Classical esophagitis and Barrett's esophagus
The standard endoscopic picture of esophagitis includes erythema and ulceration of the distal esophagus. Of particular concern is columnar cell metaplasia (Barrett's esophagus, Columnar-Lined Oesophagus).
In metaplasia, the normal pale pink stratified squamous mucosa (squamous mucosa) is replaced by dark pink tissue macroscopically resembling the gastric mucosa. The altered epithelium extends circularly or as characteristic "tongues" proximal to the gastroesophageal junction.
Double-contrast fluoroscopy may reveal a specific reticular pattern (reticular pattern), although this is an unreliable sign.
- Tactic: when changes are detected, multiple biopsies are taken to assess for the presence of dysplasia or adenocarcinoma.
- Management: if the length of the metaplastic segment exceeds 2 cm, proton pump inhibitor therapy and follow-up endoscopy every 2 years are indicated.
Specific forms of esophageal inflammation
Eosinophilic esophagitis (Eosinophilic oesophagitis) should be suspected in patients with dysphagia and food bolus impaction. The etiology is not fully understood, but the efficacy of an elimination diet confirms its allergic nature. Fluoroscopy may reveal any of the following in any segment of the thoracic esophagus: small-calibre oesophagus, transient or fixed circular rings, and benign strictures. The diagnosis is established strictly via biopsy.
Infectious esophagitis (Infectious oesophagitis) is most commonly associated with fungi of the genus Candida. Radiographs reveal linear or large mural plaques (mural plaques). Candidiasis is typical for immunocompromised patients and in cases of esophageal stasis (e.g., achalasia). Human immunodeficiency virus (HIV) and cytomegalovirus (CMV) infections manifest differently: usually as one or several large rhomboid or oval ulcers (diamond-shaped ulcers).
Iatrogenic and traumatic injuries
Drug-induced esophagitis (Drug-induced oesophagitis) directly depends on the administered medication. Antibiotics (doxycycline, tetracycline) cause only small superficial ulcers. Potassium chloride and alendronate lead to much more severe damage, forming large ulcers and strictures.
Radiation and chemical/caustic esophagitis (Radiation and caustic oesophagitis) are typically diagnosed based on medical history. Both variants of pathology inevitably lead to the formation of long strictures and significantly predispose to the development of squamous cell carcinoma.
Diverticula and motility disorders
Anatomical and functional changes of the esophagus frequently accompany inflammation:
- Traction diverticula (Traction diverticula). Located in the upper and middle thirds. They are thought to arise from the scarring of mediastinal lymph nodes (e.g., secondary to tuberculosis).
- Pulsion diverticula (Pulsion diverticula). Detected in the distal section and frequently associated with oesophageal dysmotility.
- Pseudo-diverticula (Pseudo-diverticula). These are tiny flask-like protrusions within the mucosa. They are not true diverticula and are likely associated with chronic reflux esophagitis.
The Chicago classification (Chicago classification) is used to classify and differentiate motility disorders. It is important to remember that when motility disorders are suspected, fluoroscopic examination is the first-line method and is preferred over standard endoscopy.
Briefly: answers to topical questions
What histological criteria (cell count) are required to confirm eosinophilic esophagitis?
To confirm eosinophilic esophagitis, it is necessary to identify $\ge$ 15 eosinophils per high-power microscope field ($\times$400). This count corresponds to approximately 60 eosinophils per 1 mm$^2$ in at least one evaluated biopsy specimen. Additionally, during the active phase of the disease, signs of eosinophil degranulation and pronounced intercellular space widening of the stratified squamous epithelium are noted.
What radiological signs are characteristic of achalasia cardia?
Characteristic radiological signs of achalasia cardia include the absence of thoracic esophageal peristalsis, failure of the cardia to open, and absence of the gastric air bubble.
- Distal narrowing — symmetrical "bird-beak" or "rat-tail" narrowing with smooth walls.
- Suprastenotic dilation — a significantly dilated esophagus tapering toward the gastroesophageal junction (GOJ).
- Delayed contrast clearance — retention of barium in the esophagus for more than 5 minutes.
On a plain chest radiograph in severe cases, a fluid-and-gas level may be visualized within the dilated esophagus.
What specific types of esophageal motility disorders are distinguished according to the Chicago classification?
According to the Chicago classification, three main groups of esophageal motility disorders are distinguished.
- Achalasia — includes types I, II, III, and outflow obstruction of the esophagogastric junction.
- Disorders of esophagogastric junction outflow and peristalsis — diffuse esophageal spasm, hypercontractile esophagus ("jackhammer"), and hypocontractility.
- Peristaltic abnormalities — disorders with large or small breaks, fragmented peristalsis, rapid contractions, and thoracic hypercontractility ("nutcracker esophagus").
Achalasia subtypes are further differentiated by the presence of pan-esophageal pressurization and spastic contractions.
For infectious esophagitis: "Candida creates plaques (coating on the walls), while HIV and CMV dig ulcers (rhomboid/oval)"
Class and exam questions
How to confirm the diagnosis of eosinophilic esophagitis?
The diagnosis is confirmed exclusively via endoscopic biopsy, and tissue samples must be taken from both the upper and lower thirds of the esophagus.
What are the endoscopic features of Barrett's esophagus?
Normal pale pink stratified squamous mucosa is replaced by dark pink tissue resembling gastric mucosa. It extends circularly or as "tongues" above the gastroesophageal junction.
Which imaging method is best for esophageal motility disorders?
Contrast fluoroscopy serves as the first-line imaging method when motility disorders are suspected and is considered preferable to endoscopy.
What else to study on this topic
- Dysplasia criteria on biopsy in the setting of Barrett's esophagus
- Chicago classification of esophageal motility disorders
- Fluoroscopic appearance of achalasia and esophageal stasis
- Pathogenesis of traction and pulsion diverticula formation
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