Acquired pediatric esophageal diseases Imaging approaches and findings. M. Mearadji International Foundation for Pediatric Imaging Aid

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2 Acquired pediatric esophageal diseases Imaging approaches and findings M. Mearadji International Foundation for Pediatric Imaging Aid

3 Acquired pediatric esophageal diseases The clinical signs of acquired esophageal lesions are uncharacteristic with a long or short patient history An immediate diagnostic approach is indicated in even slightly suspicious cases

4 Acquired esophageal diseases in childhood 1. Gastro esophageal reflux disease 2. Foreign body ingestion 3. Esophageal trauma and perforation 4. Achalasia 5. Caustic ingestion 6. Infective esophagitis 7. Esophageal varices

5 Non-infective esophagitis (reflux esophagitis) Reflux esophagitis as a non infective inflammation is a common complication of severe gastro-esophageal reflux disease Recurrent vomiting with hematomesis is a usual finding Additional symptoms are failure to thrive and recurrent respiratory infections Patients with psychomotoric retardation are more affected Reflux esophagitis may lead to strictures

6 Radiological findings of reflux esophagitis Dysmotility Thickening of mucosal folds Peptic ulceration Strictures Eosinophilic esophagitis as an atopic condition mimicking the reflux esophagitis

7 A B C Gastro-esophageal reflux disease with reflux esophagitis A. Hemorrhagic esophagitis endoscopical finding B. Sliding hernia with esophagitis confirmed by endoscopy C. Esophagitis detected on CT

8 Esophagitis complicated with strictures and ulcerations

9 Foreign body ingestion The peak incidence is between 6 months and 6 years The most frequent presenting symptoms are dysphagia, (drooling, retching) and vomiting Absence of symptoms does not exclude presence of foreign body in children Ingested foreign bodies range from cheap toys to costly jewels Complications: perforation and abscess formation

10 Radiological findings of esophageal foreign body ingestion Cervicothoraco-abdominal and lateral chest film X-ray film reveals all metal objects and less frequently glass and fishbones Other non-radio-opaque objects such as plastic toys should be visualized with contrast medium as filling defects Treatment: endoscopical or fluoroscopical (with extraction with Foley or magnetic catheter)

11 Several objects in esophagus 11

12 Esophageal trauma and perforation Mostly iatrogenic The incidence is increasing as more diagnostic and therapeutic endoscopy are performed Perforation occurs as a complication of stricture dilatation (4-6 per 1000 cases) Other etiologies are foreign body, caustic damage, infection and penetrating trauma Iatrogenic perforation of esophagus and pharynx due to malposition of nasogastric tube in neonatal nursery is a rare complication

13 Radiological finding and diagnostic procedures by esophageal perforation AP and lateral chestfilm is the first diagnostic procedure Findings include, pneumomediastinum, pneumothorax, hydropneumothorax, subcutaneous emphysema and pleural effusion Contrast studies with non-ionic media are needed to look for location and extention of esophageal perforation CT is only indicated, when positive clinical signs with negative esophagogram An abnormal position of nasogastric tube in neonates, outside the esophagus in mediastinum or in pharynx with or without pneumomediastinum is suspicious for perforation

14 Para esophageal perforation caused by feeding tube Edema of the upper esophagus by strangulation Iatrogenic perforation during stretching of esphageal stenosis

15 Two cases of iatrogenic perforation of esophagus with pneumomediastinum during insertion of a nasogastric tube

16 Achalasia Rare in children 5% of the affected population with achalasia are children Most affected children are above the age of 5 years, but it is not uncommon to observe the disease in younger children Characterized by defective relaxation of cardia and absence of esophageal peristalsis The clinical signs in older children are dysphagia, chest pain, vomiting of undigested food and poor weight gain In infancy the symptoms are similar to gastroesophageal reflux with regurgitation an recurrent pneumonia

17 Radiological findings of achalasia The chest radiograph may reveal a dilated esophagus with an air fluid level with or without trachea displacement Barium study of esophagus shows a dilated esophagus that tapers smoothly to a birdsbeak Normal peristaltic activity above the aortic arch with abnormal motility in distal part of esophagus Retention of contrast media in esophagus 10 minutes or later after ingestion

18 Two cases of achalasia Note the fluid level on the chestfilm and delayed esophageal passage direct 1 minute 10 minutes

19 Caustic ingestion Most common in children less than 6 years of age Injury depends on physical, characteristic and quantity of the agent ingested and the duration of mucosal contact Caustic ingestion with acidic compounds affects usually the stomach, whereas alkali ingestion causes esophagitis Swelling of epiglottis indicates that the caustic agent has reached the esophagus Most damages occur in the upper and middle esophagus To reduce the risk of perforation an endoscopical evaluation is recommended 48 hours after such incident

20 Radiological procedures and findings for caustic ingestion Initial evaluation by neck film and thoraco-abdominal film Endoscopy is considered to be the diagnostic method of choice in the acute phase, to assess the extent and severity of injury An additional early radiological examination with nonionic contrast media is indicated in case of perforation CT is also indicated if suspicion for perforation is high A barium study should be routinely performed 3 weeks after corrosive injury The presence, number, length and location of esophageal strictures should be visualized for an adequate treatment

21 Four cases with caustic esophagitis and severe strictures

22 Infective esophagitis A rare complication of some severe diseases Usually by opportunistic organisms in children with low immunity (AIDS or leukemic patients) The most common infective agent is candida albicans, but also viral agents (CMV and herpes simplex) Clinical symptoms are stomatitis, ingestion problems and vomiting The radiological finding are similar to reflux esophagitis but more severe and acute with ulceration, strictures and perforation

23 A case of infective esophagitis by a leukemic patient (monoliasis)

24 Esophageal varices (EV) Common finding in severe portal hypertension Located usually in the distal and third of the esophagus, but may extend higher to the level of the azygos vein Symptoms of EV: upper GI bleeding Clinical signs of hepatic diseases are mostly present Endoscopy is the diagnostic and therapeutic method of choice, especially in acute cases

25 Imaging and findings of EV On esophagogram varices can be detected only if the EV are filled with blood Better visualized during residual filling of esophagus Periodic increase in size and shape may be seen Hypotonicity and poor peristalsis can be an additional sign of EV on esophagogram CTA is an adequate modality in visualization of portal system, especially in imaging of collateral portal circulation

26 Three cases of esophageal varices with endoscopic findings

27 Conclusions Imaging procedures of congenital and acquired esophageal lesions need accurate patient history and clinical information Contrast studies and endoscopy have still priority in evaluation of esophageal diseases US, CT and MRI are additional modalities in more complicated abnormalities Contrast studies should be performed with non-ionic media, especially in postoperative period and neonatal age

28 Conclusions Contrast media has to be avoided in diagnostic of esophageal atresia because of the risk of aspiration Application of contrast media by feeding tube is useful to reduce the risk of aspiration, especially in tracheal fistula and leakage Gastro-esophageal reflux is a frequent finding in infancy and childhood Esophageal imaging has to be focused not only on anatomic changes, but also on functional disorders

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