Figure 1
Oesophagogram x-ray
Oesophagogram x-ray shows a diverticular dilatation located in the middle third of the oesophagus.
Clinical History
A patient, previously diagnosed with Wegener's granulomatosis, was admitted to hospital for severe dysphagic episodes refractory to analgesics and oral antiacid therapy. Chest x-ray, oesophagography, oesophagogastroduodenoscopy and spiral CT studies were performed.
Imaging Findings
The patient had a history of several episodes of sinusitis and ulcerative lesions of the palate and pharynx. At the age of 3 he was hospitalised for drainage of a right subphrenic abscess and on that occasion Wegener's granulomatosis was diagnosed. He was admitted to hospital for severe dysphagic episodes refractory to analgesics and oral antiacid therapy.
The chest x-ray showed a vasculobronchial and interstitial thickening with pseudonodular aspect. The oesophagogram detected an ectasic, tortuous, oesophagus of normal diameter with a traction diverticulum, 2.5 cm in diameter, filled with contrast medium, located in the proximal medium third, on the right side. Paradiverticular spread of contrast was evidenced and indicated a fistula.
Subsequently oesophagogastroduodenoscopy was performed and this showed a diverticulum, with an orifice of 15 mm of diameter, located 24 cm from the superior dental arch, apparently with a rose mucosa and without evidence of secretion.
To complete the work-up, a chest CT was carried out and fibrotic tissue was noted at the level of the mediastinal cavity.
Discussion
Oesophageal diverticula represent a rather frequent condition in the adult population, especially in older people. They can be characterised by their topographic location (cervical, middle or lower) and by their pathogenesis (congenital or acquired). The diverticula are frequently combined with motor disorders of upper gastro intestinal tract. Almost all oesophageal diverticula result from herniation of the oesophageal mucosa through the muscular layers (pulsion diverticula). Congenital and traction diverticula are rare.
A pulsion diverticulum originates either because of weakness of the wall or because of an increase in endoluminal pressure due to achalasia or abnormal relaxation of the oesophageal sphincter.
Traction diverticula are frequently located in the mid-oesophagus. Their associated symptoms are dysphagia, regurgitation, and chest pain; they may also be associated with compression of the mediastinal organs. Until recently their incidence was high, resulting from complications of adhesions and retractions which occurred during aspecific lymphadenitis, causing herniation of the oesophageal wall. With the lowered incidence of TB, the incidence of this diverticular pathology has decreased considerably.
Manometry, videofluorscopy and scintigraphy play an important role in the diagnosis of oesophageal pathologies, because they provide essential data about on functionality of oesophageal sphincteria and on morphofunctional aspect of oesophageal wall(peristalsys). In this case, the use of multislice spiral CT with virtual endoscopy and 3D reconstruction permitted an excellent view of the diverticulum, and allowed determination of the possible involvement of adjacent structures, the absence of fistulae and visualisation of the bottom of the diverticulum to check for possible neoplastic transformation of the oesophageal endothelium. On the basis of these results multislice spiral CT can be recommended as a valid technique for investigation of oesophageal diverticula. It is a rapid examination, valid, non-invasive and well-tolerated by patients.
Differential Diagnosis List
Oesophageal diverticulum
Final Diagnosis
Oesophageal diverticulum
References
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Oesophageal diverticula.
Br J Surg 2001 May;88(5) 629-42. (PMID: 11350433)
[2]
Bakers ME, Zuccaro G jr, Achkar E, Rice TW.
Esophageal diverticula: patient assessment.
Semin Thorac Cardiovasc Surg 1999 Oct;11(4):326-36. (PMID: 10535374)
[3]
Plavsic BM, Chen MY, Gelfand DW, Drnovsek VH, Williams JP 3rd, Kogutt MS, Terry JA, Plenkovich D.
Intramural pseudodiverticulosis of the esophagus detected on barium esophagograms: increased prevalence in patients with esophageal carcinoma.
A.J.R 1995;165:1381-5. (PMID: 7484570)
Case information
| URL: | https://www.eurorad.org/case/1280 |
| DOI: | 10.1594/EURORAD/CASE.1280 |
| ISSN: | 1563-4086 |
Oesophagogram x-ray
Oesophagogram x-ray shows a diverticular dilatation located in the middle third of the oesophagus.
