Case history

This 68 year old ex-publican presented to his GP complaining of difficulty swallowing for the past two months. The difficulty started several weeks ago with solids getting "stuck," but had become steadily worse. He also complained more recently of pain on swallowing. Over the past three months he admitted to losing 10 kg in weight. He has a history of alcohol dependency and smokes 40 cigarettes a day.

His GP sent him to hospital for the urgent procedure seen below.

Questions

(1) What type of radiological procedure has been undertaken on this man and what does it entail for the patient?
(2) Describe the pathological findings apparent on this film.
(3) What is your differential diagnosis and what may help in confirming your findings?
(4) What are the predisposing risk factors for this type of oesophageal pathology?
(5) What is the significance of Barrett's oesophagus in this type of disease?

Answers

(1) This is a barium swallow. For this the patient has to fast overnight for a morning procedure. Granules of sodium bicarbonate (Carbex) are swallowed, followed by water (or given as a dissolved solution to drink). This produces gas that distends the stomach, aiding visualisation of the upper gastrointestinal mucosa. The barium sulphate is then swallowed, with the patient in the erect position for evaluation of the oesophagus, and then supine in various positions for imaging the stomach and the duodenal loop. Sometimes the radiologist will administer an intravenous bolus of glucagon or hyoscine to briefly relax the gastrointestinal musculature and exclude spasm.

(2) There is an irregular narrowed segment (stricture) in the middle third of the oesophagus with loss of the normal mucosal pattern. There is abrupt change between the normal smooth mucosa and that seen at the level of the lesion. There is "shouldering" noted at these transition points. Proximal oesophageal dilatation is also present. The overall appearances are consistent with a malignant lesion, and the appearances have been likened to a "rat's tail."

(3) The endoscopic procedure, oesophagastroduodenoscopy (OGD), should be undertaken and multiple biopsies taken from the abnormal area. This allows histological confirmation. Differential diagnosis of an oesophageal stricture: malignant oesophageal tumour^*; corrosive stricture; mediastinal tumour or adenopathy (causing extrinsic compression); benign oesophageal tumour.
^* Practice point: benign lesions, although they may produce stricturing, tend to be smooth. Irregularity is an ominous sign.

(4) There are two histological types of oesophageal carcinoma: squamous and adenocarcinoma (see answer 5). Risk factors for squamous carcinoma: smoking, high alcohol intake, achalasia, several dietary deficiencies, Plummer-Vinson syndrome, tylosis, Coeliac's disease, mouldy food, and a previous oesophageal corrosive stricture (see box).

(5) The main risk factor for adenocarcinoma is Barrett's oesophagus. This occurs when chronic gastro-oesophageal reflux disease leads to transformation of the epithelial lining of the oesophagus from sqaumous cell to columnar glandular epithelium. This metaplastic epithelium can then transform further to become dysplastic and thus neoplastic. These patients currently have anOGD every one to two years to identify any dysplastic or neoplastic change. This has been a topic of hot debate and a recent BMJ paper concluded that the current surveillance strategy is of limited value and that it may be appropriate to restrict surveillance to particular at risk patients capable of undergoing surgery.¹

1. MacDonald C, Wicks A, Playford R. Findings from a 10 year cohort of patients undergoing surveillence for Barrett's oesophagus:observational study. BMJ 2000; 321:1252-54.