Barium studies in esophageal cicatricial pemphigoid

Dots, lines, contours, and ends: An image-based review of esophageal pathology

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Learning Point #1: Small ulcers on esophagography are usually attributable to herpes esophagitis and drug-induced esophagitis. Although rare, Crohn’s disease may produce small apthoid ulcers. Large ulcers are usually attributable to CMV or HIV esophagitis.

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Learning Point #2: The early findings of candida are plaques that mimic glycogenic acanthosis. When plaques are seen, consider early candida or glycogenic acanthosis. When shaggy esophagus is identified, consider candidiasis.

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Learning Point #3: Varices and varicoid esophageal carcinoma may appear similar on imaging. The presence of obstruction and lack of change with time and position should sway the Radiologist to diagnosing varicoid esophageal carcinoma.

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Learning Point #4: Transverse esophageal lines should suggest the entities of feline esophagus and idiopathic eosinophilic esophagitis.

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Learning Point #5: Esophageal contour abnormalities may suggest extrinsic or intrinsic lesions. Extrinsic lesions include aberrant vessels. Intrinsic lesions include intramural pseudodiverticulosis, gastroesophageal reflux, Barrett’s esophagus, and esophageal cancer.

Esophageal pathologies encountered on fluoroscopic examination may pose a diagnostic challenge to the interpreting Radiologist. Understanding the varied imaging appearances of esophageal pathology requires a thorough understanding of barium esophagography. This article reviews the various fluoroscopic imaging findings of different esophageal pathologies by describing an approach to image interpretation centered on dots, lines, contours, and ends. By utilizing this approach, the Radiologist will be better positioned to reconcile seemingly disparate pathologies into a cogent and succinct differential diagnosis.

Clinical, Imaging, and Pathologic Features of Conditions with Combined Esophageal and Cutaneous Manifestations

A variety of clinically significant conditions can affect both the esophagus and the skin. Esophageal and cutaneous manifestations may directly reflect the underlying disease process, as in infections such as herpes simplex virus, bullous diseases such as epidermolysis bullosa and mucous membrane pemphigoid, connective tissue diseases such as systemic sclerosis, and inflammatory diseases such as lichen planus. Alternatively, esophageal and cutaneous findings may result from conditions that are closely associated with and potentially pathognomonic for but distinct from the underlying disease process, as in genetic diseases such as Cowden syndrome or paraneoplastic syndromes such as acrokeratosis paraneoplastica. Other diseases such as Crohn disease may have cutaneous manifestations that directly reflect the same underlying inflammatory process that affects the gastrointestinal tract or cutaneous manifestations that represent reactive or associated conditions distinct from the underlying inflammatory process. The cutaneous manifestations of disease may precede, coincide with, or follow the esophageal manifestations of disease. The authors present the characteristic clinical features and imaging findings associated with common and uncommon conditions that have esophageal and cutaneous manifestations. Each condition is presented with a brief overview, discussion of salient clinical and cutaneous manifestations, and description of the typical esophageal imaging findings, with particular attention to implications for diagnosis, prognosis, and treatment. Recognition of potential associations between cutaneous lesions and esophageal imaging findings is important for establishing a specific diagnosis or generating a meaningful differential diagnosis.

Pharyngeal manifestations of gastroesophageal reflux disease

This article discusses the extraesophageal manifestations of gastroesophageal reflux disease, focusing primarily on the gamut of pharyngeal abnormalities that can be detected on barium swallows. Abnormalities of pharyngeal swallowing caused by gastroesophageal reflux are illustrated. We particularly emphasize how pharyngoesophageal relationships can guide the radiologist for performing tailored barium swallows to optimally evaluate pharyngeal abnormalities in patients with underlying gastroesophageal reflux disease.

Endoscopic findings of laryngopharyngeal and esophageal involvement in autoimmune bullous disease

BACKGROUND AND AIM

Autoimmune bullous disease (ABD) is induced by autoantibodies against cell adhesion molecules, and blistering may occur on the mucous membranes of the eyes, nose, mouth, oral cavity, laryngopharynx, and esophagus. Endoscopic prevalence and features of ABD-associated esophageal lesions are not well known. We conducted the present study to assess the endoscopic prevalence of ABD-associated mucosal lesions.

METHODS

Endoscopic prevalence of mucosal lesions, particularly laryngopharyngeal and esophageal lesions, was used as the primary endpoint to assess the significance of upper gastrointestinal endoscopy, and clinical and endoscopic features were secondary endpoints.

RESULTS

Of 123 ABD patients, 50.4% had apparent oral or laryngopharyngeal lesions and 30.8% had laryngopharyngeal lesions. Esophageal lesions were detected through normal observation in 16.8% of affected patients, whereas 40.6% exhibited epidermolysis or blood blisters by mechanical inducement, regardless of esophageal mucosal lesion detection by normal observation. Additionally, 56.0% exhibited the Nikolsky sign with mechanical inducement. Of the 123 patients, 29.2% did not have exposed skin lesions. Of these patients, 77.7% had oral cavity or laryngopharyngeal lesions, 36.1% had esophageal lesions, and 58.3% exhibited the Nikolsky sign on esophageal mucosa.

CONCLUSION

It is important to determine the endoscopic characteristics and findings of ABD. ABD can be suspected from endoscopic findings.

Oesophageal involvement in 26 consecutive patients with mucous membrane pemphigoid

BACKGROUND

Oesophageal involvement of mucous membrane pemphigoid (MMP) has not yet been thoroughly described.

OBJECTIVES

To characterize systematically the endoscopic lesions of a series of patients with oesophageal symptoms seen at a referral centre for autoimmune bullous diseases.

METHODS

Clinical, endoscopic and immunological findings of consecutively referred patients with MMP with oesophageal involvement, systemic and endoscopic treatments, and follow-up are described.

RESULTS

Of 477 consecutive patients with MMP consulting between 2002 and 2012, 26 (5·4%) had symptomatic oesophageal involvement. Dysphagia, observed in 23 (88%) patients, was the most frequent symptom. Oesophageal symptoms could be the first sign of MMP. Patients with oesophageal involvement had a mean of three other involved sites. At initial oesophageal endoscopy, 17 of 26 patients had active lesions (intact bullae, erosions and/or erythema), 15 had stricture(s) and 12 had other cicatricial lesions. Systemic therapy alone achieved oesophageal symptom relief for five patients. Dilatation was combined with systemic therapy for 12 patients and was successful in nine; one perforation occurred.

CONCLUSIONS

Symptomatic oesophageal involvement affected 5·4% of patients with MMP. Dermatologists and gastroenterologists should be aware of these mucocutaneous diseases and their oesophageal involvement, as it could lead to earlier diagnosis and better care. Oesophageal dilatation could be a therapeutic option for symptomatic stricture not relieved by optimized systemic therapy alone.

Hypopharyngeal presentation of cicatricial pemphigoid: videofluorographic and direct laryngoscopic findings

Objective:

Cicatricial pemphigoid can affect all mucosa of the upper aerodigestive tract; however, hypopharyngeal involvement is less frequent.

Case report:

This paper presents a 69-year-old male diagnosed as having cicatricial pemphigoid who was experiencing difficulty swallowing. Videofluorography with barium swallow demonstrated narrow flow through the medial hypopharynx, but not through the lateral hypopharynx. Direct laryngoscopy revealed that the postcricoid hypopharyngeal lumen had become narrow due to circumferential scar formation. Interestingly, detached thin membranous webs were observed beyond the circumferential scar.

Conclusion:

This report describes important videofluorographic and direct laryngoscopic findings showing rare hypopharyngeal involvement in a case of cicatricial pemphigoid.

Esophageal involvement in cicatricial pemphigoid: a rare cause of dysphagia

Cicatricial pemphigoid is a rare, autoimmune, blistering disorder affecting the mucous membranes and skin. Esophageal involvement affects a small proportion of affected individuals and may present up to 10 years after the initial onset of the disease. We present a case of esophageal cicatricial pemphigoid that presented initially as linear IgA disease. We describe the successful treatment of dysphagia by graded esophageal dilatations.

Esophageal rings, webs, and diverticula

Rings, webs, and diverticula are among the most common anatomic anomalies of the esophagus. Although these structural lesions are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation, and aspiration. This article discusses the epidemiology, pathogenesis, diagnosis, and therapy of esophageal rings, webs, and diverticula with emphasis on the clinical, diagnostic, and therapeutic strategies involved in caring for patients with these conditions.

Oesophageal involvement in cicatricial pemphigoid

Four cases of cicatricial pemphigoid complicated by oesophageal involvement are presented. All patients suffered dysphagia but repeated radiological studies were required for confirmation of oesophageal ulceration, webs and strictures. A combination of systemic drug therapy and oesophageal dilatation were necessary for the suppression of symptoms. The clinical and immunopathological features, management and complications of oesophageal involvement in cicatricial pemphigoid are discussed. Dermatologists should be aware of these features and make regular inquiries about swallowing difficulties in patients with cicatricial pemphigoid to guide appropriate investigations and treatment.