Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4547_Библиотеки_им_академика_М_И_Перельмана

Reflux esophagitis may be manifested on single­contrast barium studies by thickened folds, decreased distensibility, and marginal ulceration. However, these findings are detected only in patients with advanced disease. In contrast, double-contrast barium studies have a sensitivity approaching 90% for the diagnosis of reflux esophagitis because of the ability to detect superficial ulcers, mucosal granularity, and other findings that cannot be visualized on single­contrast studies (Creteur et al. 1983b). Conversely, prone single-contrast views permit optimal distention of the distal esophagus for demonstration of hernias, rings, or strictures that are sometimes missed on upright double-contrast views (Chen et al. 1985).

Early reflux esophagitis may be manifested on double-contrast studies by a finely nodular or granular appearance in the distal esophagus due to mucosal inflammation and edema (Fig. 1, Kressel et al. 1981). In almost all cases, this nodularity or granularity extends proximally from the gastroesophageal junc­tion as a continuous area of disease. As the disease progresses, other patients may develop shallow ulcers and erosions that are seen as streaks or dots of barium in the distal esophagus (Fig. 2, Laufer 1982). These ulcers are sometimes associated with radiating folds or surrounding halos of edematous mucosa. Occa­sionally, the ulcers may be more widespread. How­ever, ulceration in reflux esophagitis almost always involves the distal esophagus, so the presence of one or more ulcers that are confined to the upper or midesophagus should suggest another cause for the patient’s disease. Others with reflux esophagitis may have a single dominant ulcer, most commonly on the posterior wall of the distal esophagus (Hu et al. 1997). It has been hypothesized that these ulcers are located posteriorly because of prolonged exposure to refluxed acid that pools posteriorly when patients sleep in the supine position (Hu et al. 1997).

mimicking the appearance of esophageal varices. Other patients with chronic reflux esophagitis have a single prominent fold that arises in the gastric fundus and extends upward into the distal esophagus as a smooth, polypoid protuberance, also known as an inflammatory esophagogastricpolyp (Fig. 3, Bleshman et al. 1978). Because these lesions have no malignant

As esophageal ulcers heal, localized flattening or puckering of the esophageal wall may occur at the site of healing. Further scarring leads to the development of circumferential strictures, also known as peptic strictures, which typically appear as smooth, tapered areas of concentric narrowing in the distal esophagus above a hiatal hernia (Fig. 4). However, asymmetric scarring can lead to asymmetric narrowing with focal sacculation of the wall between areas of fibrosis. Scarring from reflux esophagitis can also lead to longitudinal shortening of the distal esophagus and the development of fixed transverse folds, producing a characteristic stepladder appearance due to pooling of barium between the folds (Fig. 5, Levine and Goldstein 1984). These fixed transverse folds should be differentiated from the thin transverse folds (i.e., feline esophagus) often seen as a transient finding due to contraction of the longitudinally oriented muscu­laris mucosae in patients with reflux.

condition associated with an increased risk of devel­oping esophageal adenocarcinoma through a sequence of progressively severe epithelial dysplasia.

The classic radiologic signs of Barrett’s esophagus consist of a high stricture or ulcer associated with a hiatal hernia and reflux (Fig. 6, Levine 1994). How­ever, strictures are actually more common in the distal esophagus in patients with this condition, so most cases do not fit the classic description of a high stricture or ulcer (Robbins et al. 1978). Another sign of Barrett’s esophagus is a distinctive reticular pattern characterized by tiny barium-filled grooves resem­bling the areae gastricae on double-contrast studies of the stomach (Fig. 7, Levine et al. 1983). However, this reticular pattern is also found in only a small percentage of all patients with Barrett’s esophagus.

The herpes simplex virus type I is the second most frequent cause of infectious esophagitis. Herpes esophagitis is most commonly seen in immunocom­promised patients, but it occasionally may occur as an