Esophagus

In the esophagus, early changes of motor dysfunction are hypercontractility and increased tone and hypertrophy of the circular muscle layer, often resulting in dysphagia. Later, as denervation progresses, there is decompensation, dilatation, and stasis. Food may become lodged in the esophagus and cause local irritation, leading to inflammation, ulceration, bleeding, perforation, and fistulae.

The earliest roentgen manifestations of Chagas' disease in the esophagus are those of motor dysfunction. Initially, tone is maintained and there is little or no dilatation. Gradually increasing disturbances in tone, rhythm, and motility over a number of years give the appearance of bizarre, dysrhythmic contractions on barium swallow (Fig. 4.8). In severe infections, however, there may be an extremely dilated and flaccid esophagus with a transverse diameter of 7 cm or more, exhibiting marked loss of tone with weak, uncoordinated contractions. The appearance of advanced megaesophagus both on plain radiographs of the chest and on barium swallow is remarkably similar to achalasia. In both entities the dilated esophagus appears as a vertical density along the entire right paramediastinal border on frontal films, usually distended with air and sometimes with an air-fluid level if the patient has recently ingested liquids (Figs. 4.9, 4.10, 4.11, 4.12). A tapered distal esophageal segment down to the cardiac sphincter is seen in Chagas' megaesophagus, similar to that seen in achalasia. There may be some delay in passage of food through this area because of failure of relaxation and motor incoordination at the level of the sphincter, as well as lack of propulsive peristalsis throughout the esophagus.

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Fig. 4.8 Chagas' megaesophagus in 2 different Brazilian patients showing dysrhythmic contractions, disturbance of tone and moderate dilatation of the esophagus. Note the marked alteration of peristalsis with local incoordinate, bizarre, non-propulsive contractions in patient (A). (Courtesy of Dr. Clovis Simao, Sao Paulo.) Patient (B), a 34-year-old man from the state of Bahia, lived in a clay house infested by numerous barbeiro (Triatoma infestans). He had no difficulty in swallowing but had severe constipation with 15 days between bowel movements. Machado-Guerreiro complement fixation test was positive. There is considerable esophageal dilatation with dysrhythmic contractions and a spastic distal segment at the esophagogastric junction.

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Fig.4.9 Megaesophagus in 3 different Brazilian patients. (A) Fifty year old black man with difficulty in swallowing dry foods for l5 years. He felt that food stopped behind his sternum. The dysphagia became progressively worse until he could no longer swallow fluids. The entire esophagus is dilated from the diaphragm to the thoracic inlet with a resultant air-filled vertical soft tissue density widening the entire right paramediastinal border. The appearance is identical to advanced achalasia of the esophagus on plain film examination of the chest. (B) Fifty year old white man with dysphagia of 20 years duration with frequent regurgitation and increased salivation. For the past year he had postprandial epigastric pain. Barium swallow shows both barium and air within a grossly dilated esophagus widening the right paramediastinal border. There is a tapered distal esophageal segment at the esophagogastric junction. Radiographically, this appearance is indistinguishable from achalasia. This chest film was obtained 5 minutes after ingestion of barium and shows a prominent air-barium fluid level in the dilated mid-esophagus. (C) Thirty-six year old white man with dysphagia for dry foods of 16 years duration. He had almost complete incapacity to swallow food. In addition he had a systolic murmur in the mitral area with right bundle branch block and left axis deviation. Barium swallow showed moderate dilatation of the esophagus down to a somewhat contracted esophagogastric junction. The 3 films on this patient were obtained 30 seconds, 5 minutes and 30 minutes, respectively, after ingestion of barium and indicate markedly delayed emptying of the esophagus due to loss of effective peristalsis and a failure of the cardiac sphincter to relax. All three patients had a positive serologic reaction for Chagas' disease. (A-C Courtesy of Dr. Clovis Simao, Sao Paulo.) (D) Gross specimen of Chagasic megaesophagus. AFIP 69-6536.

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Fig. 4.10 Massive megaesophagus in an adult Brazilian man with chronic dysphagia. (A) A soft tissue mass widens the right paramediastinum and projects almost to the lateral chest wall. The esophagus is distended with fluid and a minimal amount of air. Barium swallow (B) shows the full extent of the markedly dilated mid- and lower esophagus with barium having settled to the bottom of the fluid column. The contracted distal esophageal segment follows a tortuous course to the esophagogastric junction. This PA film of the chest was taken 30 minutes after ingestion of barium, indicating marked delay in esophageal emptying due to virtually complete loss of peristalsis within the dilated, atonic esophagus.

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Fig 4. 11 Megaesophagus in a Brazilian man showing massive dilatation of the esophagus on frontal (A) and oblique (B) views of the chest following barium swallow. Food residue, barium and fluid fill the entire distended esophagus down to the tapered esophagogastric junction. (Courtesy of Dr. Clovis Simao).

Fig. 4.12 Chagas' megaesophagus in an adult Brazilian man showing only slight dilatation of the esophagus but multiple shallow ulcerations with a ragged contour of the mid-esophagus. Note the tapered distal esophageal segment. (Courtesy of Dr. Clovis Simao).