Imaging Pearls ❯ Esophagus ❯ Inflammatory Disease
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- Computed tomography (CT) imaging is a crucial diagnostic tool in the emergency department (ED) for evaluating nontraumatic esophageal conditions. Advanced imaging techniques such as multidetector CT (MDCT) quickly provide detailed 3D images with high spatial resolution, making it ideal for rapid assessment of a variety of esophageal pathologies. This pictorial essay presents 10 illustrative cases to highlight the clinical applications of MDCT and its critical role in diagnosing conditions like perforation, foreign body impaction, inflammatory or infectious esophagitis, achalasia, fistulae, and neoplasms. Optimized CT protocols, such as contrast-enhanced imaging and advanced postprocessing techniques like maximum intensity projection (MIP) images and volumetric rendering technique (VRT), in addition to 3D cinematic rendering, are crucial in improving diagnostic accuracy and enhancing the visualization of anatomical structures
CT of the esophagus in the ER: what you need to know and what you need to remember.
Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK.
Emerg Radiol. 2025 Apr 16.Epub ahead of print. PMID: 40238070. - “Compared to conventional double-contrast upper GI studies or endoscopy, MDCT provides a detailed overview of surrounding anatomical structures and extramural involvement of the pathology. However, evaluation of the esophagus has generated less interest even though the esophagus has a range of pathologies and clinical presentations, and due to overlapping presentations with other emergencies involving mediastinal structures and pathologies, esophageal processes may be further down the list of differential diagnosis at first. Delay in diagnosis and management of esophageal emergencies is a leading cause of mortality and morbidity, necessitating the need for timely diagnosis and early prognosticationof the injury or disease process .”
CT of the esophagus in the ER: what you need to know and what you need to remember.
Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK.
Emerg Radiol. 2025 Apr 16.Epub ahead of print. PMID: 40238070. - “Esophagitis refers to inflammation of the esophagus predominantly in the mucosa but occasionally involves the underlying submucosa and muscularis and can present acutely in the emergency setting with odynophagia, dysphagia, retrosternal pain, hematemesis, and regurgitation. There are several etiologies, including infectious, GE reflux disease, medication-related, and caustic ingestion. Infectious etiologies are common in immunocompromised patients, such as those with HIV/AIDS, malignancy, autoimmune diseases, or posttransplant status.”
CT of the esophagus in the ER: what you need to know and what you need to remember.
Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK.
Emerg Radiol. 2025 Apr 16.Epub ahead of print. PMID: 40238070. - Aortoesophageal (AE) fistulae are a life-threatening pathology that can present in the ED, with symptoms classically ranging from hematemesis and melena to chest pain and massive upper GI hemorrhage following a symptom free interval. They can develop primarily due to aortic aneurysms, or more commonly, secondarily after aortic reconstructive interventions as abnormal connections develop between the repaired aortic segment and the esophageal walls. As discussed below, neoplastic processes are responsible for over half of all acquired tracheoesophageal (TE) fistulae in adults; both esophageal and lung malignancies can lead to a fistulous connection, while other causes include esophagitis and traumatic injury, and occasionally congenital TE fistulae that are not diagnosed until later in adulthood.
CT of the esophagus in the ER: what you need to know and what you need to remember.
Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK.
Emerg Radiol. 2025 Apr 16.Epub ahead of print. PMID: 40238070. - While esophageal neoplasms develop more insidiously, they can present with sudden onset symptoms leading to an ED visit. Esophageal neoplasms, primarily squamous cell carcinoma (SCC) and adenocarcinoma, can present acutely with dysphagia, chest pain, hematemesis, or fistula-related complications such as aspiration . SCC typically affects the upper/mid esophagus and is linked to smoking and alcohol use, while adenocarcinoma commonly arises in the distal esophagus, often in the setting of Barrett’s esophagus and chronic gastroesophageal reflux disease (GERD). CT findings include asymmetric wall thickening, luminal narrowing, and mediastinal lymphadenopathy, with advanced cases showing invasion into adjacent structures or distant metastases. Differentiating malignancy from severe esophagitis can be challenging, as both may exhibit mucosal irregularity and enhancement, necessitating endoscopic biopsy.
CT of the esophagus in the ER: what you need to know and what you need to remember.
Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK.
Emerg Radiol. 2025 Apr 16.Epub ahead of print. PMID: 40238070. - CT imaging of the esophagus in the emergency setting is invaluable in assessing a wide range of non-traumatic esophageal conditions. From life-threatening perforations and neoplastic processes to esophagitis and functional disorders like achalasia, MDCT allows for rapid and accurate diagnosis. Correlation with endoscopic findings, clinical history, and laboratory parameters allows the radiologists and treating Physicians to devise an appropriate management strategy. CT imaging of the esophagus in the emergency setting is invaluable in assessing a wide range of non-traumatic esophageal conditions. From life-threatening perforations and neoplastic processes to esophagitis and functional disorders like achalasia, MDCT allows for rapid and accurate diagnosis. Correlation with endoscopic findings, clinical history, and laboratory parameters allows the radiologists and treating physicians to devise an appropriate management strategy.
CT of the esophagus in the ER: what you need to know and what you need to remember.
Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK.
Emerg Radiol. 2025 Apr 16.Epub ahead of print. PMID: 40238070.
- Intramural Hematoma
● Intramural hematoma of the esophagus is a rare entity on the spectrum of esophageal injuries ranging from Mallory-Weiss tears to esophageal rupture
● Most common causes:
○ Iatrogenic
○ Abrupt increase in intraluminal pressure from forceful emesis or foreign body impaction
○ Spontaneous, usually in the setting of coagulopathy
● Majority of patients report sudden onset retrosternal chest pain, hematemesis or dysphagia/odynophagia
● High clinical suspicion, in addition to rapid evaluation with MDCT are important in differentiating intramural hematoma from ACS or aortic injury
● Management is most often conservative with resolution within few days to weeks - Pearls and Pitfalls
● Mimics of tumor
● Varices on noncontrast or arterial phase CT
● Wall thickening due to severe esophagitis
● Mimics of obstruction- dilated esophagus
● Achalasia
● Scleroderma
● Gastric pull through or colonic interposition (check surgical history!) - "Zenker’s diverticulum (ZD) is a posterior phar- yngoesophageal pouch that forms through pulsion forces in an area of relative hypopharyngeal wall weakness between the oblique fibers of the inferior pharyngeal constrictor and the horizontal fibers of the cricopharyngeus (CP) muscles. Poor upper esophageal sphincter (UES) compliance is the presumed pathophysiologic mechanism of action. This dysfunction creates a high- pressure zone eventuating in increased pulsion forces and subsequent ZD formation."
Zenker’s Diverticulum
Ryan Law, David A. Katzka, and Todd H. Baron
Clinical Gastroenterology and Hepatology 2014;12:1773–1782 - "This entity most commonly presents in the elderly and can be associated with a plethora of potential symptoms, of which dysphagia is most common."
Zenker’s Diverticulum
Ryan Law, David A. Katzka, and Todd H. Baron
Clinical Gastroenterology and Hepatology 2014;12:1773–1782 - Zenkers Diverticulum: Facts
● an outpouching of tissue through the Killian triangle that is believed to be caused by dysfunction of the cricopharyngeal muscle.
● ZD is a relatively uncommon disorder occurring in the elderly.
● The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. - "Zenker's diverticulum is an unusual site of origin for clinically significant upper gastrointestinal hemorrhage and differential diagnosis must include other more frequent causes of upper gastrointestinal bleeding. In our opinion, classicalsurgical therapy is indicated when distal esophageal imaging cannot be obtained during endoscopic examination, there is a large diverticulum or in an emergency setting when fast control over the bleeding source is required."
Zenker's diverticulum, a rare cause of upper gastrointestinal bleeding.
Bălălău C et al.
Rev Med Chir Soc Med Nat Iasi. 2013 Apr-Jun;117(2):297-301. - "The most common complication of Zenker's diverticulum is aspiration pneumonia, compression of the trachea and esophageal obstruction with large diverticulum, and increased risk of development of carcinoma. Thus bleeding occurs rarely, can be massive and life threatening, with ulceration being the most common cause."
Zenker's diverticulum, a rare cause of upper gastrointestinal bleeding.
Bălălău C et al.
Rev Med Chir Soc Med Nat Iasi. 2013 Apr-Jun;117(2):297-301.
- “When Norman Barrett described columnar metaplasia in the esophagus in 1950, he could not have predicted the controversies that would arise from the condition that now bears his name. In response to chronic injury from reflux esophagitis, the normally squamous-lined lower esophagus becomes reepithelialized with intestinal-type (mucus-secreting) columnar epithelium, giving rise to Barrett esophagus. In a minority of cases, this metaplastic epithelium develops dysplasia, which, in turn, can progress to esophageal adenocarcinoma, a malignant neoplasm associated with substantial morbidity and a 5-year survival rate of less than 20%.”
Screening and Surveillance for Barrett Esophagus Paul Lochhead, Andrew T. Chan JAMA Intern Med. 2015 Feb 1; 175(2): 159–160. - “Barrett esophagus is typically asymptomatic and is usually only identified when macroscopic mucosal changes are observed incidentally at upper endoscopy, prompting biopsies for histologic confirmation. Because the diagnosis requires upper endoscopy, an invasive procedure that most people do not routinely undergo, the true prevalence is unknown. Endoscopic studies from Europe have suggested that Barrett esophagus affects less than 2% of asymptomatic individuals, although simulation modeling has generated a higher estimate of 5% to 6% for the United States.”
Screening and Surveillance for Barrett Esophagus Paul Lochhead, Andrew T. Chan JAMA Intern Med. 2015 Feb 1; 175(2): 159–160.