Update on esophageal radiology.

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933

Review

Update Marc

on Esophageal

S. Levine,1

Stephen

E. Rubesin,1

Radiology and David

J. Ott2

This article reviews the current status of double-contrast radiography in diagnosing pharyngeal tumors and opportunistic esophagitis and the radiologic evaluation of esophageal motility disorders in patients with chest pain. Double-contrast pharyngography

is a valuable

technique

for detecting

pharyngeal

tumors. mubarium studies may demonstrate lesions involving the valleculae, tongue base, lower hypopharynx, and pharyngoesophageal segment that are difficult to visualize at endoscopy. Double-contrast radiography is also a valuable technique for detecting opportunistic esophagitis and for differentiating the underlying causes. Mucosal plaques should suggest Candida esophagitis, whereas discrete ulcers should suggest herpes esophagitis, and one or more large, relatively flat ulcers should suggest cytomegalovirus esophagitis. Finally, in evaluating patients with chest pain, in only a small percentage are esophageal motility disorders found to be a possible cause of their pain. Instead, the majority are found to have cardiac disease, structural esophageal lesions, or gastroesophageal reflux, so that barium studies are more useful in documenting normal motility or structural abnormalities in these patients.

These lesions may be manifested by an intraluminal mass, cosal irregularity, or asymmetric distensibility. Furthermore,

Double-Contrast

Radiography

of Pharyngeal

Tumors

The radiologist often is the first physician to suggest the diagnosis of pharyngeal carcinoma (Fig. 1) [1]. Some patients

are asymptomatic, studies performed

and the tumors are detected on barium for other reasons. Other patients who are

symptomatic may undergo pharyngography as the initial diagnostic examination. Thus, the radiologist must be familiar with the morphology and behavior patterns of pharyngeal carcinoma.

Anatomy

and Technique

During double-contrast pharyngography, high-density barium (E-Z-HD, E-Z-EM Co., Westbury, NY) coats the squamous mucosa overlying the muscular tube of the pharynx [2, 3]. Longitudinal striations are often observed on the posterior or lateral pharyngeal wall because of the close apposition of the mucosa to the inner longitudinal muscle layer (palatopharyngeus,

155:933-941,

November

1990 0361 -803X/90/1

555-0933

© American

and

horizontal

its

pharyngeal

striations

aponeu-

may be seen

overlying the muscular processes of the arytenoid cartilages owing to redundant mucosa in this region (Fig. 2) [3]. The mucosa overlying the palatine and lingual tonsils may also have a finely nodular appearance due to lymphoid hyperplasia [4].

The radiologic study should include double-contrast spot films to assess morphology and a dynamic examination (cineor videofluoroscopy) to assess function [5]. For the doublecontrast examination, vertically split two-on-one spot films are obtained in a lateral projection during suspended respiration and during phonation with the sound “Eee...” [6]. Frontal spot films are also obtained during suspended respiration and during maximal distension by a modified Valsalva

Received April 30, 1990; accepted after revision June 10, 1990. Presented at the annual meeting of The Society of Gastrointestinal Radiologists, Hawaii, HI, January 1 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, 2 Department of Radiology, Bowman Gray School of Medicine, Winston-Salem, NC 27103. AJR

stylopharyngeus)

rosis (Fig. 2) [3]. In contrast,

Roentgen

Ray Society

1990. PA 19104. Address reprintrequests to M. S. Levine.

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Fig. 1.-Unsuspected squamous cell carcinoma of soft palate in 80-year-old man with dementia and epigastric pain. Lateral view from doublecontrast pharyngogram shows large, lobulated mass (arrows) arising from soft palate. Note how distal soft palate and uvula have been obliterated. Nodular mucosa in region of tonsilar fossa (t) also indicates tumor spread into palatine tonsil. (Reprinted with permission from Rubesin and Glick [1].)

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Fig. 2.-Normal lines of pharynx. A and B, Frontal (A) and lateral (B) views from double-contrast striations in hypopharynx (white arrows) due to close apposition

November

Evaluation

The radiologic findings of pharyngeal carcinoma include (1) an intraluminal mass, (2) mucosal irregularity, and (3) asymmetric distensibility [7-1 0]. An intraluminal mass may be manifested by an abnormal luminal contour, extra bariumcoated lines in an abnormal location (Fig. 3), a focal area of increased radiodensity, or a filling defect in the barium pool. Mucosal irregularity may be recognized by abnormal barium collections due to ulceration or by a nodular surface pattern due to mucosal elevations (Fig. 4). Lymphoid hyperplasia of the lingual tonsil may result in small, uniform nodules that are distributed symmetrically at the base of the tongue [4]. However, nonuniform nodules that have an asymmetric distribution should be considered suspicious for tumor in this region. Finally, asymmetric distensibility may be caused by an infiltrating tumor or extrinsic nodal mass impinging on the pharynx. Squamous cell carcinoma of the palatine tonsil is the most common malignant lesion arising in the pharynx [11]. Bulky, exophytic tumors are easily detected radiologically. However, infiltrativetumors may be obscured by the nodular mucosa overlying the lymphoid tissue of the tonsillar fossa. Palatine tonsil tumors frequently spread to the soft palate, lateral base of the tongue, and posterior pharyngeal wall. Most squamous cell carinomas of the base of the tongue are clinically silent until they are advanced lesions with nodal metastases, so that affected patients have a 5-year survival rate of only 15% [12]. These tumors may be manifested by polypoid or ulcerated lesions at the base of the tongue [13].

1990

pharyngogram show longitudinal of squamous mucosa to inner

longitudinal muscle layer and pharyngeal aponeurosis. Transverse lines overlying cesses of arytenoid cartilages reflect redundant mucosa (black arrow). v = vallecula, (Reprinted with permission from Rubesin and Glick [1].)

maneuver (blowing against closed lips) [7]. Oblique films may provide additional information. Radiologic

ET AL.

muscular e

=

pro-

epiglottis.

The tumors subsequently may spread to the palatine tonsils, valleculae, and pharyngoepiglottic folds. Supraglottic squamous cell carcinomas are defined as “Iaryngeal”

tumors

even though

they arise in the pharyngobuccal

anlage [1 1]. They may involve various tis, aryepiglottic

folds,

arytenoid

portions

cartilages,

of the epiglot-

false vocal

cords,

laryngeal ventricle, and preepiglottic space (Fig. 3). Affected individuals may present with respiratory symptoms such as coughing, choking, or hoarseness. About 30% of patients have nodal metastases at the time of diagnosis, and the 5year survival rate is 40% [8]. Patients with squamous cell carcinoma of the piriform sinus often

present

with a neck

mass

or hoarseness.

At the time of

diagnosis, 70% of patients already have metastases to jugular lymph nodes [1 1]. Early lesions may be recognized by relatively subtle areas of mucosal nodularity in the piriform sinus (Fig. 4). However, more advanced lesions typically appear as bulky, exophytic masses in this region. Tumors arising on the medial wall of the piriform sinus may invade the paraglottic space and cause hoarseness. Tumors arising on the lateral wall of the piriform sinus may invade the thyroid gland and carotid sheath. Squamous

cell carcinomas

of the posterior pharyngeal

wall

are usually bulky, fungating tumors (Fig. 5). They often spread vertically into the naso- and oropharynx or cervical esophagus. Affected patients usually present with a neck mass. About 50% of patients have metastases to jugular and/or retropharyngeal

5-year survival

lymph

nodes

rates are poor.

at the time of diagnosis,

so that

This is the type of pharyngeal

carcinoma that is most frequently associated with a synchronous malignancy in the pharynx or esophagus. Postcricoid squamous cell carcinomas are rare lesions, except

in northern

Europe,

where

they are encountered

more

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Fig. 3.-Squamous cell carcinoma of left aryepiglottic fold. A, Frontal view from double-contrast pharyngogram shows abnormal line (arrows) coursing from level of obliterated left vallecula to lower right aryepiglottic fold. Note preservation of lateral walls

of hypopharynx and tip of epiglottis (e). B, Lateral view shows mass of aryepiglottic fold depicted by elevated contour of left aryepiglottic fold (arrows) with nodular mucosa and abnormal lines in this region. Note how tip of epiglottis is spared. (Reprinted

with permission

from Rubesin

et al.

[3].)

Fig.

4.-Nodular

mucosa

in pharyngeal

carci-

noma in 43-year-old woman with known squamous cell carcinoma of tip of tongue. A and B, Frontal (A) and lateral (B) views from double-contrast pharyngogram show focal area of mucosal nodulanty (arrows) in anterolateral region of right

piriform

sinus.

Endoscopic

biopsies

re-

vealed a synchronous primary squamous cell carcinoma of piriform sinus invading the submucosa.

Fig. 5.-Squamous pharyngeal

wall

cell carcinoma of posterior

in 62-year-old

patient

with

dys-

phagia and smoking and alcohol addiction. Lateral view from double-contrast pharyngogram shows large, lobulated mass (arrows) on posterior pharyngeal wall, extending from level of uvula to mucosa overlying muscular processes of arytenoid cartilages (a). Initial barium study alerted endoscopist to size of tumor. At panendoscopy, endoscope could not safely pass this lesion. (Reprinted with permission from Rubesin and Glick [1].)

Fig. b.-Postcricoid carcinoma. Lateral view from double-contrast pharyngogram shows irregular contour and fine lobulations of mucosa in distal hypopharynx and pharyngoesophageal segment (arrows).

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often. The association between postcricoid carcinomas, irondeficiency anemia, and webs is controversial and probably does not occur in the United States. These tumors usually appear radiologically as anular, infiltrating lesions (Fig. 6). They often spread vertically into the hypopharynx or cervical esophagus and mediastinum. Occasionally, skip lesions may occur.

Lymphomas constitute 1 5% of oropharyngeal tumors [8]. They usually involve the lingual and palatine tonsils. Lymphomas arising in the hypopharynx are rare. Most lymphomas appear radiologically as large, lobulated tumors. Clinical

Perspective

Symptoms of pharyngeal carcinoma are nonspecific and may include a sore throat, odynophagia due to mucosal ulceration, and dysphagia due to blockage of the passage of a bolus. The patient may experience coughing or choking due to laryngeal penetration during swallowing or aspiration of a bolus trapped in an ulcerated tumor. Hoarseness may be caused by laryngeal or supraglottic carcinomas. Voice changes may also occur when tumors arising on the medial wall of the piriform sinus infiltrate the cricoarytenoid joint or arytenoid cartilage. Some patients may have referred pain from the pharynx, producing an earache. Some asymptomatic patients may have a palpable neck mass. Double-contrast pharyngography is a valuable technique for diagnosing pharyngeal tumors. It is particularly helpful for evaluating the hypopharynx. In one study, about 97% of lesions below the pharyngoepiglottic fold were detected radiologically [1 4]. Pharyngography is also helpful for determining the size, extent, and inferior limit of the tumor and the degree of functional impairment. However, the barium study is of much less value in detecting lesions in the oral cavity. Flat, infiltrating lesions arising in the palatine tonsils also may be missed radiologically. Thus, it is important to be aware of the limitations of pharyngography in these patients. At the same time, endoscopy is not an infallible technique for examining the pharynx. Barium studies may detect lesions in the valleculae, vertical surface of the tongue base, lower hypopharynx, and pharyngoesophageal segment, which are difficult to visualize at endoscopy. Barium studies may also demonstrate bulky tumors, pharyngoesophageal narrowing, or Zenker diverticula that are difficult to circumvent safely at endoscopy (Figs. 5 and 6). Therefore, the complementary roles of these techniques should be recognized. In patients with known pharyngeal carcinoma, barium studies are also helpful for detecting separate, coexisting carcinomas of the pharynx or esophagus. About 10% of patients with squamous cell carcinomas of the head and neck develop a second primary lesion [15], and 1% develop synchronous or metachronous carcinomas of the esophagus [16, 17]. Thus, a double-contrast esophagogram should be obtained when

a lesion is detected

in the pharynx

on double-contrast

pharyngography. Opportunistic Clinical

Esophagitis

Perspective

Because of the increased and other immunosuppressive

use of steroids, cytotoxic drugs, agents, opportunistic esopha-

ET

AL.

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gitis has become an increasingly common problem in modern medical practice. Candida albicans is the usual offending organism, but the herpes simplex virus and cytomegalovirus (CMV) also have been recognized with increasing frequency as opportunistic invaders of the esophagus. The recent AIDS epidemic has led to the development of more fulminant forms offungal and viral esophagitis, accentuating the need for early diagnosis and treatment. Opportunistic esophagitis may be manifested clinically by odynophagia, dysphagia, chest pain, or, less frequently, upper gastrointestinal bleeding. Although many patients with Candida esophagitis have associated lesions in the oropharynx (i.e., thrush), esophageal symptoms in some patients with oropharyngeal candidiasis result from herpes or CMV esophagitis. Thus, it is often difficult or impossible to differentiate fungal and viral esophagitis on clinical grounds.

Radiologic

Evaluation

Although conventional single-contrast esophagography has been considered an unreliable technique for diagnosing opportunistic esophagitis, double-contrast esophagography has dramatically improved the ability of the radiologist to detect this condition and to differentiate the various underlying causes. The accurate diagnosis of fungal or viral esophagitis on barium studies is particularly important for patients with AIDS, as gastroenterologists are reluctant to perform endoscopy in these individuals because of fear of contaminating their endoscopic instruments or exposing themselves to the AIDS virus. Thus, double-contrast radiography has an important role in examining these patients. Candida esophagitis.-The radiologic diagnosis of Candida esophagitis has been limited by the fact that it tends to be a superficial disease with mucosal abnormalities that are difficult to recognize on conventional single-contrast barium studies. As a result, endoscopy has been advocated as a more reliable test for this disease. However, recent studies have shown that double-contrast esophagography has a sensitivity of approximately 90% in diagnosing Candida esophagitis [18, 19]. The major advantage of this technique is its ability to demonstrate mucosal plaques that cannot be seen easily on single-contrast studies. As a result, only mild cases of Candida esophagitis are likely to be missed on the doublecontrast examination. Candida esophagitis is usually manifested on double-contrast radiographs by discrete plaquelike lesions corresponding to the characteristic white plaques seen at endoscopy. The plaques tend to be longitudinally oriented, appearing as linear or irregular filling defects with normal intervening mucosa (Fig. 7) [1 8, 20]. Because these lesions have discrete borders, they may be etched in white by a thin layer of barium trapped between the edge of the plaque and the adjacent mucosa (Fig. 7B). Some patients may have giant plaques or pseudomembranes in the esophagus, whereas others may have tiny, nodular lesions producing a granular appearance of the mucosa (Fig. 8) [20]. Thus, the classic radiologic features of Candida esophagitis are not present in all patients. Patients with AIDS may have a more fulminant form of Candida esophagitis, manifested by a grossly irregular or

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Fig. 9.-Double-contrast esophagogram in patient with AIDS shows severe candida esophagitis with shaggy esophagus owing to multiple coalescent pseudomembranes and plaques.

b:-. 1

Fig. 7.-Candida esophagitis with plaques. A, Double-contrast esophagogram shows classic appearance of candidiasis with multiple linear plaques. Note how lesions have well-defined borders and longitudinal orientation in relation to long axis of esophagus. B, More irregular plaquelike lesions in different patient. Note how some lesions are etched in white owing to barium trapped between edge of plaque and adjacent mucosa.

Fig. 8.-Double-contrast esophagogram in patient with Candida esophagitis shows tiny, nodular elevations, producing granular appearance of mucosa.

“shaggy” esophagus owing to coalescent plaque and pseudomembrane formation with barium trapped between these plaques and pseudomembranes (Fig. 9) [20]. Occasionally, the shaggy esophagus of candidiasis may be the initial manifestation of AIDS [20]. Because this degree of esophagitis rarely occurs in other immunocompromised patients, the possibility of AIDS should be suspected when a shaggy esophagus is detected on barium studies [211. Although the presence of mucosal plaques should be highly

suggestive of Candida esophagitis, glycogenic acanthosis also may be manifested radiologically by plaques or nodules in the esophagus (Fig. 1 0) [22, 23]. Glycogenic acanthosis is a benign, degenerative condition characterized by accumulation ofcytoplasmic glycogen in squamous epithelial cells lining the esophagus [22, 23]. However, it rarely causes esophageal symptoms, so that the clinical history is extremely helpful in distinguishing this condition from Candida esophagitis. Occasionally, an undissolved effervescent agent, air bubbles, or debris in the esophagus can also be mistaken for the plaques of candidiasis. If an artifact is suspected, however, additional double-contrast radiographs should be obtained to demonstrate the transient nature of these findings. Herpes esophagitis.-Herpes esophagitis is initially manifested by esophageal blisters or vesicles that subsequently rupture to form discrete, punched-out ulcers on the mucosa. Although esophageal vesicles rarely have been demonstrated on radiologic examinations, discrete, superficial ulcers may be visualized on double-contrast esophagograms in more than 50% of patients with endoscopically proved herpes esophagitis [24]. These ulcers may have a punctate, linear, ringlike, or stellate configuration and often are surrounded by a radiolucent halo of edematous mucosa (Fig. 1 1 ) [20, 2426]. The ulcers can be clustered together in the mid esophagus or widely separated by normal mucosa. In the appropriate clinical setting, the presence of discrete ulcers on an otherwise normal mucosa should be highly suggestive of herpes esophagitis, as ulceration almost always occurs on a background of diffuse plaque formation in patients with candidiasis [18, 20]. Although discrete ulcers are characteristic of herpes esophagitis, other conditions such as drug-induced esophagitis, reflux esophagitis, and, less frequently, Crohn disease may produce similar findings. Oral medications, particularly tetracycline and doxycycline, may produce a focal contact esoph-

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Fig. 10.-Glycogenic acanthosis with multiple plaquelike lesions in mid esophagus, mimicking appearance of Candsda esophagitis. However, this patient had no esophageal symptoms. (Reprinted with permission from Levine [21].)

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Fig. 12.-Double-contrast esophagogram in patient with drug-induced esophagitis shows several shallow ulcers (arrows) in mid esophagus. Although herpes esophagitis could produce similar findings, the correct diagnosis was suggested by the patient’s recent history of ingesting doxycycline.

Fig. 13.-Patient with AIDS and cytomegalovirus esophagitis. Double-contrast esophagogram shows giant, relatively flat ulcer (arrows) in distal esophagus. Because herpetic ulcers rarely become so large, this finding should be highly suggestive of cytomegalovirus infaction in patients with AIDS. (courtesy of P. c. Freeny, Seattle, WA.)

Fig. 11.-Herpes esophagitis with ulcers. A, Double-contrast esophagogram shows discrete, widely separated ulcers (arrows) in mid and distal esophagus on otherwise normal background mucosa. Ringlike appearance of some ulcers is due to barium coating rim of crater. B, Different patient with multiple linear and serpiginous ulcers (arrows). (Reprinted with permission from Levine [21].)

agitis with superficial ulceration, most frequently in the mid esophagus at the level of the aortic arch or left main bronchus (Fig. 12) [27, 281. Although the radiologic findings may be indistinguishable from those of herpes esophagitis, a history

of recent drug ingestion should suggest the correct diagnosis. The ulcers of reflux esophagitis almost always can be distinguished from the ulcers of herpes esophagitis by their characteristic location in the distal esophagus at or near the gastroesophageal junction. Rarely, esophageal involvement by Crohn disease can be manifested by discrete aphthous ulcers in the esophagus [29, 30]. However, these patients almost always have associated Crohn disease involving the lower gastrointestinal tract, so that this diagnosis should be considered only if there is known Crohn disease in the small bowel or colon.


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Fig. 15.-Diffuse esophageal spasm (DES). A, Spot film of esophagus in patient with DES shows disrupted peristalsis with obliterative focal contraction in lower esophagus. B, Spot film of another patient with DES shows typical “corkscrew” or “curling” appearance.

A

Fig. 14.-Nonspecific esophageal motility disorder (NEMD). A, Spot film of esophagus in patient without esophageal symptoms shows simultaneous tertiary contractions. This patient had intermittent disruption of primary peristalsis at fluoroscopy. NEMD was diagnosed manometrically. B, Spot film of disrupted primary peristalsis with tertiary contractions in another patient with NEMD. clinical and manometric correlation is needed to distinguish this disorder from diffuse esophageal spasm.

Cytomegalovirus (CMV) esophagitis.-CMV is another member of the herpes virus group that has recently been recognized as a cause of opportunistic esophagitis in patients with AIDS. CMV esophagitis may also be manifested radiologically by discrete, superficial ulcers in the mid or distal esophagus [31 -33]. In other patients, however, CMV may lead to the development of one or more large, relatively flat ulcers, surrounded by a radiolucent rim of edematous mucosa (Fig. 1 3) [20, 31 33]. Because ulcers in herpes esophagitis rarely become this large, the presence of one or more giant esophageal ulcers should be highly suggestive of CMV esophagitis in patients with AIDS. However, endoscopic brushings, biopsies, or cultures are required for a definitive diagnosis. ,

Conclusions The double-contrast esophagogram is a valuable technique for diagnosing opportunistic esophagitis. The presence of mucosal plaques should suggest Candida esophagitis, whereas discrete ulcers should suggest herpes esophagitis, and one or more large, relatively flat ulcers should suggest

CMV esophagitis, particularly in patients with AIDS. Thus, fungal and viral esophagitis often can be differentiated by their characteristic features on double-contrast radiographs, eliminating the need for endoscopic intervention [21 ]. Nevertheless, endoscopy may be required for a definitive diagnosis if the radiologic findings are equivocal or if appropriate treatment with antifungal or antiviral agents fails to produce an adequate clinical response in these patients.

Esophageal

Motility Disorders

as a Cause of Chest Pain

Recurrent chest pain is a serious complaint because of the possibility of cardiac disease. Patients often remain anxious even after reasonable exclusion of coronary artery disease, making evaluation of a noncardiac cause of the pain paramount. The enormity of this problem is evident by the finding of normal coronary arteries at cardiac catheterization in up to 30% of patients with anginal symptoms [34]. Structural and functional esophageal abnormalities are potential causes of noncardiac chest pain. This discussion concerns esophageal motility disorders as a possible explanation of anginalike symptoms and the contribution of radiologic evaluation.

Clinical

Perspective

To place this clinical problem into perspective, can be suggested for evaluating all patients

an algorithm with recurrent

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940

chest pain. Cardiac disease must be excluded first, because about 70-80% of those with anginalike chest pain will have coronary artery disease [35]. Only 1 0-1 5% will have an esophageal cause, which may include structural disease, gastroesophageal reflux, or a motility disorder. Structural disease of the esophagus, such as neoplasm or esophagitis, is diagnosed by endoscopic or radiologic examination, which is done next if the chest pain is believed to be of noncardiac origin.

If cardiac disease and a structural esophageal disorder have been excluded, the presence of gastroesophageal reflux as a cause of chest pain is then evaluated. About 40% of patients with symptomatic reflux will have normal esophageal mucosa at endoscopy, and even about 40% of those with endoscopic esophagitis do not show radiologic abnormalities [36]. These patients with reflux disease and normal esophageal mucosa need to be identified by histologic examination, acid perfusion testing, or prolonged pH monitoring of the lower esophagus. Indeed, ambulatory pH monitoring for 24 hr is the simplest and most sensitive means of diagnosing abnormal gastroesophageal reflux [37]. After these exclusions, a small minority of patients remain for whom an esophageal functional disorder might explain their chest pain. In a recent study of 91 0 patients with noncardiac chest pain, only 255 (28%) had abnormal esophageal motility on manometric examination [38]. Nutcracker esophagus (1 22/255), nonspecific esophageal motility disorder (NEMD) (92/255), and diffuse esophageal spasm (DES) (26/255) accounted for 94% of the abnormal manometric diagnoses. Achalasia, which more often presents with dysphagia and is the motility disorder best detected radiologically [39], was rare (5/255) in patients with chest pain. A hypertensive lower esophageal sphincter was uncommon (10/255), but it is a controversial entity without radiologic findings [40].

Radiologic

Evaluation

The role of radiologic evaluation of abnormal esophageal motility as a cause ofchest pain will apply to a small proportion of these patients, especially if cardiac disease has not been excluded. Most patients with noncardiac chest pain have normal esophageal motility on manometric examination [38]. Proper fluoroscopic observation accurately assesses normal esophageal peristalsis with reported specificities of 91 -95% [41 -43]. Multiple single swallows of barium must be observed with the patient prone to determine the actual prevalence of primary peristalsis. The use of five separate swallows is recommended and has shown a 92% agreement with synchronous manometric evaluation [43]. Radiologic detection of esophageal motility disorders depends on the disorder being evaluated and on the quality of the examination done. In the previously quoted manometric study of 910 patients with noncardiac chest pain, nutcracker esophagus was present in 48% of those with abnormal motility [38]. Nutcracker esophagus is a manometric diagnosis showing normal peristalsis but high-amplitude lower esophageal contractions. Radiologic examination is normal, although nonspecific tertiary contractions are seen occasion-

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ally [44]. NEMD accounted for 36% of abnormal manometric diagnoses, and is a catchall term to describe those motility disturbances that defy specific classification. Radiologic findings in NEMD are also nonspecific and include primary penstaltic disturbance and tertiary contractions (Fig. 1 4). In our retrospective experience, about half of NEMD cases are detected radiologically [42]. DES was responsible for only 1 O% of abnormal manometnic findings, and is seen as intermittent absence of penistalsis with spontaneous, repetitive nonpenistaltic contractions on fluoroscopic examination (Fig. 1 5). The reported radiologic sensitivity in DES is about 75% [45], although with careful fluoroscopic observation of five single swallows, detection of NEMD and DES probably would improve [43]. With these detection rates and the spectrum of motility disorders seen in the 255 patients with noncardiac chest pain, the overall radiologic sensitivity in this selected population translates to nearly 30% (71/255). What are the general implications of this sensitivity rate for the role of radiologic evaluation of esophageal motility in patients with chest pain? If 1000 patients presented with anginalike chest pain, cardiac disease would be found in approximately 750, esophageal disorders in 1 50, and miscellaneous causes in 1 00. Structural esophageal disease and gastroesophageal reflux would account for most causes of esophageal origin, leaving perhaps 50 patients with motility disorders on manometric examination. Of these 50 patients, about 1 5 cases would be detected radiologically for an overall return of 1 .5% (i.e., 15/1000). Indeed, the radiologic examination has greater impact in diagnosing normal motility and the presence of structural abnormalities of the esophagus.

Caveats

and Conclusions

Several caveats in this scenario must be mentioned. First, the concept of “microvascular angina” warrants discussion, since some patients with small-vessel disease and normal coronary arteries on angiography would be categorized as having noncardiac chest pain [34]. These patients would dilute the pool of those with a potential esophageal cause of chest pain. The relative importance of microvascular angina in this analysis is not known. Second, as patients age, the chance of coexisting cardiac and esophageal disease increases and may confuse the attribution of symptoms. Finally, recognition of abnormal esophageal motility does not prove an esophageal origin for the chest pain [35]. Most patients with chest pain and abnormal motility do not have symptoms at the time of manometric or radiologic examination, and only a minority respond to provocative testing with acid perfusion or drugs, such as edrophonium. Furthermore, prolonged ambulatory monitoring of esophageal function has shown changing motility patterns, questioning the validity of the short temporal sampling of esophageal function done with most standard manometnic examinations. In conclusion, the efficacy of the radiologic examination of the esophagus is related, in part, to the presenting complaint of the patient. Dysphagia is more effectively evaluated radiologically because structural disease is often found and acha-


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ESOPHAGEAL

Iasia is an important component of the spectrum of abnormal motility [39]. However, only a minority of those with recurrent chest pain will have symptoms originating in the esophagus. Structural disease and gastroesophageal reflux account for most esophageal causes of chest pain. This leaves only a small fraction of patients in whom abnormal esophageal motility is a potential source of their pain, and the radiologic examination is normal in many of these patients.

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RADIOLOGY

22.

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L, Redmond

P, Horowitz

L, Ruoff

M. Glycogen

plaques

(glycogen

acanthosis) of the esophagus. Radiology 1981;141 :607-610 Glick SN, Teplick 5K, Goldstein J, Stead JA, Zitomer N. Glycogen acanthosis of the esophagus. AJR 1982:139:683-688 Levine MS, Loevner LA, Saul SH, Rubesin SE, Herlinger H, Laufer I. Herpes esophagitis: sensitivity of double-contrast esophagography. AJR 1988;151 :57-62 Levine MS, Laufer I, Kressel HY, Friedman HM. Herpes esophagitis. AJR

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Agha FP, Lee HH, Nostrant lenge in immunocompromised

U.

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esophagitis: a diagnostic chalAm J Gastroentero! 1986;81:

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Update on metastatic gastric and esophageal cancers.

[Reporting initiatives. An update on treatment in radiology].

Oro-Maxillofacial Radiology and Imaging: An Update.

GEP-NETS update: Interventional radiology: role in the treatment of liver metastases from GEP-NETs.

[A 1st evaluation by the Ultrasound Professional Society, AGUS - ultrasound update radiology].

Whither radiology? Wither radiology?

Sclerosing bone dysplasias: genetic, clinical and radiology update of hereditary and non-hereditary disorders.

Non-operative management of hepatic trauma and the interventional radiology: an update review.

[Melanoma: introduction and special demands on radiology].

On the importance of teaching undergraduate radiology.

Knee bone tumors: findings on conventional radiology.

Editorial: Radiology now. Which? On radiation.

Autoimmune pancreatitis mimicking Klatskin tumour on radiology.

ESR concept paper on value-based radiology.

Radiology department organization and radiology education.

Real view radiology-impact on search patterns and confidence in radiology education.

Update on Takayasu's arteritis.

Update on Newborn Screening.

Update on Autoimmune Hepatitis.

Update on juvenile spondyloarthritis.

Update on equine allergies.

Update on laser angioplasty.

Radiology on the move--phase II: planning of a new outpatient specialty center radiology department.

Update on selenoprotein biosynthesis.