Imaging Pearls ❯ Esophagus ❯ Varices
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- Esophageal Vascular Malformations
● Esophageal hemangiomas are rare, comprising approximately 3% of all benign esophageal tumors
○ Prevalence of 0.04% on autopsy
● Subtypes: Cavernous, capillary, hamartomatous, AVM???
● Imaging characteristics include intramural location, well-circumscribed and lobulated mass and presence of multiple phleboliths
○ Most often solitary, however multiple lesions may be seen in Osler-Weber-Rendu disease or Klippel-Trénaunay syndrome
● Easily mistaken with esophageal leiomyoma
○ Distinguished by presence of phleboliths and enhancement
● Often asymptomatic
○ When symptomatic, most often associated with hemorrhage and dysphagia
● Surgical or endoscopic resection is performed for symptomatic cases
- Esophageal Varices
● "Downhill" varices are less common than the so-called "uphill varices associated with portal hypertension
● Most often secondary to SVC obstruction
○ SVC obstruction from lung malignancy, mediastinal tumor/adenopathy, systemic vasculitis, and catheter-related thrombosis has been described
● Commonly located in the upper third of the esophagus
● Location of SVC obstruction in relation to azygous vein determines extent of venous collaterals
○ Superior to azygos-esophageal varices bypass SVC obstruction via drainage into azygos vein
○ Inferior to azygos-esophageal collaterals drain superior systemic system into portal vein, often involving entire thoracic segment of the esophagus
● Decreased rate of variceal hemorrhage
- "MPR imaging using MDCT provides excellent visualization of portosystemic collateral circulation. Accurate evaluation using MPR MDCT images should help predict esophageal varices relapse after endoscopic injection sclerotherapy."
Evaluation of Patients with Esophageal Varices After Endoscopic Injection Sclerotherapy Using Multiplanar Reconstruction MDCT Images Kodama H et al. AJR 2009; 192:122-130 - "MPR MDCT images on portosystemic collaterals can accurately predict relapse of esophageal varices after endoscopic injection sclerotherapy."
Evaluation of Patients with Esophageal Varices After Endoscopic Injection Sclerotherapy Using Multiplanar Reconstruction MDCT Images Kodama H et al. AJR 2009; 192:122-130
"The use of CT esophagography allows grading of esophageal varices, as well as differentiation between low and high risk varices with regard to the propensity fr bleeding."
Esophageal Varices in Patients with Cirrhosis: Multidetector CT Esophagography-Comparison with Endoscopy
Kim SH et al.
Radiology 2007; 242:759-768- Grading System for Varices
Grade
Endoscopic criterion
0 No varices
1 Varices run straight
2 Varices show beaded appearance 3 Varices run in oblique course and are tortuous with tumorlike appearance