Dr W.J. ConradieDepartment of Diagnostic Radiology

March 2012

Case studyEsophagus

Housewife

No previous major surgery

Medical history: Hypertensive with mild CCF on medication. Irritable bowel syndrome

Medication: Fosamax Disprin Adco Dol Enalapril and Lasix

Family history: Eldest son died of esophageal Ca in 2007

93 year old Caucasian female

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

2008: Presented with..

Large para-tracheal mass on the left extending into/through thoracic inlet

Moved with swallowingNo features of thyrotoxicosis

No cervical lymphadenopathy

Severe kypho-scoliosis

Clinically:

CXR: Degenerative spineClear lung fields

Bloods:Normal

FBC, U&E, LFT CRP and ESR Thyroid functions

S-albumin

Special investigations:

Large irregular mass from left thyroid lobeExtends deep into superior mediastinumCyst with calcifications inferiorlyNodule in superior aspect of lobe with central

breakdownNo mediastinal lympnodes

Lung fields clear

Incidental: Aorta arch anomaly

Special investigations:CT chest (19-06-2008)

Aorta arch anomaly:

1. Main stem for right and left common carotid

2. Left subclavian artery

3. Aberrant right subclavian artery

Special investigations:Barium swallow (AP)

Barium swallow (lateral)

Differential diagnosis for

dysphagia

1. Thyroid mass

2. Zenker ‘s Diverticulem

3. Aberant right subclavian artery (dysphagia lusoria)

4. Achalasia

Named after Friedrich Albert von Zenker who was a German pathologist (1825 – 1898)

Definition: Mucosal outpouching of posterior hypopharyngeal wall. Proximal to upper esophageal sphincter (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 cricopharyngeus muscles.

Due to cricopharyngeal dysfunction luminal pressure

Zenker ‘s Diverticulem

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 diagnosis1. Killian-Jamieson diverticulum

(K-J)

2. Esophageal web

3. Lateral pharyngeal pouch

4. Epidermolysis bullosa dystrophica

General features:Location: Killian’s dehiscence Posterior above cricopharyngeusC5-6Size: 0.5-8cm (average 2.5cm)Best diagnostic clue: Barium filled sac!

Radiographic findings: CXR/CT:

Air-fluid level in superior mediastinum

Zenker ‘s DiverticulemImaging findings

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

Zenker ‘s DiverticulemClassification

Dysphagia secondary to extrinsic esophageal compression by an aberrant right subclavian artery

Described by Bayford in 1794 

lusoria - Greek phrase lusus naturae, meaning  “ freak or zest of nature”, which refers to the freaky course of the artery (lusoria artery) 

Dysphagia Lusoria

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-subclavian bypass

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 (trypanosoma cruci neurotoxin destroys

ganglia)

Achalasia

AchalasiaPrevalence

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 Esophageal carcinoma (2-7%)

Management: Aimed at improving

esophageal emptying Calcium channel blockers Botulinum toxin injection Pneumatic dilatation Heller myotomy

General findings2 criteria:

Absent primary/secondary peristalsisLES fails to relax when swallowing

Tertiary waves

"Bird-beak" deformityDilated esophagus with smooth, symmetric,

tapered narrowing at GEJ

AchalasiaImaging findings

AchalasiaImaging findings

CXR:Mediastinal widening

Double contour

Anterior tracheal bowing

Air-fluid level in mediastinum

Small or absent gastric air bubble

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

Achalasia

Differential diagnosis1. Scleroderma

2. Esophageal carcinoma

3. Gastric carcinoma

4. Esophagitis with stricture

5. Diffuse esophageal spasm

Cause for dysphagia: Thyroid massSurgicaly removed 16-07-2008Histology: Benign, Non toxic Nodular goitre

Outcome (2012): Improved but still suffers from dysphagia!!

Zenker’s divertikulem?ARSA?

THANK YOU

Back to grandma..

1. Weissleder, Wittenberg, Harisinghani, Chen. Primer of Diagnostic Imaging. Fifth edition. 2011.

2. Federle, Jeffrey, Desser, Anne, Eraso. Diagnostic Imaging of the Abdomen. First edition. 2004.

3. (PPP) ZENKER’S DIVERTICULUM. N. D’Souza,Underbrink. 2010

4. J. Dandelooy, J.P.M. Coveliers, P.E.Y. Van Schil, S.Anguille. Dysphagia lusoria. CMAJ • October 13, 2009 • 181(8)

5. P.D. Kent, T.H. Poterucha. Aberrant Right Subclavian Artery and Dysphagia Lusoria. N Engl J Med, Vol. 346, No. 21 May 23, 2002

REFERENCES