Radiation Esophagitis

Clinical

Patients with malignancies of the lung, mediastinum, or thoracic spine are often treated with high-dose external beam radiation to the chest. Total doses of 4500 to 6000 rad can lead to severe, irreversible esophagitis with stricture formation, while lower doses between 2000 to 4500 rad can cause self-limited esophagitis that is reversible. Chronic radiation esophagitis is marked by thickening of the submucosa secondary to edema and fibrosis. Strictures often develop 4 to 8 months after high dose radiotherapy. There is also a subgroup of patients that can develop esophagitis that is caused by low-dose radiotherapy (as low as 500 rad) in combination with chemotherapy, specifically Adriamycin (doxorubicin). It is believed that Adriamycin potentiates the effects of radiotherapy. Patients often present with acute onset of substernal burning sensation, odynophagia or dysphagia within 2 weeks of the initiation of radiotherapy. Chronic radiation esophagitis may lead to the development of deep ulcers, TE fistulas or esophageal perforations.

Radiological findings

Double contrast studies can demonstrate superficial esophageal ulceration as shallow, irregular collections of barium within 7 to 10 days of radiotherapy. In severe cases, the esophagus may have an irregular, serrated contour due to ulceration and sloughing. After this acute phase, the most frequent finding on contrast studies is abnormal esophageal motility. Strictures that develop later often appear as smooth, tapered areas in the upper or midesophagus. Chronic radiation esophagitis has a tendency to develop ulcerations that can lead to tracheoesophageal or esophagobronchial fistulas. The most common site of fistula formation is in the left main bronchus.