Reflux esophagitis

Clinical

Gastroesophageal reflux disease is the most common inflammatory disease that involves the esophagus. The reflux of gastric or duodenal contents into the esophagus secondary to LES dysfunction is a major cause of esophageal ulceration. Reflux of gastric acid and pepsin or even bile and pancreatic juices act as irritants to the esophageal mucosa. Patients have the classic history of episodic heartburn and regurgitation that is worsened by lying down. If the reflux disease has progressed, patients may develop peptic strictures and complain of slowly progressive dysphagia for solid foods. Assessment for a patient with suspected reflux disease can include radiologic, endoscopic, manometric, or pH monitoring studies.

Radiological findings

Double contrast esophagography have a greater radiographic sensitivity (~90%) in detecting reflux esophagitis than single contrast studies. Some findings that might appear in reflux esophagitis include abnormal motility, ulcerations, mucosal nodularity, thickened folds, and scarring or strictures.

-Abnormal motility: Approximately 25 to 50% of patients with reflux esophagitis exhibit weak or absent primary peristalsis with an increased frequency of nonperistaltic contractions. This may be secondary to neuronal damage to Auerbach's plexus caused by direct inflammatory extension.

-Mucosal nodularity: Mucosal edema and inflammation may manifest on contrast studies as a granules or fine nodules in the distal esophagus. This mainly reflects the early stages of reflux esophagitis.

-Ulceration: Ulcers or erosions appear as tiny collections of barium in the distal esophagus near the gastroesopohageal junction. The ulcers can have an irregular appearance or may even be linear. They are often associated with surrounding edematous mucosa, radiating folds, or puckering of the adjacent esophageal wall.

-Thickened folds: Esophageal folds greater than 3mm are considered abnormal. In reflux esophagitis, thickened folds are due to submucosal edema and inflammation. The folds may have a smooth, nodular or scalloped appearance.

-Scarring/strictures: Scarring of the esophageal mucosa can manifest in multiple ways. They can appear as focal outpouchings or sacculations. Scarring may also manifest as fixed transverse folds in the distal esophagus resembling a "stepladder" appearance. Approximately 10 to 20% of patients with reflux esophagitis develop strictures due to circumferential scarring of the distal esophagus. This concentric area of smooth, tapered narrowing in the esophagus is usually located above a sliding hiatal hernia. Most strictures range in 1 to 4cm in length with a width between 0.2 to 2.0 cm. In contrast to Schatzki rings, the vertical height of these reflux esophagitis strictures tends to be greater than 4mm.