AJR 2003; 181:1391-1396
© American Roentgen Ray Society
CT of the Pediatric Esophagus
Michael J. Callahan1 and
George A. Taylor
1 Both authors: Department of Radiology, Children's Hospital Boston and Harvard
Medical School, 300 Longwood Ave., Boston, MA 02115.
Received November 27, 2002;
accepted after revision March 4, 2003.
Address correspondence to M. J. Callahan
(michael.callahan{at}tch.harvard.edu).
Introduction
The pediatric esophagus is most frequently evaluated dynamically with
real-time fluoroscopy using orally administered contrast material. However,
direct anatomic information is limited to the esophageal mucosa. Intramural
abnormalities may or may not be visible on fluoroscopic examination, and
extraluminal abnormalities can only be inferred. The purpose of this pictorial
essay is to familiarize the reader with the CT appearances of esophageal
lesions in children. Although not traditionally used to evaluate the esophagus
in pediatric patients, CT can be a valuable tool for evaluating intrinsic
abnormalities of the esophagus and pathologic processes that directly affect
the esophagus and adjacent mediastinum.
Normal Esophagus
The normal pediatric esophagus is a thin-walled structure that can be
readily identifiable on helical CT images of the chest and upper abdomen, but
the esophagus can be difficult to visualize in its entirety unless the lumen
is opacified with fluid or air (Fig.
1). When the esophagus is adequately distended, wall thickness
should be no more than 5 mm
[1].
Congenital Lesions
The most common congenital abnormalities affecting the pediatric esophagus
are esophageal duplications and bronchogenic cysts. Both lesions appear on CT
as round, thin-walled fluid-attenuation masses and are typically located
immediately adjacent to the esophagus (Fig.
2) or in a mediastinal, perihilar
(Fig. 3), or pulmonary
parenchymal location [2]. The
differential diagnosis of cystic lesions also includes lymphatic
malformations. These lesions are unusual in the mediastinum but can displace
the thoracic esophagus if present (Fig.
4).
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Fig. 2. —Transverse helical CT image with IV contrast material in
9-month-old girl shows lateral displacement of air-filled esophagus
(arrow) by round low-attenuation mass. Surgical pathology revealed
esophageal duplication cyst. Esophagus is second most common location for
duplication cysts of gastrointestinal tract. Cyst density may vary depending
on its contents.
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Fig. 3. —Transverse helical CT image with IV contrast material in
8-year-old girl shows round low-attenuation mass (white arrow) in
right perihilar region, typical of bronchogenic cyst. Mass is not associated
with, and does not displace, esophagus (black arrow). Bronchogenic
cysts occur as result of abnormal budding of embryologic tracheobronchial
tree.
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Fig. 4. —Transverse helical CT image in 17-year-old boy with known
widespread macrocystic lymphatic malformation shows anterior displacement of
air-filled esophagus by round low-attenuation mass (arrow) later
confirmed to represent mediastinal extension of lymphatic malformation. Note
irregular cortical expansion of right-sided rib (arrowhead) caused by
bony involvement of lymphatic malformation. Mediastinal lymphatic malformation
can mimic foregut duplication cysts.
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Esophageal dilatation may be the predominant imaging sign in children with
esophageal obstruction caused by mechanical or functional congenital lesions.
These include achalasia [3]
(Fig. 5), multiple or complex
atresias (Fig. 6A,
6B), and intrathoracic stomach
with gastric volvulus (Fig. 7A,
7B). Multiplanar reformatted
imaging complements conventional imaging in the transverse plane to better
show the relationship between the proximal and distal segments of the
esophagus, as well as the relationship between the gastroesophageal junction
and the stomach.
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Fig. 5. —Transverse helical CT image with IV contrast material in
9-year-old boy with vomiting and weight loss shows dilated thin-walled
air-filled esophagus (arrow). Luminal dilatation results from
functional obstruction at lower esophageal sphincter. Upper gastrointestinal
series (not shown) confirmed diagnosis. Typical CT findings of achalasia
include moderate to marked esophageal dilatation with normal wall thickness
[3].
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Fig. 6A. —CT image of 1-day-old female neonate with known esophageal
atresia. Transverse helical CT image with IV contrast material was obtained to
exclude coexisting diaphragmatic hernia suspected from results of chest
radiograph (not shown). Study shows distended air-filled proximal esophagus
(arrow). There is volume loss in association with fluid attenuation
opacification in right hemithorax (R), representing dilated, fluid-filled
distal esophagus, which resulted in aplasia of adjacent right lung.
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Fig. 6B. —CT image of 1-day-old female neonate with known esophageal
atresia. Coronal reformatted CT image shows blind-ending air-filled proximal
esophagus (small arrows) and fluid-filled distended distal esophagus
(large arrows). Stomach (S) and duodenal bulb (D) are markedly
distended. Surgery confirmed CT diagnosis of esophageal atresia without
tracheoesophageal fistula and duodenal atresia.
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Fig. 7B. —CT images of 1-day-old male neonate. Sagittal reformatted CT
image shows air in distal esophagus (arrows) and herniation of
stomach (S) into chest. Gastroesophageal junction is located inferior to body
of stomach, in keeping with organoaxial gastric volvulus confirmed at surgery.
Gastric volvulus involves abnormal rotation of stomach along its transverse or
longitudinal axis and may be associated with intestinal malfixation. Gastric
volvulus in infants and children is frequently associated with other
congenital abnormalities, including malrotation, hiatal hernia, or
diaphragmatic hernia.
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Inflammation and Infection
Several inflammatory and infectious processes may directly affect the
pediatric esophagus. The most commonly encountered include severe
gastroesophageal reflux, fungal or viral esophagitis, and esophagitis caused
by chemotherapy or radiation. Complications of significant gastroesophageal
reflux include stricture formation (Fig.
8A,
8B), recurrent pneumonia, and
adenocarcinoma. Esophageal replacement surgery may still be necessary for
complicated cases of esophageal atresia or severe esophageal strictures caused
by gastroesophageal reflux or corrosive injury (Figs.
9 and
10). In the immuno-suppressed
or pediatric oncology patient with esophageal wall thickening, fungal
esophagitis should be suspected
[4]. Debris may also be present
in the esophageal lumen (Fig.
11). Septic shock and radiation-induced esophagitis may result in
mucosal or submucosal edema in hollow viscera such as the esophagus (Figs.
12 and
13). CT can be very useful to
evaluate the presence and extent of disease and potential complications.
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Fig. 8A. —8-year-old boy with Kartagener's syndrome. Transverse helical
CT image with IV contrast material shows marked inflammation and thickening of
distal esophagus (arrow). Note associated dextrocardia.
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Fig. 8B. —8-year-old boy with Kartagener's syndrome. Coronal
reformatted CT image after delayed oral contrast administration shows reflux
of enteric contrast material to thoracic inlet and marked mucosal thickening
of mid to distal esophagus (arrows). Note right-sided stomach (S) and
polysplenia (Sp).
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Fig. 9. —Coronal reformatted minimum-intensity-projection CT image in
9-year-old boy shows air- and fluid-filled colonic interposition
(arrows) in left paraspinal location. Interposition surgery was
performed to treat severe esophageal stricture.
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Fig. 10. —Transverse CT image of lower lungs in 17-year-old girl shows
patchy air-space opacities (arrowheads) in both lower lobes. Findings
were consistent with aspiration pneumonia. Air–fluid level is present in
colonic interposition (arrow) in medial posterior left
hemithorax.
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Fig. 11. —Transverse helical CT image with IV contrast material in
7-year-old neutropenic boy with acute leukemia shows dilated thickened
cervical esophagus (arrow) filled with debris. Aspergillus
fungal esophagitis was confirmed at autopsy. Other common causes for
infectious esophagitis include Candida organisms, herpes, and
Cytomegalovirus organisms.
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Fig. 12. —Transverse helical CT image in 15-year-old boy with septic
shock shows dilated fluid-filled esophagus with thickened wall
(arrow) and submucosal radiolucency caused by edema associated with
marked capillary leak and interstitial fluid losses.
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Fig. 13. —Transverse helical CT image in 16-year-old girl with
paraspinal neuroblastoma treated with radiation shows thickened, fluid-filled
esophagus (arrow) with prominent surrounding collateral vessels.
Residual right paraspinal soft tissue (arrowheads) is identified at
site of primary tumor. Although esophagus is relatively radioresistant,
radiation-induced esophagitis is potential complication of treatment of some
thoracic malignancies.
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Tumors
Primary benign tumors of the esophagus are considerably more common than
primary malignant tumors in pediatric patients. Localized leiomyoma or diffuse
leiomyomatosis predominate in this category of tumors
[5] (Figs.
14 and
15). Posttransplantation
lymphoproliferative disorder occurs as a result of immunosuppression after
solid-organ transplantion, resulting in bulky mediastinal adenopathy that can
displace an otherwise normal esophagus
(Fig. 16). Perforation is a
potential complication of esophageal lymphoma
(Fig. 17). CT is particularly
useful for diagnosing and planning the biopsy of esophageal tumors.
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Fig. 14. —Transverse helical CT image with IV contrast material in
15-year-old girl with chief complaint of "heart pain" shows
collapsed esophagus (arrow) in association with large, round
heterogeneously enhancing submucosal mass (M). Pathologic diagnosis was
esophageal leiomyoma.
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Fig. 15. —Transverse helical CT image in 16-year-old girl with Alport's
syndrome shows marked thickening of esophagus (white arrow) caused by
leiomyomatosis. Oral contrast material (black arrow) is seen within
lumen of thickened esophagus.
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Fig. 16. —Transverse helical CT image with IV contrast material in
9-year-old boy with posttransplantation lymphoproliferative disorder after
cardiac transplantation shows lateral displacement of collapsed esophagus
(arrow) by multiple large necrotic mediastinal lymph nodes
(arrowheads). Metastatic mediastinal adenopathy or mediastinal
adenopathy from lymphoma may have similar effect on esophagus.
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Fig. 17. —Transverse helical CT image with IV contrast material in
14-year-old girl shows multiple mediastinal gas collections (white
arrows) surrounding thoracic esophagus demarcated by nasogastric tube
(black arrow). Patient had lymphoma of esophageal wall, ultimately
resulting in esophageal perforation.
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Vascular Abnormalities
Anomalous mediastinal vessels are a well-known cause of tracheal or
esophageal compression. Contrast-enhanced CT may be helpful in identifying the
specific vascular abnormalities, including vascular rings and slings
[6]. An anomalous origin of the
left pulmonary artery results in the displacement of both the trachea and the
thoracic esophagus as the anomalous left pulmonary artery passes between these
two structures (Fig. 18),
whereas an anomalous left subclavian artery in association with a right aortic
arch causes posterior esophageal compression. Although less obvious on a
series of conventional transverse CT images of the chest
(Fig. 19A), sagittal
reformatted images can readily show extrinsic esophageal vascular compression
(Fig. 19B). CT can also show
the extent of paraesophageal varices in children with portal hypertension
(Fig. 20).
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Fig. 18. —Transverse helical CT image with IV contrast material in
2-month-old boy shows lateral displacement of air-filled esophagus (white
arrow) and anterior displacement and narrowing of trachea
(arrowhead) by anomalous left pulmonary artery (black
arrows).
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Fig. 19A. —CT images of 7-year-old boy with shortness of breath.
Contrast-enhanced transverse helical CT image shows anterior displacement of
air-filled thoracic esophagus (arrowhead) by aberrant left subclavian
artery (S). Note right aortic arch (A).
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Fig. 19B. —CT images of 7-year-old boy with shortness of breath.
Compared with A, sagittal reformatted CT image better illustrates
aberrant left subclavian artery (arrow) with posterior compression of
air-filled esophagus (arrowheads), analogous to findings that can be
seen on barium esophagram (not shown).
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Fig. 20. —Transverse helical CT image with IV contrast material in
10-year-old boy with cirrhosis caused by  1–antitrypsin
deficiency shows thickening of collapsed distal esophagus (arrowhead)
in association with multiple distal esophageal varices (arrows).
Esophageal varices can occur as result of portal hypertension from variety of
causes of cirrhotic liver disease in pediatric patients.
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Trauma
Foreign-body ingestion is a relatively common problem encountered in a
radiology practice with a large number of pediatric patients. Unfortunately, a
large percentage of ingested foreign bodies are radiolucent. Plastic foreign
bodies lodged in the esophagus can be identified on CT
(Fig. 21). However, CT is not
useful in the primary evaluation of metallic foreign bodies (Fig.
22A,
22B). CT is an excellent tool
to evaluate potential complications of foreign-body ingestion, including
esophageal perforation, abscess, and stricture formation
(Fig. 23). CT of the chest
remains the gold standard to evaluate acute injury to the mediastinum.
Esophageal tears or ruptures are typically associated with penetrating injury
and are unusual injuries to sustain during blunt trauma to the chest
[7]. CT findings of esophageal
rupture include extraluminal gas collections and mediastinal or esophageal
hematoma (Fig. 24).
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Fig. 21. —Transverse helical CT image in 14-month-old girl presenting
with 4 months of noisy breathing shows diskshaped density (arrow) in
lumen of upper thoracic esophagus. There was surrounding mediastinal
inflammation, but no direct CT evidence of esophageal perforation. Plastic toy
coin was removed uneventfully at esophagoscopy.
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Fig. 22A. —2-year-old boy reportedly swallowed coin 1 week before
presenting to emergency department with fever. Frontal digital scout
radiograph shows round metallic density projecting over thoracic inlet. CT
scan was requested by referring surgeons to rule out abscess before removing
coin.
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Fig. 22B. —2-year-old boy reportedly swallowed coin 1 week before
presenting to emergency department with fever. Transverse helical CT image
shows marked beam-hardening artifact from metallic coin that completely
obscures surrounding soft-tissue structures. This study was performed with
single-detector CT scanner. Despite the fact that recent multidetector CT
technology has significantly decreased effects of metallic beam-hardening
artifact, CT is still probably not an appropriate modality for evaluating
metallic coins in esophagus.
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Fig. 23. —Transverse helical CT image in 6-year-old boy who swallowed a
toy "jack" that was removed endoscopically before CT scan. Oral
contrast material in lumen of thoracic esophagus (arrow) communicates
with walled-off perforation (white arrowheads) via small tract
(black arrowhead) within mediastinum. The study was requested to
delineate anatomy and extent of perforation before surgical repair.
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Fig. 24. —Transverse helical CT image with IV contrast material was
obtained in 7-year-old boy who was struck by motor vehicle. There is marked
thickening of esophagus and surrounding mediastinal soft tissues (white
arrow). Esophageal lumen is demarcated by air-filled nasogastric tube.
Tiny collection of gas (black arrow) located just lateral to
esophagus was thought to represent tiny loculated pneumothorax or
pneumomediastinum. Bilateral pulmonary contusions are also noted.
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Conclusion
CT is a useful tool for accurately evaluating the character and extent of
esophageal abnormalities in infants and children. CT has the unique ability to
evaluate both the effects of surrounding mediastinal abnormalities on the
esophagus and the effects of esophageal abnormalities on the adjacent
mediastinum.
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Introduction
Normal Esophagus
