CT-imaging of post-inflammatory strictures of esophagus (corrosive, peptic and anastomotic) using contrastenhanced CT

Transcription

1 CT-imaging of post-inflammatory strictures of esophagus (corrosive, peptic and anastomotic) using contrastenhanced CT Poster No.: C-2191 Congress: ECR 2015 Type: Educational Exhibit Authors: S. A. Buryakina, G. Karmazanovsky, D. Ruchkin, Q. Yang, N. Tarbaeva, A. Vishnevskaia; Moscow/RU Keywords: Stomach (incl. Esophagus), CT, Contrast agent-intravenous, Contrast agent-oral, Image verification, Inflammation DOI: /ecr2015/C-2191 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives The purpose of this presentation is to describe and to illustrate the CT-signs of postinflammatory strictures of esophagus (corrosive, peptic and anastomotic) using contrastenhanced CT. Background Many diseases can cause benign esophageal stricture formation: acid peptic, autoimmune, infectious, caustic, congenital, iatrogenic, medication induced, radiationinduced, malignant, and idiopathic disease processes. The most common cause is gastroesophageal reflux disease, which accounts for approximately 70-80% of all cases of esophageal stricture [1]. Postoperative strictures account for about 10%, and corrosive strictures account for less than 5% in western population [2]. Ingestion of corrosives is a common cause of benign strictures in Asia [3]. The injuries are frequently more serious because they are usually intentional, with large volumes of ingestion. This can result in lifelong debilitating conditions and later development of esophageal cancer. Mortality rate after caustic ingestion are reported to be as high as 20%. Morphologically the inflammation in esophageal walls leads to scarring after single or repeated injury and healing. Double-contrast esophagography and endoscopy are the two major diagnostic modalities for evaluating the esophagus. In patients with known esophageal cancer, however, CT is often performed for TNM staging. Although there are considerable data on the role of CT in diagnosis and staging esophageal cancer [4-9], CT findings in postinflammatory strictures are not well documented in the radiology literature. We report the CT-findings of post-inflammatory strictures in series of patients to show typical and common CT-findings of these diseases. Findings and procedure details Peptic strictures are found commonly as a result of prolonged gastroesophageal reflux disease, the resultant scarring from reflux esophagitis presenting as a stricture. It is the most common cause of stricture in the lower esophagus. Esophageal anastomotic strictures often develop after esophagogastrostomy. The incidence of benign anastomotic strictures ranges from 5% to 46% in the recent literature [10]. Risk factors responsible for anastomotic stricture formation are various: a history of cardiac disease, preceding anastomotic leakage, intraoperative blood loss and poor vascularization of the gastrictube etc. Page 2 of 16

3 Corrosive injury to the esophagus may be caused by ingestion of strong acids (hydrochloric acid) or a strong base (lye) either with suicidal intent or accidental ingestion. Resultant marked caustic oesophagitis leads to stricture formation within 1 to 2 months after the initial injury. Depending upon the degree of injury and scar formation, affected patients may develop one or more segmental caustic strictures that have unpredictable location or diffuse esophageal stricture that reduces the entire esophagus to filliform strictures [2]. Despite different origins of these strictures formation morphologically they are similar. Long period of inflammation in esophageal walls leads to the formation of fibrotic stroma in pathologically changed esophageal walls and inflammation in the mucosa, and as a result to the common CT findings in all these diseases. CT imaging key points: 1. Symmetry of esophageal thickened walls 2. Presence of the mucous membrane in the stenosis 3. Smooth mucous membrane at the transition to stenosis 4. Smooth upper and lower boundaries without intralumunal mass 5. Conically-shaped suprastenotic dilatation 6. Homogeneity of contrast medium uptake by pathologically changed esophageal walls Images for this section: Page 3 of 16

4 Fig. 1: Patient 1. Ingestion of strong acid (acetic acid) 5 years ago. Image A - MDCT. Arterial phase. Coronal reconstruction. Concentric esophageal wall thickening of the caustic stricture, which has a homogeneous structure (short arrow). The mucosa is traceable as a thin hyperintense line in the center of hypodense thickened walls, caused by scarring (long arrow). Conically-shaped suprastenotic dilatation (*), smooth upper and lower boundaries of the stricture. Diagnosis: caustic stricture Page 4 of 16

5 Fig. 2: Patient 1. Ingestion of strong acid (acetic acid) 5 years ago. MDCT. Arterial phase. Axial CT scan. Target sign - thickening of the esophageal mucosa (thick arrow) in the center of fibrotically changed submucosal, muscular layers and adventitia of esophageal walls (thin arrow) Diagnosis: caustic stricture Page 5 of 16

6 Fig. 3: Patient 2. Ingestion of strong lye years ago. Image A - MDCT. Arterial phase. Coronal reconstruction. The entire esophagus reduced to the homogeneous filliform stricture (arrow). Diagnosis: caustic stricture Page 6 of 16

7 Fig. 4: Patient 2. Ingestion of strong lye years ago. MDCT. Arterial phase. Axial CT scan. Fibrotically changed thin esophagus (arrow). Diagnosis: caustic stricture Page 7 of 16

8 Fig. 5: Patient 3 complained of dysphagia, nausea, vomiting rare, regurgitation of food. MDCT. MPR - reconstruction. Symmetrically thickened esophageal walls have a homogeneous structure (short arrow). The esophageal mucosa is traced throughout the wall (long thin arrow). Diagnosis: peptic stricture. Page 8 of 16

9 Fig. 6: Patient 3 complained of dysphagia, nausea, vomiting rare, regurgitation of food. Specimen of the esophagus after the extirpation. Diffusely thickened wall of the esophagus (thick arrow). Diagnosis: peptic stricture Page 9 of 16

10 Fig. 7: Patient 4. Ingestion of strong lye 8 years ago, Transhiatal extirpation of the esophagus with posterior mediastinal gastric tube replacement 8 years ago. MDCT Arterial phase. Axial CT scan shows a short stricture performed by concentrically thickened hypodense esophageal walls in the area of the anastomosis, which have a homogeneous structure (short arrow). The hyperintense mucosa is in the center of hypodense thickened walls (long arrow). Diagnosis: anastomotic stricture Page 10 of 16

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12 Fig. 8: Patient 4. Ingestion of strong lye 8 years ago, Transhiatal extirpation of the esophagus with posterior mediastinal gastric tube replacement 8 years ago. MDCT Arterial phase. MPR - reconstruction. The esophageal mucosa is traced throughout the thickened walls (long thin arrow) Conically-shaped suprastenotic dilatation (*) above the stricture. Diagnosis: anastomotic stricture Fig. 9: Patient 5. Ingestion of strong acid (acetic acid) 21 years ago. Resection of the esophagus with posterior mediastinal gastric tube replacement 20 years ago. For 19 years she has fed only on liquid food. MDCT Arterial phase. Axial CT scan. The esophageal mucosa is in the center of hypodense thickened walls - target sign (arrow). Diagnosis: anastomotic stricture Page 12 of 16

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14 Fig. 10: Patient 5. Ingestion of strong acid (acetic acid) 21 years ago. Resection of the esophagus with posterior mediastinal gastric tube replacement 20 years ago. For 19 years she has fed only on liquid food. MDCT Arterial phase. MPR - reconstruction. Stomach is located in the posterior mediastinum (*). Concentrically thickened esophageal walls are found in the area of the anastomosis at the level of throat. Esophageal walls have a homogeneous structure (short arrow). The hyperintense mucosa is in the center of hypodense thickened walls (long arrow) Diagnosis: anastomotic stricture Page 14 of 16

15 Conclusion Patients with post-inflammatory strictures have common abnormalities on CT: a concentric esophageal wall thickening, conically-shaped suprastenotic dilatation, smooth upper and lower boundaries, presence of the mucous membrane in the stenosis, smooth mucous membrane at the transition to stenosis and homogeneity of contrast medium uptake by pathologically changed esophageal walls on contrast-enhanced images. Corrosive esophageal strictures may be atypically presented by filliform strictures. Although barium studies and endoscopy are more sensitive modalities for detecting this condition, the CT finding of a relatively these features should suggest the diagnosis of post-inflammatory stenosis. To our knowledge, however, no detailed description of the CT findings in post-inflammatory benign esophageal strictures using contrast-enhanced CT has been published previously in the radiology literature. Personal information References 1. Patterson DJ, Graham DY, Smith JL, Schwartz JT, Alpert E, Lanza FL, et al. Natural history of benign esophageal strictures treated by dilatation. Gastroenterology 1983; 85: Qureshi S. et al. Benign esophageal strictures: Behaviour, pattern and response to dilatation. JPMA. The Journal of the Pakistan Medical Association. 2010; 60(8): Lahoti D, Broor SL. Corrosive injury to upper gastrointestinal tract. Indian J Gastroenterol 1993; 12: Kim TJ, Kim HY, Lee KW, Kim MS Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy1. Radiographics 2009; 29(2): Ba-Ssalamah A, Matzek W, Baroud S, Bastati N, Zacherl J, Schoppmann SF, Gore RM Accuracy of hydro-multidetector row CT in the local T staging of oesophageal cancer compared to postoperative histopathological results. European radiology 2011; 21(11): Dionigi G, Rovera F, Boni L, Bellani M, Bacuzzi A, Carrafiello G, Dionigi R Cancer of the esophagus: the value of preoperative patient assessment. Expert Rev Anticancer Ther 2006; 6(4): Page 15 of 16

16 7. Onbas O, Eroglu A, Kantarci M, Polat P, Alper F, Karaoglanoglu N,, Okur A Preoperative staging of esophageal carcinoma with multidetector CT and virtual endoscopy. European journal of radiology 2006; 57(1): Plukker JTM, Van Westreenen HL Staging in oesophageal cancer. Best Practice & Research Clinical Gastroenterology 2006; 20(5): Thompson WM, Halvorsen RA, Foster Jr WL, Williford ME, Postlethwait RW, Korobkin M Computed tomography for staging esophageal and gastroesophageal cancer: reevaluation. American Journal of Roentgenology 1983; 141(5): Honkoop P. et al. Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. The Journal of thoracic and cardiovascular surgery 1996; 111(6): Page 16 of 16