referred for an upper GI (UGI) examination (Figure 1).

Key Findings

Gastroesophageal junction narrowing with esophageal dilation

Differential Diagnosis

Esophagitis

Achalasia

Esophageal carcinoma

Discussion

Dysphagia is a common indication for an UGI fluoroscopy examination or esophagography. The goal of imaging is to identify mucosal irregularity, ulceration, or stricture. There are numerous causes of distal esophageal strictures with the most common etiologies being esophagitis from a variety of causes, achalasia, and malignancy.1,2 Classically, malignant strictures have a recent onset of rapidly progressive dysphagia and weight loss, while benign strictures present with long-standing, nonprogressive dysphagia.1 The most common etiology overall of distal esophageal narrowing results from gastroesophageal reflux disease (GERD).

Esophagitis

Inflammation of the esophagus is most commonly caused by GERD but can also be secondary to infection, chemotherapy, caustic ingestion, or radiation.1-3 Reflux esophagitis or GERD affects an estimated 40% of adults.3 Common symptoms include esophageal dysphagia, substernal or epigastric pain, food regurgitation, and dry cough. Patients with hiatal hernias are at an increased risk of having reflux. During fluoroscopy, contrast is seen refluxing into the esophagus from the stomach. Chronic reflux can result in luminal narrowing, which appears smooth and concentric, typically 1 to 4 cm in length (Figure 2).2 A more severe complication of GERD is intestinal metaplasia of the lower esophageal mucosa, called Barrett esophagus, which rarely can progress to adenocarcinoma.1 Treatment for GERD includes lifestyle modifications, pharmaceutical treatment with proton pump inhibitors, H-2 receptor blockers, or antacids.3 In patients with a hiatal hernia, fundoplication may also alleviate symptoms.3

Achalasia

Achalasia is a motility disorder of the esophagus with absent primary peristalsis resulting in impaired relaxation of the lower esophageal sphincter (LES).4 Patients present with symptoms of dysphagia to solids and liquids, chest pain, food regurgitation, and are typically middle-aged.5 Achalasia is categorized as primary (idiopathic) or secondary, which results from destruction of the plexus by an infiltrating tumor (commonly known as pseudoachalasia) or infections such as Chagas disease.4,6 Idiopathic achalasia occurs from destruction of the myenteric plexus neurons in the LES, resulting in failure to relax. Esophagography classically shows a dilated esophagus and symmetrical tapering near the LES with a characteristic “bird-beak” appearance (Figures 1 and 3). Manometric testing is the gold standard for diagnosing primary achalasia. Idiopathic achalasia is more definitively treated surgically, with graded pneumatic balloon dilation or with Heller myotomy, but can be conservatively managed with calcium channel blockers or Botulinum toxin.6

Esophageal Carcinoma

Esophageal carcinoma is most often squamous cell carcinoma (SCC), followed by adenocarcinoma. SCC is typically seen in the proximal two-thirds of the esophagus, while adenocarcinoma is more common in the distal one-third of the esophagus. Risk factors for esophageal SCC include tobacco use, alcohol consumption, achalasia, and long-standing esophagitis.7 Adenocarcinoma is more closely related to GERD and Barrett metaplasia.1,2,7 Patients with pseudoachalasia from tumor infiltration present with an abrupt onset of symptoms, compared with benign etiologies.1 On fluoroscopy studies, carcinomas usually appear as eccentric or asymmetric wall thickening with irregular nodular mucosa, abrupt “shouldering,” and mass effect (Figure 4). The diagnosis is confirmed with endoscopy and biopsy.

Diagnosis

Achalasia

Summary

Upper GI and esophagography examinations are commonly performed in the setting of dysphagia with the primary goal of identifying potentially treatable areas of mucosal irregularity, ulceration, or stricture. Distal esophageal strictures are relatively common and are most often due to esophagitis, achalasia, or esophageal carcinoma. Each entity has fairly characteristic imaging findings, which often can be readily identified on fluoroscopic studies. Therefore, it is imperative that radiologists recognize these findings, especially in terms of distinguishing benign from malignant strictures, to help guide appropriate management and follow-up.

References

  1. Luedtke P, Levine MS, Rubesin SE, et al. Radiologic diagnosis of benign esophageal strictures: a pattern approach. RadioGraphics 2003;23:897-909.
  2. Gupta S, Levine MS, Rubesin SE, et al. Usefulness of barium studies for differentiating benign and malignant strictures of the esophagus. Am J Roentgenol 2003;180:737-744.
  3. Levine MS, Carucci LR, Disantis DJ, et al. Consensus statement of society of abdominal radiology disease-focused panel on barium esophagography in gastroesophageal reflux disease. Am J Roentgenol 2016;207:1009-1015.
  4. Carucci LR, Turner MA. Dysphagia revisited: common and unusual causes. RadioGraphics 2015;35:105-122.
  5. Hansford B1G, Mitchell MT, Gasparaitis A. Water flush technique: a noninvasive method of optimizing visualization of the distal esophagus in patients with primary achalasia. Am J Roentgenol 2013;200:818-821.
  6. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013;108:1238-1249.
  7. Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology 2005;237:414-427.
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Saenz R, Corley L, Franks Z.  Gastroesophageal Junction Narrowing with Proximal Esophageal Dilation: A Case-Based Illustrative Review.  J Am Osteopath Coll Radiol.  2019;8(1):11-13.

About the Author

Rocky Saenz, D.O., Lauren Corley, D.O., Zack Franks, D.O.

Rocky Saenz, D.O., Lauren Corley, D.O., Zack Franks, D.O.

Dr. Saenz, Dr. Corley, and Dr. Franks work with the Department of Radiology, Beaumont Farmington Hills, Botsford Campus, Farmington Hills, MI and Michigan State University, College of Osteopathic Medicine, East Lansing, MI.



 

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