1.11 barrett's oesophagus- radiological features in 100 cases, r.m.bremner, c.g.bremner

8/9/2019 1.11 Barrett's Oesophagus- Radiological Features in 100 Cases, r.m.bremner, c.g.bremner

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660 SAMJ VOL 78 1 DES 1990

arrett soesophagus radiological features

in 1 cases

R.M.BREMNER, C.G.BREMNER

Summary

The columnar-lined

or

BarreU s oesophagus is an ac quired

condition resu ing

from

long-continued

gastro-oesophageal

r ef lux . I n t he l as t 2 0 y ea rs 149 p at ie nt s wi th B ar re tt s oes o

phagus have been studied in the clinics of the Johannesburg

Teaching Hospitals. Important radiological predictors of Bar

rett s oesophagus, as defined from a ser ies of 100 cases, are

the

presence

of

a stricture well above the gastro-oesophageal

junction 4 cases), a long stricture 13 cases) and ulceration

in

the body of

the oesophagus 16 cases). An ear ly str icture

ma y b e so subUe that i t is missed or disregarded, and is the

usual site

of the

squamocolumnar junction. Significant stric

tures

may be seen even in the absence of a hiatus hernia.

When associated with a hiatus hernia the strictures are usually

concentric and are longer than the usual reflux strictures. The

v ar yi ng l en gt h of t he se s tr ic tu re s s ug ge st s an upward pro

gression

of

the disease process,

which

begins

at the

gastro

oesophageal junct ion. This featur e, seen in 6 of our patients,

has

not previously been str essed as a

predictor for

BarreU s

oesophagus. Radiological reflux, although in itself a poor

p re di ct or , l en ds s up po rt t o t he d ia gn os is o f B ar re tt s o es o

phagus if o ne or more of t he other predictors i s p re se nt . A

less important predictor i s a r et ic ul ar m uc os al paUern s een

on double-contrast radiography.

S t ed1990;

1. :

660-664.

Col umnar- li ned oesophagus was fIrst descr ibed by Torman

Bar rett in 1950

1

and

is

now known to

be

t he r esul t of long

continued gastro-oesophageal reflux, during which the denuded

squamous epithelium is r eplaced by an upgrowt h

of

columnar

epithelium from the cardia.

2

The

replacement epithelium has

b ee n re po rt ed to be p re se nt in as ma ny as 10

of

patients with

gastro-oesophageal reflux. t is an important disease because

the complications of stricture, ulceration, haemorrhage and

adenocarcinoma are a signi li cant cause

of

morbidity. Once

diagnosed the patient will require vigorous antireflux treatment

and r egular sur veil lance t o det ect mal ignant degener at ion.

3

Regular endoscopic

and

biopsy surveillance

is

pract ised by

most gastro-enterologists in order to detect dysplastic changes

at an early stage.

In

one series

50

patients were followed

up

for

a mean of 5,2 years, and 5 developed adenocarcinoma.

4

Because

t he prognosis of a de no ca rc in oma a ft er s urge ry is d irec tly

related to the de pth of invasion and

the

presence of nodal

spread, early surgery will have a better prognosis. It is therefore

recommended that resectional surgery is

the

treament

of

choice

for high-grade dysplasia.

4

Although there are well-described

radiological f eatures t hat support t he diagnosis of Barrett s

oesophagus, i n our series

of 100

patients with histologically

Department

of Surgery, Hillbrow

Hospital an d

University

of the Witwatersrand, Johannesburg

R.

M.

BREMNER,

B.Se.

MED.),

M.R

RCH.

C.

G.

BREMNER,

CH.M., F.R.e.S. ENG.), F.R.e.S. EDIN.)

Reprin[ requests

[0 :

Professor e . G. Bremner, Dep[ of Surgery, Medical ScHool, York Road,

Parktown, 2193 RSA.

proven columnar-lined oesophagus, the radiological reports all

failed t6 suggest this diagnosis. We believe that the reasons for

th is are twofold: i) ignorance

of

t he radi ol ogical patt er ns

f ound i n Bar rett soesophagus; and iz) some confusion about

which radiological features constitute

the

typical features

of

this condition. A review of the barium-swallow radiographs of

100 patients, who were subsequently shown on endoscopy and

biopsy to have a columnar-lined oesophagus, detected patterns

that

s ho ul d have a le rt ed

the

rad iolog ist t o t he diag nosis.

Should

the

diagnosis

of

Barrett s oesophagus be suggested on

barium-swallow examination, the patient should undergo endo

scopy and biopsy, since histological examination is necessary

to confI rm t he diagnosis. A clarifIcation

of

the

radiological

features of the disease may suggest t he diagnosis

of

Barrett s

oesophagus more often, and thus alert clinicians to the disease

at an earl y stage. A report of Barrett s oesophagus would also

alert t he endoscopi st t o t he condi ti on, whi ch

is

often missed

even on endoscopy.

atients and methods

The barium-swallow radiographs performed on

100

a r r e t t ~ s

oesophagus patients

in

the Johannesburg Teaching Hospitals

from

1970 to 1989 were reviewed. During t hi s per iod 149

patients with a columnar-lined oesophagus were studied. The

series presented is not consecutive

but

represents a retrospective

study

of

radiographs from patients with Barrett s oesophagus

proven on endoscopic and histological examination. Al l patients

ha d a columnar-lined oesophagus at least 3 cm above the

gastro-oesophageal junction, and this was confIrmed by biopsy

at the time

of

endoscopy.

The

presence of a c on ti nu ou s

segment

of

biopsy-proven columnar epithelium which extends

at least 3 cm above the gastro-oesophageal junction is t he gol d

standard for diagnosis of Barrett s oesophagus. We confIned

our study

to

the single-contrast barium-swallow examinations

t ha t were available, since o nly a few double-contrast studies

were included. a d i o l o g i ~ a l patterns were categorised. Stric

t ur es s een were d iv id ed in to hig h, m id ,

or

low, according to

the height in centimetres above the gastro-oesophageal junction

less

than

5 cm above t he j un ct io n

=

low; bet ween 5

cm

an d

10

cm

=

mid; above

10

cm

=

high). Strictures were classilied

as long

i

they were great er t han 1 cm in length and short if

less t ha n 1 cm.

The

presence

of

ulceration, hiatus hernia,

peptic ulceration

of

the stomach and

duodenum

was also

noted.

The

presence of reflux was noted from the radiological

reports.

Var ious mucosal patterns, including intramural

diverticulosis and reticular patterns were carefully looked for.

esults

Fig.

I

summarises

our

findings. By far the most common

feature was a hiatus hernia. Reflux was r ep ort ed in only 32

cases;

58

of p atie nt s were se en to have a s tr ic tu re F ig . 2).

The

stricture might be early,

as

demonst rated i n Fig. 2A,

and

usually occurred at the squamocolumnar junction. High stric

tures Fig. 2B) were found in almost

20

of cases

and

if

grouped

with the mid-oesophageal

strictures Fig. 2C


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Hiatus hernia

Reflux

Stricture Total

Hi

Mid

Low

Shon

Long

Oes. ulceration

Gastric

ulcer

uodenalulcer

Reticular pattern

Intramuraldiverti culosis

ouble stricture

Narrowing

above

H H

Cancer

Fig.

1.

Summary of findings.

account ed f or mor e

than

40

of

pa tie nt s Fig. 2D). L on g

strictures were seen in

13 of

radiographs. A double stricture

was seen i n 2 pat ient s Fig. 2E) .

In

6 patients a narrowing

of

a

few centimetres was seen to extend above the gastro-oesopha

geal junction Fig. 3). Oesophageal ulceration Figs 4A - 4C)

was seen in

16

patients

and

in a further 13 patients the

columnar-lined oesophagus was associated with peptic ulcer

disease

of

t he stomach or duodenum. A r emarkable mucosal

panern

reticu1ar) was seen in only 6 patients on single

contrast barium swallow studies Fig. 5). Pseudodiverticulosis

was noted in 2 patients Fig. 6).

The

radiological features

suggesting carcinoma included ulceration, shouldering or

an

irregular narrowing Fig. 7).

is ussion

In

1978 Robbins

et al.

5

showed in a series

of

39 patients with

Bar ren s oesophagus t hat t he majorit y

of

patients

72 )

did

A

SAMJ VOL 78 1 OEe 1990 661

not have t he classic signs

bu t

in ste ad sh owed a va rie ty

of

radiological lesions.

Their

fmdings were supported

by

Chemin

et al. 6

i n 1986, who concluded

that

stricture is

the

most

helpful radiological feature in differentiating Barren s oeso

patients from normal persons. Chemin

et al.

6

further

concluded that oesophagography was

an

inadequate method

for diagnosing Barren s oesophagus

and

that endoscopy and

biopsy were necessary.

Gilchrist

et al.,7

however, used radiological criteria to classify

patients

as

high, moderate or low risk for Barren s oesophagus,

and predicted the diagnosis correctly

on

oesophagography in 9

ou t

of 10

patients.

The

features t hey used

as

c ri teria for a

patient

being at high r isk were:

i) a

high

stricture;

iz

ulceration; and

iiz

reticular-mucosal panern.

Alt hough we saw 6 pat ient s wit h t he so- call ed reti cu1ar

mucosal

panern

descr ibed by Levine

et al.,8

t he mucosal

characteristics should be seen on double-contrast studies which

were n ot available in this series. However, th e particular

mucosal panerns that are common or characteristic

of

Barren s

oesophagus are controversial.

8

-

1O

also seems

that

these

mucosal panerns are less obvious

and

more difficult to detect

accurately

th an th e

characteristics easily seen

on

straight

barium-swallow studies.

The

most common f eature is hiatus

her ni a Fi g.

1) but,

as discussed b y C he mi n

et al.,6

the

specificity

of

t hi s f mding i n associati on with Bar ren s oeso

phagus is low. Re flu x was r ep or te d in only 32 p at ie nts

bu t

assessment

of

reflux radiologically is notoriously inaccurate. A

patient may in fact have a columnar-lined oesophagus

and

not

demonstrate reflux during radiography. Furthermore, reflux

may be a normal fmding, a nd a p atien t with a normal oeso

phagus may exhibit reflux during radiography. We agree with

Chemin

et al.

6

t hat t he presence and charact eristics

of

a

stricture is t he single mo st i mp or ta nt feature le adin g to th e

diagnosis

of

Barren s oesophagus. As discussed

by

Lackey

et

al l l the stricture may occur at the squamocolumnar junction

o r below it. Almost

60 of our

patients ha d a s tri ctu re o n

barium-swallow examination, and more than

40 of

all patients

had a stricture above a level 5 cm from the gastro-oesophageal

junction.

Fig. 2. Types of strictures associated with Barrett s oesophagus: A) Early stricture at the squamocolumnar junction; B) high short

stricture at the squamocolumnar junction; C) mid-oesophageal tight stricture no hiatal hernia); D long stricture and associated

hiatal hernia;

E

double stricture - the upper stricture is at the squamocolumnar junction and the lower stricture in the columnar

segment probably represents the site of previous ulceration.


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SAMJ VOL 78 1

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99

Fig. 3. Series

of

barium-swallow radiographs demonstrating the possible segmental increase in the length

o f the

nar-rowed

seg-

ment above a hiatal hernia. The squamocolumnar junction lies at the

upper

limit

of

the stricture.

B

Fig. 4 A Ear ly u lcerat ion in

the mid

oesophagus; B penetrating ulceration; C stricture

and

ulceration

above

a narrowed

columnar segment.


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Fig Reticular pattern in the columnar segment

Fig 6 Pseudodiverticulosis in Barrett s oesophagus

SAMJ

V

78 DEC 99

Fig 7 Adenocarcinoma arising in Barrett s epithelium

The re are

other

causes

of

a high stricture such as a web

e pide rmolys is bullos a a nd infec tive c ause s

ut

th es e are

uncommon and not usually associated with a hiatus hernia

or

a

history

of

reflux. A long stricture

is

a strong indicator

ut

was

present in only

3

of

patie nts. Nevertheles s onc e other

causes

of

a lon g s tr ic tu re s uc h as previous in sert io n

of

a

nasogastric tube

or

caustic ingestion have been excluded on

the history the presence

of

a long stricture

is

highly suggestive

of

a columnar-lined oescphagus.

We found that in 6 patients there was a distinctive narrowing

of

varying length a bove the hia tus hernia.

o

our

knowledge

this has not previously been stressed as an important predictor

of

Barrett s oesophagus and suggests an upward progression of

the disease process starting at

the

gastro-oesophageal junction.

Such a stricture has not been noted in any

other

benign


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SAMJ

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DES

99

oesophageal condition an d it may be a pathognomonic finding

of Barren s oesophagus.

Pseudodiverticulosis is no t a specific finding in B ar re n s

oesophagus bu t has been linked to reflux

in

some cases.

Ulceration in the

body

of

th e

oesophagus was found in

6

o f o ur patients, and

again,

although not a sensitive indicator,

its presence strongly suggests an underlying columnar-lined

oesophagus.

Of

interest,

we

noted

that

2

pat ie nt s h ad two

s tr ic tu re s - one located hi gh in t he oesophagus, p roba bl y a t

th e squamocolumnar junction, th e ot her located ne ar t he

cardia Fig. 7).

We agree with previous authors that there are a large variety

of radiological features seen in Barren s oesophaguS.12 Th e

results of

ou r

study show

that

there are distinctive features

seen on barium-swallow examination that should suggest the

di agnosis. A h iat us h er ni a may n ot always be p re se nt

bu t

its

occurrence with an oesophageal stricture 5 cm above the

gastro-oesophageal junction is a common fmding. Furthermore,

a long stricture or

ulceration

of

the body of the oesophagus is

higWy suggestive of Barren s oesophagus.

A background

of

a long history of reflux sy mpt oms , a

s tr ic tu re 5 c m above t he gas tro -oe so pha gea l j unc ti on i n t he

presence of a hiatus hernia, with or without ulceration seen on

barium meal radiographs, are features which should make the

radiologist suspect a columnar-lined or Barren s oesophagus.

These patients should then undergo endoscopy and biopsy to

confirm the condition.

REFERENCES

I. Barren NR. Chronic peptic ulcer of the oesophagus an d oesophagitis .r J

Surg 1950; 38:

175

2

Bremner

CG

Lynch

V P, E ll is F H. B ar re n esophagus: congenital or

acquired? An experimental srudy

of

esophageal mucosal regeneration in the

dog. Surgery 197 ; 68: 209-216.

3 Bremner CG. Barrenoesophagus Editorial). rJ Surg 1989; 76: 995-996.

4 Hameeteman W, Tyrgat GNJ Houthoff HJ Van d en T we el JG.

Barren s

esophagus: development of dysplasia and adenocarcinoma. astroenterology

1989; 96: 1249-1256.

5

R ob bi ns A H, V in ce nt ME Saini M Schmidt EM . Revised radiologic

concepts of the Barrenesophagus. astrointest Radial 1978; 3: 377-381.

.

6 Chemin

MM Amberg

JR

Kogan FJ Morgan TR SampIiner RE. Efficacy

of

radiologic srudies in the detection of r r ~ n esophagus. JR 1986; 147:

257-260.

7 GiIchrist AM, Levine MS Ca n

RF

er l Barren esophagus: diagnosis by

doubIe-eontraSt esophagography. J R 1988; 150: 97-102.

8 Levine MS Kressel HY, Caroline OF Laufer

I

Herlinger H Thompscin

JJ Barren

esophagus: reticuiar

panern

of the mucosa. Radiology 1983; 147:

663-667.

9

Levine MS K re ss el H Y, L au fe r I Herling H. Reticular panern as a

radiologic sign

of

the Barren esophagus Editorial). Radiology 1985; 156:

843-844.

1 Vincent ME Robbins AH, Spechler

SI Schwaru R

Doos

WG

Schimmer

EM. Th e reticular

panern

as a radiographic sign

of th e Barren

esophagus:

an assessment.

Radiology

1984; 153: 333-335.

I

L ac ke y C , R an ki n RA , W el sh JD. Stricture location in

Barren

esophagus.

astrointeSl ndosc 1984;

30:

331-333.

12 Missakian MM Carlson

HC

Anderson HA. Th e roentgenologic fearures

of

the columnar-epitheIiaI lined lower esophagus. J R 1967; 99: 212-217.

1.11 barrett's oesophagus- radiological features in 100 cases, r.m.bremner, c.g.bremner

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