What’s the cause of this man’s esophageal striations?
Vol.18, No.10, December 2010

A 68-year-old man undergoes a barium swallow and air-contrast upper GI series for symptoms of chronic cough and intermittent heartburn. The patient was new to the family doctor and was a poor historian; as such, not much is known about his past medical history.

What is the most likely cause of this esophageal appearance?

a) feline esophagus

b) esophageal varices from hepatic cirrhosis

c) chronic esophagitis

d) Barrett’s esophagus

e) esophageal achalasia

ANSWER
Solution to Analyze This!

a) feline esophagus

The term feline esophagus applies to the appearance of the esophagus on a barium swallow exam, where there is demonstration of fine, symmetric, transverse mucosal folds crossing the majority of the esophagus. The term comes from the appearance of the normal folds in the distal esophagus of a cat. The folds are 1-2 mm wide and extend circumferentially around the entire esophageal lumen. The appearance is a transient phenomenon, lasting seconds to perhaps a minute or two, and is virtually always associated with the presence of gastroesophageal reflux disease (GERD). The transient appearance has also been referred to as “esophageal shiver.” The appearance is pathognomonic of this benign condition of GERD and should not be confused with other more serious pathologic entities. The appearance may be associated with the presence of a hiatus hernia, a coincidental correlation, as both are commonly seen in patients with GERD. The presence of a “feline esophagus” appearance during a barium swallow exam does not require further intervention or investigation, as long as the underlying condition of GE reflux is being treated adequately.

In contrast, both acute and chronic esophagitis will typically lead to thicker, slightly irregular fold thickening of the esophageal mucosa with the thickened folds usually traversing less than 50% of the esophageal lumen, and measuring 3-5 mm in thickness. In comparison, the fold thickness is significantly greater than the thin, regular, symmetric transient transverse folds of feline esophagus. The thick, irregular folds of chronic esophagitis are relatively fixed, and are often associated with mucosal plaques, nodules and ulcerations. Ulcers are the hallmark finding of esophagitis. Ulcers less than 1 cm in size are associated with conditions such as severe reflux esophagitis, herpes, and drug and radiation-induced inflammation. Larger ulcerations of greater than 1 cm can be seen with cytomegalovirus (CMV), human immunodeficiency virus (HIV), carcinoma and Barrett’s esophagus.

Barrett’s esophagus is a pathologic condition of the mid and distal esophagus arising from chronic chemical irritation of the esophageal lining secondary to long-standing GERD. It occurs in approximately 10% of patients with chronic untreated GERD. The acidic make-up of the refluxed gastric juices cause inflammation of the normal columnar epithelium of the distal esophagus. Over time, this leads to columnar metaplasia, which is a pre-malignant condition and predisposes to a 30-40-fold increase in a risk of development of adenocarcinoma of the distal esophagus. About 15% of patients with Barrett’s esophagus will develop mid or distal esophageal carcinoma. On barium swallow exam, Barrett’s esophagus will appear as a mid or distal esophageal smooth or mildly irregular stricture, or perhaps a region of prominent ulceration (greater than 1 cm – see above). Diagnosis is confirmed by upper endoscopy with biopsy.

Esophageal varices typically result as a complication of hepatic cirrhosis and portal hypertension. There’s a relative obstruction to hepatopetal flow of blood into the liver, and eventual reversal of flow (hepatofugal flow) resulting in moderate to marked dilation of regional veins in the upper abdomen, abdominal wall, and lower thorax. Esophageal varices will produce large irregular, serpiginous mucosal defects on a barium swallow exam. The thickened snaking folds are often oriented vertically or obliquely, unlike the fine transverse regular folds of benign feline esophagus. The presence of esophageal varices is a serious complication of cirrhosis and portal hypertension, as the enlarged veins can rupture into the esophageal lumen, resulting in potentially massive internal hemorrhage.

Achalasia is an uncommon muscular disorder of the esophagus resulting from failure of relaxation of the distal gastroesophageal sphincter. There is secondary chronic aperistalsis of the distal two thirds of the esophagus with eventual moderate to severe esophageal lumen dilatation. On barium swallow, a markedly dilated esophagus is often seen with sharp distal tapering to a point at the distal GE junction, resulting in a “bird’s-beak” appearance of the distal esophagus. Complications include long-standing relative obstruction to passage of foods and even fluids, potential infections from fluid and food product stasis (i.e. candidiasis), and carcinoma in the upper esophageal segments. The diagnosis of achalasia is confirmed with esophageal manometry.

References

  1. Samadi F, et al. Am J Roentgenol 2010;194:972-6.
  2. Kaplan M, et al. Clin Gastroenterol Hepatol 2003;6:433-7.
  3. Furth EE, Rubesin SE, Rose D. Am J Roentgenol 1995;164:900.
  4. Goldberg HI, Dodds WJ, Jenis JH. Am J Roentgenol 1970;110:288-94.
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Clinical challenge image
Figure 1 is a select image from the barium swallow exam showing the mid and lower aspect of the esophagus, coated with barium. Numerous horizontal striations are evident along the esophageal mucosa. The appearance was transient, but appeared a few times during the procedure. No evidence of stricture, mass lesion or perforation. A small direct hiatus hernia is evident at the lower esophageal margin.
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