OTHER SYSTEMS -- RADIO

AIDS and CD4

AIDS defined as ≤ 200 CD4 cells per microliter

HIV/AIDS & the Nervous System

• Atrophy: HIV, CMV

• Mass lesions: Toxoplasmosis, Lymphoma

• White matter: HIV, progressive multifocal leukoencephalopathy (PML)

• Myelopathy: HIV, intrinsic disease, lymphoma, extrinsic compression

• Meningitis: the usual bugs + Cryptococcus, HIV, Mycobacteria

• Most common post-mortem finding in patients who die of AIDS

• Poor correlation between severity of imaging abnormality and degree of cognitive impairment

• Widened sulci and cisterns (CSF spaces) 

• Enlarged ventricles

Mass Lesions — Mass Effect Present

• Toxoplasmosis

• Primary CNS Lymphoma

• Cryptococcal disease

• Other infections including Herpes simplex/zoster, M. tuberculosis, M. avium intracellulare, T. pallidum, Fungi (Aspergillosis, Candidiasis, Nocardiosis, Coccidioidomycosis), Amebiasis

• Infarction

Mass Lesions — Mass Effect Absent

• PML (progressive multifocal leukoencephalopathy)

• HIV encephalitis

• CMV encephalitis

• Cerebral Atrophy

TOXOPLASMOSIS

• Most common opportunistic CNS (central nervous system) infection in AIDS

• Caused by Toxoplasma gondii (reservoir: infected cats)

• Radiographic features:

  • Solitary or multiple ring-enhancing lesions on post-contrast imaging (MRI and CT)

  • Target appearance

  • Marked surrounding edema

Primary CNS Lymphoma

• Primary CNS Lymphoma in the immunocompetent patient is uncommon

• After toxoplasmosis, focal intracranial lymphomatous masses are the second most common focal brain lesions in adults with AIDS

• Typically low CD4 counts <50

• Lesions are seen on CT and MRI although both modalities may underestimate the true extent of disease

  • Hyperdense on unenhanced CT secondary to dense cells

  • Variable contrast enhancement

  • MRI is more sensitive than CT for detection

• tendency for midline structures

• butterfly appearance

MR T1 post-contrast axial image of lymphoma in an immunocompromised patient

• peripherally and heterogeneously enhancing masses (arrows) in the frontal lobes 

Primary CNS Lymphoma

• Primary CNS Lymphoma in the immunocompetent patient is uncommon

• After toxoplasmosis, focal intracranial lymphomatous masses are the second most common focal brain lesions in adults with AIDS

• Typically low CD4 counts <50

• Lesions are seen on CT and MRI although both modalities may underestimate the true extent of disease

  • Hyperdense on unenhanced CT secondary to dense cells

  • Variable contrast enhancement

  • MRI is more sensitive than CT for detection

• tendency for midline structures

• butterfly appearance

Toxoplasmosis vs. CNS Lymphoma ****

Toxoplasmosis

• More likely to present with multiple ring-enhancing intracranial masses

• Random distribution 

• Empiric treatment with anti-protozoan drugs and reassessment of lesions on follow up imaging is often used to distinguish between the two

• Nuclear medicine thallium scan appears as a cold lesion

CNS Lymphoma

• Lymphoma is more likely to present with a single intracranial mass than toxoplasmosis

• Though lymphoma can present as multiple ring enhancing lesions in immunocompromised PTs 

• Periventricular location and subependymal spread

• Nuclear medicine thallium scan appears as a hot lesion

Progressive Multifocal Leukoencephalopathy (PML)

• Demyelinating disease caused by the reactivation of JC virus

  •  reactivated virus infects and destroys the oligodendrocytes

• Classically presents with neurologic deficits

• No current treatment has proven effective

• Also has been reported with use of immunosuppression medications and other immunosuppressive conditions

  • Rituxan (rituximab) treatment for rheumatoid arthritis, certain hematological cancers etc

  • Tysabri (natalizumab) treatment for multiple sclerosis and Crohn’s disease

  • Organ transplant recipients

• Abnormal confluent periventricular and subcortical white matter

  • Focal areas of low density on CT

  • High T2 signal and low T1 signal on MRI

  • Bilateral and asymmetrical

• No significant contrast enhancement

• No mass effect

HIV Encephalopathy

• Direct infection

•  Difficult to differentiate from PML 

  • Both affect the white matter

  • No mass effect

  • Bilateral and symmetric

    • PML = asymmetrical

  • High T2 signal and low T1 signal on MRI

HIV and Pulmonary Manifestations

• Streptococcal pneumonia is the most common pulmonary infection

• Opportunistic infections — infectious diseases

  • PCP (now called pneumocystis jirovecii or PJP)

  • Other: mycobacterial TB, CMV, fungal

• Non-Infectious disease

  • asthma

  • emphysema

  • Kaposi sarcoma

Pneumocystis Jirovecii Pneumonia (PCP)******

• Formerly known as Pneumocystis carinii

• Normal Chest X-ray in 10-15%

• Fine reticular interstitial pattern in up to 80%

  • Chest x-ray: Bilateral perihilar or diffuse markings

  • CT: ground glass appearance predominantly in upper lobes with cysts

  • NM: Increased nuclear medicine Gallium scan uptake

• Progression to diffuse consolidation within days

• Upper lobe air-filled cysts or pneumatoceles 10%

  • cause Pneumothorax - lung collapse and air in pleural space

• Pleural effusions are uncommon (<5%)

Mycobacterial Infection - Post Primary TB

• Appearance depends on CD4 counts

  • CD4 <350 – typical post primary infection (upper lung zones)

  • CD4 <200 – resemble primary infection, miliary pattern, nodal enlargement

• Radiographic features

  • Post primary pattern (reactivation) – keep in Ddx!

    • Upper lung zone consolidations with cavitation

  • Primary pattern

    • Patchy areas of consolidation in any lung zone, effusions

    • Hilar and/or mediastinal adenopathy

      • Necrotic lymph nodes have low attenuation center and a rim of contrast enhancement

  • Miliary TB

    • Hematogenous spread of diffuse tiny nodules, all lung zones

Mycobacterial Infection - Primary TB

• Appearance depends on CD4 counts

  • CD4 <350 – typical post primary infection (upper lung zones)

  • CD4 <200 – resemble primary infection, miliary pattern, nodal enlargement

• Radiographic features

  • Post primary pattern (reactivation) – keep in Ddx!

    • Upper lung zone consolidations with cavitation

  • Primary pattern

    • Patchy areas of consolidation in any lung zone, effusions

    • Hilar and/or mediastinal adenopathy

      • Necrotic lymph nodes have low attenuation center and a rim of contrast enhancement

  • Miliary TB

    • Hematogenous spread of diffuse tiny nodules, all lung zones

Mycobacterial Infection - Miliary TB

• Appearance depends on CD4 counts

  • CD4 <350 – typical post primary infection (upper lung zones)

  • CD4 <200 – resemble primary infection, miliary pattern, nodal enlargement

• Radiographic features

  • Post primary pattern (reactivation) – keep in Ddx!

    • Upper lung zone consolidations with cavitation

  • Primary pattern

    • Patchy areas of consolidation in any lung zone, effusions

    • Hilar and/or mediastinal adenopathy

      • Necrotic lymph nodes have low attenuation center and a rim of contrast enhancement

  • Miliary TB

    • Hematogenous spread of diffuse tiny nodules, all lung zones

Fungal Pneumonia

• Variety of organisms

  • Cryptococcus

  • Histoplasmosis

  • Candida

  • Coccidioidomycosis

• Non specific appearance

  • Can appear as any pneumonia - thus sampling is key!

  • Nodules, reticulonodular pattern, consolidation, adenopathy, effusions

Gastrointestinal Manifestations of HIV

• Dysphagia: Candidiasis, viral esophagitis (herpes, CMV, HIV), KS

• Diarrhea: Cryptosporidiosis, Giardia, mycobacteria

• Colitis: CMV, mycobacteria, C. difficile

• Cholangitis: CMV and/or cryptosporidiosis

Esophagitis

L — Cadidiasis

• “Shaggy” mucosa from plaques

R — HSV Ulcers (also CMV, HIV —» but lead to larger ulcer)

• “Target” shaped small, superficial ulcers

Esophagitis

HIV ulcers

• larger and deeper ulcers

  • compared to herpes

Acalculus cholecystitis (gallbladder) — no stone, common bile duct/gallbladder inflammation (sludge)

• Secondary to

  • cytomegalovirus (CMV) or cryptosporidial infection

• Biliary ductal dilatation and cholangitis

  • caused by CMV or cryptosporidium

• Drugs such as didanosine (DDI)

  • may precipitate pancreatitis

Biliary disease

— AIDS cholangitis

L — RUQ US without and with doppler

R — CT - biliary ductal dilation

Biliary disease

L — focal stenosis at distal CBD

R — papillary stenosis

Pancreatic Disease

Renal System and HIV

• Renal disease may be an early, unsuspected manifestation of HIV infection

• Most patients are asymptomatic

• Sonographic findings include

  • enlarged echogenic kidneys with poor corticomedullary differentiation

• Degree of echogenicity

  • does not directly correlate with extent of renal disease

• CT shows

  • enlarged kidneys

  • occasionally increased attenuation of the medulla on non-contrast study

HIV Nephropathy

• liver brighter than kidney — fatty liver

• kidney brighter than liver — indicative of diease

Renal Colic****

• Indinavir - a protease inhibitor

  • After each dose approximately 12% of the drug is excreted and forms crystals

  • These crystals can

    • obstruct the ureter and form crixivan stones which are radiolucent

• Non-contrast CT scan is study of choice to identify renal stones

Cellulitis

• Swelling, calor, pain

• Staph and strep most common

• Subcutaneous fat stranding

Necrotizing Fasciitis

• Must distinguish superficial cellulitis from necrotizing fasciitis

• Infection of deeper tissue, potentially life threatening

• MR can identify necrosis, hemorrhage and osteomyelitis

• CT can identify subcutaneous gas bubbles

Soft tissue abscess

• Pre and post contrast MRI T1 images
  demonstrate a rim-enhancing fluid collection

Pyomyositis

• Staph most common

• Infection of the muscle

• Can lead to abscess formation and myonecrosis

Osteomyelitis

• Hematogenous spread, direct extension, direct inoculation

• Staph most common

• Tibia, wrist, femoral heads, ribs, spine TL junction

• X-ray changes not evident for 10-14 days

• Nuclear medicine (MDP, Ga-67, In-111)

• MRI with contrast (decreased T1 signal)

Osteomyelitis with Brodie abscess

• Hematogenous spread, direct extension, direct inoculation

• Staph most common

• Tibia, wrist, femoral heads, ribs, spine TL junction

• X-ray changes not evident for 10-14 days

• Nuclear medicine (MDP, Ga-67, In-111)

• MRI with contrast (decreased T1 signal)

Septic Arthritis

• Important to keep in the differential diagnosis with a mono-articular process

• Early diagnosis with aspiration and culture is key to correct diagnosis and determining bug sensitivity

• Can be aggressive and lead to early destruction of cartilage and bone

Kaposi Sarcoma – Skin manifestations

L — Cutaneous lesions seen in 66% of cases; Often pink to purple or brown; Varying in size and appearance

R — Cutaneous and subcutaneous nodules

• AIDS defining malignancy

• Associated with human herpesvirus 8 (HHV-8)

• Low-grade vascular tumor that involves the lymphovascular system

• Affects many organ systems:

  • Pulmonary

  • Gastrointestinal

  • Musculoskeletal

  • Skin

• Several types are recognized

  • HIV/AIDS

  • Organ transplant recipients

  • Endemic in Africa

Kaposi Sarcoma – GI manifestations

L — Marked small-bowel thickening

R — large bowel involvement

• Involves the liver, spleen and bowel

• Liver and spleen

  • Multiple nodules

• Bowel

  • Early disease consists of flat lesions that are not demonstrated on barium studies

  • Lesions coalesce, enlarge and become more nodular

  • Extension into the muscular wall🡪 large bulky polypoid masses and irregular fold thickening

Kaposi Sarcoma – GI manifestations

L — pelvis; lobulated mass of rectosigmoid

R — endoscopy - gross lesion with multiviolaceous nodules

• Involves the liver, spleen and bowel

• Liver and spleen

  • Multiple nodules

• Bowel

  • Early disease consists of flat lesions that are not demonstrated on barium studies

  • Lesions coalesce, enlarge and become more nodular

  • Extension into the muscular wall🡪 large bulky polypoid masses and irregular fold thickening

Kaposi Sarcoma – Pulmonary manifestations ***

• Nodules, linear opacities, 40% have pleural effusion, adenopathy

• Present with cough, fever, shortness of breath, hemoptysis and chest pain

• Occurs in 45% of Kaposi sarcoma cases

• Multiple bilateral symmetric flame-shaped or ill-defined nodular lesions, with a peribronchovascular distribution

Kaposi Sarcoma – Pulmonary manifestations ***

• Nodules, linear opacities, 40% have pleural effusion, adenopathy

• Present with cough, fever, shortness of breath, hemoptysis and chest pain

• Occurs in 45% of Kaposi sarcoma cases

• Multiple bilateral symmetric flame-shaped or ill-defined nodular lesions, with a peribronchovascular distribution

Lymphoma

• Second most common AIDS-defining malignancy is Non-Hodgkin Lymphoma

  • Diffuse B-cell lymphoma

  • Burkitt lymphoma

  • Primary CNS Lymphoma

• Primarily present as masses and lymphadenopathy

• Biopsy is required for diagnosis

• PET/CT is helpful in initial staging, guidance for biopsy, and assessing treatment response

Gastrointestinal Lymphoma

• Less than 10% of AIDS patients will develop GI lymphoma

• Non-Hodgkin’s lymphoma is more common than Hodgkin’s

• Highly aggressive with poor prognosis

• Advanced disease is usually present at the time of diagnosis

• Peripheral lymphadenopathy often absent

• Stomach, enteric and rectal lymphoma will appear as irregular fold thickening on barium studies

• CT helpful in demonstrating extraluminal extent

• Liver, spleen and pancreas involvement suggested by single or multiple focal, homogeneous low density masses on CT scan or focal hypoechoic lesions on ultrasound

• Bulky retroperitoneal or mesenteric adenopathy is common

• Differential diagnosis

  • Kaposi Sarcoma

  • Tuberculosis

Burkitt Lymphoma

• Most commonly seen in HIV-infected and posttransplant patients

• Associated with Epstein-Barr virus (EBV) infection

• Occurs in HIV-infected patients with high CD4 lymphocyte count (>200/µl)

• Involves lymph nodes, bone marrow, CNS

L - Rheumatoid Arthritis

• Chronic inflammatory disorder

• Unknown etiology

  • Unknown agent initiates a non-specific immune response.

• Clinical diagnosis based on ACR criteria (at least 4)

  • Morning stiffness

  • Arthritis in three or more joints

  • Symmetrical arthritis

  • Rheumatoid nodules

    • sparing of DIP joints in hands

  • Serum rheumatoid factor

  • Radiographic changes

Rheumatoid Arthritis

• Chronic inflammatory disorder

• Unknown etiology

  • Unknown agent initiates a non-specific immune response.

• Clinical diagnosis based on ACR criteria (at least 4)

  • Morning stiffness

  • Arthritis in three or more joints

  • Symmetrical arthritis

  • Rheumatoid nodules

    • sparing of DIP joints in hands

  • Serum rheumatoid factor

  • Radiographic changes

Rheumatoid Arthritis

• Chronic inflammatory disorder

• Unknown etiology

  • Unknown agent initiates a non-specific immune response.

• Clinical diagnosis based on ACR criteria (at least 4)

  • Morning stiffness

  • Arthritis in three or more joints

  • Symmetrical arthritis

  • Rheumatoid nodules

    • sparing of DIP joints in hands

  • Serum rheumatoid factor

  • Radiographic changes

Rheumatoid Arthritis

• Chronic inflammatory disorder

• Unknown etiology

  • Unknown agent initiates a non-specific immune response.

• Clinical diagnosis based on ACR criteria (at least 4)

  • Morning stiffness

  • Arthritis in three or more joints

  • Symmetrical arthritis

  • Rheumatoid nodules

    • sparing of DIP joints in hands

  • Serum rheumatoid factor

  • Radiographic changes

Rheumatoid Arthritis

• Chronic inflammatory disorder

• Unknown etiology

  • Unknown agent initiates a non-specific immune response.

• Clinical diagnosis based on ACR criteria (at least 4)

  • Morning stiffness

  • Arthritis in three or more joints

  • Symmetrical arthritis

  • Rheumatoid nodules

    • sparing of DIP joints in hands***

  • Serum rheumatoid factor

  • Radiographic changes

Rheumatoid Arthritis — Extra-articular Clinical Features

• Skin

  • Nodules

  • Vasculitis (purpura)

• Eye

  • Sicca complex

  • Episcleritis

  • Scleritis

• Heart

  • Pericarditis

  • Myocarditis (rare)

• Lung

  • Pleural effusion

  • Interstitial fibrosis***

• Nerve

  • Entrapment

  • Vasculitis

    • Sensory neuropathy

    • Mononeuritis

• Blood

  • Anemia

  • Amyloidosis

RA

• Small to moderate effusion

• Unilateral

• Often chronic

L — RA

• Interstitial Fibrosis and Pneumonitis

• CT Findings

  • Reticular opacities

  • Subpleural zones

  • Thickened interlobular septa

  • Honeycombing

RA

• Interstitial Fibrosis and Pneumonitis

• Radiographic Features

  • Linear opacities

  • Bases

  • Honeycombing

RA — Necrobiotic (rheumatoid) nodule

• Multiple

• Well-circumscribed

• Periphery of lung

• Cavitation is common

• Thick, smooth walls

• Change in size

Systemic Lupus Erythematosus
- ACR Revised Criteria

• Malar rash

• Discoid Rash

• Oral Ulcers

• Arthritis

• Serositis

• Renal disorder

• Neurologic disorder

• Hematologic disorder

• Immunologic disorder

• Antinuclear antibody

Systemic Lupus Erythematosus — description

• Chronic immune disorder of unknown etiology

  • Circulating immune complexes and autoantibodies cause tissue damage 

• Multisystem involvement

• Exacerbations and remissions

• Young woman > Men

• Positive antinuclear antibodies

Systemic Lupus Erythematosus

• “Water Bottle” Sign***

  • pericardial effusion***

• pleuritis / effusion = most common

  • small, bilateral effusions

  • pericardial effusion

  • early manifestation

Systemic Lupus Erythematosus

• “Water Bottle” Sign***

  • pericardial effusion***

• pleuritis / effusion = most common

  • small, bilateral effusions

  • pericardial effusion

  • early manifestation  

Systemic Lupus Erythematosus → Atelectasis

• Subsegmental

• Generally in bases

• May be migratory and fleeting

• Associated with pleural effusion or diaphragm dysfxn

L — Systemic Lupus Erythematosus (Intestinal Vasculitis)****

• Esophagus to colon

• CT findings

  • Dilated bowel

  • Wall thickening

  • Target sign

  • Engorged mesenteric vessels (comb sign)

  • Ascites

Systemic Lupus Erythematosus

• CNS Vasculitis

Systemic Lupus Erythematosus

• Jaccouds Arthropathy***

  • swan neck

  • rare, chronic, non-erosive joint condition characterized by reversible hand and finger deformities

Systemic Lupus Erythematosus

• soft tissue calcifications

Scleroderma — description

Scleroderma

• Progressive systemic sclerosis

• Widespread fibrosis and atrophy

  • Skin

    • Fingers and hands

    • Raynaud’s phenomenon

    • Subcutaneous calcifications**

    • Acroosteolysis**

  • Lung (2^nd most common site)

    • Isolated pulmonary hypertension

    • Interstitial lung disease

  • GI tract (esophagus most common)

    • Esophageal dilatation (Achalasia)**

    • Small bowel dysfunction

• Limited form and diffuse form

• Females > Males

• Age 40 to 70 years

Scleroderma — CREST Syndrome

C = Calcinosis

R = Raynaud’s phenomenon

E = Esophageal dysmotility

S = Sclerodactyly

T = Telangiectasia

Scleroderma — Acroosteolysis***

• a medical condition characterized by the resorption, breakdown, and disappearance of the distal phalanges

Scleroderma — Acroosteolysis***

• a medical condition characterized by the resorption, breakdown, and disappearance of the distal phalanges

Scleroderma — Fibrosis

• Linear opacities

• Bases

• Calcinosis of soft tissues

Scleroderma — Esophagus

• Proximal third unaffected

• Incompetent LES

• Patulous G-E junction

• No normal peristalsis

• Resultant reflux

• Eventual stricture

Scleroderma — “Bird’s Beak”

Achalasia***

• a rare swallowing disorder where the lower esophageal sphincter (the valve between the esophagus and stomach) fails to relax, and the normal muscle contractions of the esophagus stop working

Scleroderma

• Narrow separation between folds “hide bound” 

• Small-bowel dilatation and air-fluid levels 

• Wide-mouthed diverticula

Polymyositis/Dermatomyositis

Polymyositis/Dermatomyositis

• Idiopathic inflammatory muscle disease

• Peak incidence in childhood and late adulthood

• Woman > Men (2:1)

• ? Viral infection with altered immune response

• Minority of cases a/w malignancy

Polymyositis vs Dermatomyositis

• Polymyositis

  • Proximal muscle weakness

  • Muscle enzyme elevation

  • Characteristic EMG

  • Inflammatory infiltrates on Bx

• Dermatomyositis

  • As above, with characteristic rash

** erythematous patches — face, neck, chest, extensor surfaces

** muscle weakness — gradual/steady progression

Polymyositis

• CT findings

  • Linear abnormalities

  • Ground-glass attenuation 

  • Air-space consolidation 

    • mainly in the middle and lower lung zones

    • peribronchial and subpleural distribution 

Polymyositis

• Chronic interstitial pneumonitis

• Aspiration pneumonia

  • Due to hypotonic esophagus/pharynx

• Hypostatic pneumonia

  • Due to chest wall involvement/hypovent

• Diffuse soft tissue calcifications

L — Ankylosing Spondylitis = BAMBOO SPINE***

• Autoimmune disease of unknown pathogenesis 

• Primarily affects the axial skeleton

•  Male > Female (3:1)***

• Involvement of thoracic spine is most common

• Pleuro-pulmonary manifestations in 1-2%

Ankylosing Spondylitis = Anterior syndesmophytes

• Autoimmune disease of unknown pathogenesis 

• Primarily affects the axial skeleton

•  Male > Female (3:1)***

• Involvement of thoracic spine is most common

• Pleuro-pulmonary manifestations in 1-2%

Ankylosing Spondylitis = Fused SI Joints

• Autoimmune disease of unknown pathogenesis 

• Primarily affects the axial skeleton

•  Male > Female (3:1)***

• Involvement of thoracic spine is most common

• Pleuro-pulmonary manifestations in 1-2%

Ankylosing Spondylitis

• Radiographic findings

  • Reticulonodular opacities in the lung apices

  • Become confluent as the disease progresses

  • Upper-lobe fibrotic *** and bullous disease

    • can mimic tuberculosis 

Ankylosing Spondylitis

• CT Findings

  • Peripheral interstitial lung disease

  • Bronchiectasis

  • Paraseptal emphysema

  • Apical fibrosis 

L — Ankylosing Spondylitis

R — TB

Sjögren Syndrome — Imaging

• Bronchiectasis

• Bronchiolar inflammation

• Increased parenchymal lines

• Pulmonary fibrosis 

  • 10-15% of cases

Sjögren Syndrome — Description

• Idiopathic , autoimmune disorder

• Characterized by dry mouth and dry eyes***

• Woman > Men (9:1)

• Infiltration of exocrine glands by immunoglobulin-producing lymphocytes

• Salivary and lacrimal glands most frequently involved

• Extraglandular involvement occurs in 5%–10% of cases

Sjögren’s syndrome — Primary vs Secondary

• Primary Sjögren’s syndrome

  • Skin: Dry skin, Raynaud’s, purpura

  • Lung: Recurrent infection & interstitial fibrosis

  • GI: Angular cheilitis, oral candidiasis, beefy glositis

  • Kidney: RTA, interstitial nephritis

  • Endocrine: chronic thyroiditis

• Secondary Sjögren’s 

  • Associated with other rheumatic disorders (RA, SLE, scleroderma)

Sjögren Syndrome — Imaging

• Lymphocytic Interstitial Pneumonitis****

  • Increased prevalence with Sjögren’s

  • Reticulo-nodular pattern, esp. lower lobes

  • Ground-glass attenuation 

  • Interlobular/bronchovasc. thickening

  • Cysts 

L — Sjögren Syndrome

• Idiopathic , autoimmune disorder

• Characterized by dry mouth and dry eyes***

• Woman > Men (9:1)

• Infiltration of exocrine glands by immunoglobulin-producing lymphocytes

• Salivary and lacrimal glands most frequently involved

• Extraglandular involvement occurs in 5%–10% of cases

Imaging Modalities and Esophagus Dysfunction

• XR (plain film) – limited; assess for free air/obstruction

• Fluoroscopy – mainstay; esophagram, upper GI series 

  • anatomy, obstruction, extravasation (i.e. post-op leak), motility, mucosal abnormalities (mass, ulcer, diverticulum etc)

  • xray guidance to obtain real time images with contrast

• CT - extent of disease; metastatic work-up

• US – endoscopic view for local extent of disease and lymph node involvement

Esophagram

• Indications:

  • dysphagia, odynophagia, heartburn, chest pain

• Standard protocol:

  • NPO for 4 hours

  • EZ gas/fizzies + High density barium (double contrast)

    • to show the wall

  • Low density barium (single contrast)

    • to show the lumen

  • Check for reflux

Normal Esophagus Anatomy

Deep → Superficial

1. mucosa — strat squam

2. submucosa

3. muscle

• inner circular layer

• outer longitudinal

  • upper 1/3 — striated

  • middle 1/3 — striated and smooth

  • lower 1/3 — smooth

• no serosa

(L) Double contrast – high density barium with EZ gas/fizzies

•  mucosal abnormalities

•  masses

  • looks at wall

(R) Single Contrast – low density barium

• caliber, motility

• assess for reflux or obstruction

  • looks at lumen

Indication for use of gastrograffin:

• Suspicion of perforation or post-operatively

Esophagus Dysmotility Disorders

• Dysphagia

Esophagus Dysmotility Disorders

• Achalasia → Birds beak sign

  • Etiology: Failure of relaxation of the lower esophageal sphincter, absence of primary peristalsis

  • Types:

    • Primary (idiopathic): young males 

    • Secondary (neoplasm, peptic stricture, scleroderma): older patients

  • Presentation: Dysphagia (100%), weight loss (90%)

    • Also regurgitation, aspiration pneumonitis

  • Treatment: Pneumatic dilatation, surgical myotomy, medications (CCB’s, botox)

Esophagus Dysmotility Disorders

• Diffuse Esophageal Spasm

  • Repetitive, high amplitude non-propulsive contractions

    • can be prolonged

  • Associated with chest pain

    • which can mimic cardiac disease

  • Presentation → Typically shows “corkscrew” or “rosary bead” pattern

  
  
  

Anatomic Abnormalities — Esophageal Diverticula

• Zenker diverticulum

• Midesophageal diverticulum

• Epiphrenic diverticulum

• Pseudodiverticulosis

Anatomic Abnormalities — Zenker diverticulum

• pulsion diverticulum through cricopharyngeal muscle

• typically at level of C5-6

• dysphagia, regurgitation of food

• foul breath

Anatomic Abnormalities — Zenker diverticulum

• pulsion diverticulum through cricopharyngeal muscle

• typically at level of C5-6

• dysphagia, regurgitation of food

• foul breath

Anatomic Abnormalities — Epiphrenic diverticulum

• pulsion diverticulum: chronic inc. pressures

• Complications: perforation

Anatomic Abnormalities — Pseudodiverticulosis

• Caused by dilation of excretory ducts of deep mucous glands

Anatomic Abnormalities — Hiatal Hernia

• Sliding hernia (95%)

  • incidence increases with age

  • associated with reflux esophagitis (25%)

  • gastroesophageal junction remains above the diaphragm

• Paraesophageal Hernia (5 %)

  • gastroesophageal junction below the diaphragm

  • usually nonreducible and more prone to complications

  • reflux not necessarily associated

Mucosal Pathology — Infectious Esophagitis

• Herpes (Herpes simplex virus type 1)

  • Presentation: flulike prodrome 3-10 days (fever, sore throat, upper respiratory infection, myalgia), odynophagia

  • Imaging: small ulcers <5mm in the midesophagus with radiolucent halos (edema), abnormal motility

  • Diagnosis: viral culture 

  • Treatment: acyclovir

Mucosal Pathology — Infectious Esophagitis

• Candidiasis 

  • Risk Factors: Immunocompromised patients (HIV/AIDS, transplant patients, diabetes mellitus, steroids, chemotherapy, radiotherapy), antibiotics, scleroderma, strictures, achalasia

  • Presentation: dysphagia , severe odynophagia, retrosternal pain

  • Imaging: multiple plaques, “shaggy” esophagus, abnormal motility

  • Treatment: ketoconazole

Mucosal Pathology — Infectious Esophagitis

• Cytomegalovirus (CMV)

  • Immunocompromised

  • severe odynophagia

  • Large ulcers or discrete superficial ulcers

  • Dx by biopsy and culture

  • Tx: Gancyclovir

• HIV

  • Large ulcers

  • Similar to CMV

  • Rx - steroids