AJR 2000; 175:371-374
© American Roentgen Ray Society
Intramural Tracking
A Feature of Esophageal Intramural Pseudodiverticulosis
Cheri L. Canon1,
Marc S. Levine2,
Ravi Cherukuri2,3,
Lawrence F. Johnson4,
J. Kevin Smith1 and
Robert E. Koehler1
1
Department of Radiology, University of Alabama at Birmingham, 619 S. 19th St.,
Birmingham, AL 35249-6830.
2
Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
3
Present address: Department of Radiology, University of Pittsburgh Medical
Center, 200 Lothrop St., Pittsburgh, PA 15206.
4
Department of Medicine, Division of Gastroenterology, University of Alabama at
Birmingham, Birmingham, AL 35249.
Received October 26, 1999;
accepted after revision January 4, 2000.
Address correspondence to C. L. Canon.
Abstract
OBJECTIVE. Our purpose was to determine the frequency of intramural
tracking in patients with esophageal intramural pseudodiverticulosis and to
characterize the morphologic features of this finding on barium studies.
MATERIALS AND METHODS. A review of radiology files at two
institutions revealed 30 cases of esophageal intramural pseudodiverticulosis
diagnosed at esophagography. In all cases, the radiographs were reviewed
retrospectively to determine the frequency and morphologic features of
intramural tracking in these patients. The number and distribution of
pseudodiverticula and the presence or absence of strictures or esophagitis
were also noted.
RESULTS. Fifteen (50%) of 30 patients with esophageal intramural
pseudodiverticulosis had intramural tracking on esophagography. The tracks had
an average length of 1.2 cm (length range, 0.3-7 cm) and an average width of
1.6 mm (width range, 1-4 mm). The pseudodiverticula were more numerous and had
a more diffuse distribution in patients with tracking than in patients without
tracking. Although patients with and without tracking had a similar frequency
of strictures and esophagitis, patients with tracking were more likely to have
strictures involving the upper or mid esophagus, whereas patients without
tracking were more likely to have strictures in the distal esophagus. These
findings indicate that intramural tracking is more likely to occur in patients
with the diffuse form of esophageal intramural pseudodiverticulosis.
CONCLUSION. Intramural tracking was detected on esophagography in
50% of patients with esophageal intramural pseudodiverticulosis, so this type
of tracking is a more common radiographic finding than has previously been
recognized. Although intramural tracking has little or no known clinical
significance, it is important to be aware of this finding so that it is not
mistaken for a large flat ulcer in the esophagus or for an extramural
collection associated with esophageal peridiverticulitis.
Introduction
Esophageal intramural pseudodiverticulosis is a well-recognized condition
in which excretory ducts of submucosal esophageal mucus glands become dilated,
forming tiny outpouchings or pseudodiverticula. Affected individuals
classically have a diffuse form of esophageal intramural pseudodiverticulosis
associated with strictures in the upper or mid esophagus
[1,2,3].
In a large series [4], however,
esophageal intramural pseudodiverticulosis was found to occur more frequently
as a localized condition in the distal esophagus with a focal cluster of
pseudodiverticula in the region of a peptic stricture.
Esophageal intramural pseudodiverticulosis is detected on esophagography in
less than 1% of all patients who undergo radiologic examination of the
esophagus [4]. Despite its
rarity on barium studies, early changes of esophageal intramural
pseudodiverticulosis have been found in "normal" esophageal
specimens in 55% of patients
[5]. This discrepancy between
the prevalence of esophageal intramural pseudodiverticulosis on radiologic and
pathologic examinations may be related to the greater degree of ductal
dilatation needed to visualize the ducts on barium studies and related to
squamous debris occluding the pseudodiverticula that prevent them from filling
with barium.
Pseudodiverticular perforation and mediastinitis are rare but serious
complications of esophageal intramural pseudodiverticulosis. To our knowledge,
five cases of mediastinitis or fistula formation caused by pseudodiverticular
perforation have been reported
[6,7,8,9].
In addition, other patients with esophageal intramural pseudodiverticulosis
develop intramural tracks parallel to the esophageal lumen that bridge two or
more adjoining pseudodiverticula on esophagography
[2,
4,
10]. We recently noticed this
finding in a number of patients with esophageal intramural
pseudodiverticulosis, some of whom had striking intramural tracking. The
purpose of our investigation was to determine the frequency of intramural
tracking in patients with esophageal intramural pseudodiverticulosis and to
characterize its morphologic features on barium studies.
Materials and Methods
Computerized radiology files and radiology logs at two institutions
revealed 30 patients in whom esophagography showed findings of esophageal
intramural pseudodiverticulosis, including 18 patients from one institution
between 1989 and 1999 and 12 from the other institution between 1993 and 1998.
The esophagrams were obtained as biphasic examinations, including single- and
double-contrast studies in 29 patients and as a single-contrast study only in
one. The radiographs from these examinations were reviewed retrospectively by
three abdominal radiologists to determine the frequency and appearance of
intramural tracking. The pseudodiverticula typically appear as teardrop- or
flask-shaped collections of barium in the esophageal wall, ranging from 0.5 to
2.0 mm in diameter [10]. The
location and number of pseudodiverticula were noted in all patients. The
location, length, and thickness of the intramural tracks were noted. The
images were also assessed for the presence of esophagitis or strictures in
patients with and without intramural tracking. Whenever possible, the cause of
esophagitis or stricture was suggested on the basis of the radiographic
findings and clinical presentation. A chi-square test was used to determine
statistical significance; a p value less than 0.05 was considered
significant.
Of the 30 patients, 19 were men and 11 were women. The mean age of the
patients was 58 years (age range, 17-94 years). Clinical history was available
in nine of 15 patients with esophageal intramural pseudodiverticulosis and
intramural tracking: three of these patients had dysphagia. One had
odynophagia, one had symptoms of gastroesophageal reflux, and four were
asymptomatic. The clinical history was also available in 12 of 15 patients
with esophageal intramural pseudodiverticulosis and no intramural tracking:
four of these patients had dysphagia. Two had hematemesis, one had vomiting
and retrosternal pain, one had AIDS and oral thrush, one had undergone a
recent esophageal dilation procedure, and three were asymptomatic.
Results
Fifteen (50%) of the 30 patients with esophageal intramural
pseudodiverticulosis had intramural tracking. The tracks had an average length
of 1.2 cm (length range, 0.3-7 cm) and an average thickness of 1.6 mm
(thickness range, 1-4 mm) (Figs.
1A,1B,2A,2B,3,4A,4B).
The tracks ranged in appearance from short thin connections between two or
more adjoining pseudodiverticula (Fig.
1A,1B)
to long intramural collections of barium that paralleled the lumen (Fig.
2A,2B).
Pseudodiverticula and intramural tracks, when present, were seen on both the
single- and double-contrast portions of the examinations and did not appear
significantly different.
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Fig. 1A. —58-year-old woman with reflux disease, dysphagia, and failed Nissen
fundoplication. Double-contrast esophagram reveals mild corrugated stricture
(curved arrow) of distal esophagus. Extending from stricture are tiny
pseudodiverticula, with thin interconnecting intramural tracks (straight
arrows).
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Fig. 1B. —58-year-old woman with reflux disease, dysphagia, and failed Nissen
fundoplication. Esophagram also using high-density barium obtained 6 months
after A shows marked progression of esophageal stricture (curved
arrows). Note greater number of pseudodiverticula and tracks
(straight arrows).
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Fig. 2A. —17-year-old boy with reflux disease and dysphagia. Double-contrast
esophagram reveals 7-cm intramural track (black arrows) seen
obliquely in mid esophagus. This track was initially misdiagnosed as giant
flat ulcer. Scattered pseudodiverticula (white arrows) are seen
throughout esophagus.
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Fig. 2B. —17-year-old boy with reflux disease and dysphagia. Single-contrast
esophagram obtained 3 years before A shows same track in profile
(arrows). Pseudodiverticula are not apparent on this study.
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Fig. 3. —75-year-old asymptomatic woman. Double-contrast esophagram shows
smooth stricture in mid esophagus. Note pseudodiverticula are present in mid
and distal esophagus. Both thin (open arrow) and thick (closed
arrow) tracks are seen in region of stricture.
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Fig. 4A. —71-year-old asymptomatic man with diabetes. Double-contrast
esophagram shows diffuse esophageal intramural pseudodiverticulosis with short
intramural tracks bridging two pseudodiverticula (arrows).
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Fig. 4B. —71-year-old asymptomatic man with diabetes. Follow-up
double-contrast esophagram obtained 4 years after A shows resolution of
tracking and pseudodiverticula. Note peptic stricture (arrow) in
distal esophagus near gastroesophageal junction.
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Statistically significant differences were observed in the frequency and
distribution of pseudodiverticula in patients with and without intramural
tracking. The pseudodiverticula were more numerous in patients with intramural
tracking than in patients without tracking (p = 0.0007). The
pseudodiverticula also had a more diffuse distribution in patients with
tracking, whereas the pseudodiverticula were predominantly located in the
distal esophagus in patients without tracking (p = 0.006).
Patients with esophageal intramural pseudodiverticulosis had a high
frequency of strictures, regardless of the presence or absence of intramural
tracking. Twelve (80%) of 15 patients with esophageal intramural
pseudodiverticulosis and intramural tracking had strictures; six (50%) of
these strictures involved the upper or mid esophagus
(Fig. 3). Similarly, 12 (80%)
of 15 patients with esophageal intramural pseudodiverticulosis and no tracking
had strictures; nine (75%) of these strictures involved the distal esophagus.
However, the difference in stricture location was not statistically
significant (p = 0.3). All five symptomatic patients with esophageal
intramural pseudodiverticulosis and bridging had an underlying stricture. In
addition, one of these patients also had esophagitis caused by Candida
albicans.
Patients with esophageal intramural pseudodiverticulosis also had a similar
frequency of esophagitis, regardless of the presence or absence of intramural
tracking. Five (33%) of 15 patients with esophageal intramural
pseudodiverticulosis and intramural tracking had esophagitis, including reflux
esophagitis in two patients and Candida esophagitis in three.
Similarly, three (20%) of 15 patients with esophageal intramural
pseudodiverticulosis and no tracking had esophagitis, including reflux
esophagitis in two patients and Candida esophagitis in one.
Three of the 15 patients with esophageal intramural pseudodiverticulosis
and intramural tracking had two or more serial esophagrams over an average
period of 2.5 years (time range, 0.5-4 years). In one patient, the
pseudodiverticula and an associated distal stricture changed in appearance
over a 6-month period (Fig.
1A,1B);
the intramural tracks connecting the pseudodiverticula also had a variable
appearance with disappearance of some tracks and formation of others between
radiologic studies. In another patient, serial studies revealed disappearance
of pseudodiverticula and resolution of intramural tracks over a 4-year period
(Fig.
4A,4B).
In the third patient, a 7-cm track persisted on serial studies over a 3-year
period (Fig.
2A,2B).
When viewed obliquely on one of the studies, the track was initially
misinterpreted as a giant flat ulcer (Fig.
2A). However, subsequent endoscopy revealed esophageal intramural
pseudodiverticulosis without evidence of ulceration in the esophagus.
Discussion
Intramural tracking has been reported anecdotally as an unusual
complication of esophageal intramural pseudodiverticulosis
[2,
4,
10]. In our study, however,
intramural tracking was detected on esophagography in 15 (50%) of 30 patients
with esophageal intramural pseudodiverticulosis, indicating that intramural
tracking is a more common feature of esophageal intramural
pseudodiverticulosis than has previously been recognized. Tracks ranged in
appearance from short thin bridges between two or more adjoining
pseudodiverticula to long intramural collections of barium that paralleled the
lumen. Although the pathophysiology of this finding is uncertain, it most
likely results from disruption of the dilated excretory ducts in esophageal
intramural pseudodiverticulosis, allowing barium to track in the esophageal
wall.
Of those patients with intramural tracking and known clinical history, all
symptomatic patients had underlying strictures that were thought to explain
the symptoms. The other patients were asymptomatic. Intramural tracking in
esophageal intramural pseudodiverticulosis should be distinguished from a much
rarer and more serious condition in which frank perforation of a
pseudodiverticulum results in esophageal peridiverticulitis with a
periesophageal inflammatory mass and clinical signs of mediastinitis (e.g.,
chest pain and fever)
[6,7,8,9].
In one such patient, a contrast study revealed extravasation of contrast
medium via a track perpendicular to the esophageal wall into a periesophageal
collection [6]. Such extramural
collections should not be mistaken for the more innocuous intramural tracks in
esophageal intramural pseudodiverticulosis.
Both intramural tracking and the associated pseudodiverticula were found to
have a variable appearance over time. We are uncertain whether the
disappearance of the tracks and pseudodiverticula on follow-up studies in our
patients resulted from actual resolution or from plugging of these structures
with squamous debris that prevented them from filling with barium. It has been
reported that esophageal intramural pseudodiverticulosis is more likely to be
detected on single-contrast than on double-contrast esophagrams, but we did
not find this true [4]. This
finding was previously thought to be because the thin low-density barium
enters the pseudodiverticula more readily than the high-density barium used
for double-contrast esophagography. For similar reasons, intramural tracks are
more likely visualized on single-contrast studies, although we do not have
enough data to support this hypothesis. Multiple swallows of barium may also
be needed to show these tracks or pseudodiverticula, perhaps representing
another factor that contributed to the variable appearance of these structures
on serial esophagrams in our series.
Although intramural tracking in esophageal intramural pseudodiverticulosis
has little or no known clinical significance, it is important not to mistake
this finding for a large ulcer in the esophagus, an error that occurred in one
patient in our series. This differentiation can be particularly difficult when
the tracks are viewed obliquely on barium studies. When viewed in profile,
however, these intramural tracks can often be seen to bridge two or more
adjoining pseudodiverticula. Pseudodiverticular tracks also tend to be thinner
than ulcers and are not associated with surrounding mounds of edema.
A high frequency of esophageal strictures has been reported previously in
patients with esophageal intramural pseudodiverticulosis
[2,
4,
7,
10]. Similarly, our patients
with esophageal intramural pseudodiverticulosis had a high frequency of
strictures, regardless of the presence or absence of intramural tracking.
However, the strictures had a variable location in patients with tracking,
whereas they were predominantly located in the distal esophagus in patients
without tracking. The pseudodiverticula also were more numerous and had a more
diffuse distribution in patients with intramural tracking than in patients
without tracking. Presumably, increased numbers and more diffuse distribution
of pseudodiverticula are the result of an increase in severity of the
underlying insult, most commonly gastroesophageal reflux. This condition would
result in more inflammation and most likely a higher incidence of intramural
tracking. We found that intramural tracking is more likely to occur in
patients with the diffuse form of esophageal intramural pseudodiverticulosis
associated with strictures in the upper or mid esophagus than in patients with
the localized form of esophageal intramural pseudodiverticulosis associated
with peptic strictures in the distal esophagus.
In summary, intramural tracking was detected on esophagography in 50% of
patients with esophageal intramural pseudodiverticulosis, so this radiographic
finding is more common than has previously been recognized. It is important to
be aware of this finding so that it is not mistaken for ulceration. Intramural
tracks should also be distinguished from tracks perpendicular to the
esophageal wall or tracks from extramural collections associated with frank
perforation and esophageal peridiverticulitis, a much rarer and more serious
complication of esophageal intramural pseudodiverticulosis.
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Abstract
Introduction
