What is the diagnosis and management for a focal fluid-filled area in the mid esophagus with possible peristalsis and no evidence of a distal esophageal mass or wall thickening?

Focal Fluid-Filled Area in the Mid-Esophagus: Diagnosis and Management

A focal fluid-filled area in the thoracic mid-esophagus with possible peristalsis likely represents a non-specific finding that requires barium swallow for further evaluation, as recommended in the initial imaging report. 1

Differential Diagnosis

• Esophageal Motility Disorders: The finding of "possible peristalsis" suggests this could be related to an esophageal motility disorder, which can present with non-specific findings on imaging 1

• Eosinophilic Esophagitis (EoE): This condition can present with subtle findings on imaging and should be considered, especially if the patient has dysphagia 1

• Non-specific Peristaltic Abnormality: Peristaltic abnormalities are reported in up to 53% of adults with esophageal disorders, often appearing as non-specific findings 1

• Gastroesophageal Reflux Disease (GERD): Can cause secondary peristaltic abnormalities that may appear as focal fluid-filled areas 2, 3

Diagnostic Approach

1. Barium Swallow (Esophagram):

   • Should be performed as the next step to better characterize the finding 1
   • Helps identify the presence, caliber, and length of any stenosis or abnormality 4
   • Can demonstrate dynamic abnormalities not visible on static imaging 1

2. Endoscopy with Biopsy:

   • Essential for direct visualization and tissue sampling 1
   • Multiple biopsies (at least 6) from different esophageal locations should be obtained 4
   • Biopsies should be taken regardless of gross mucosal appearance 1
   • Stomach and duodenal biopsies should also be obtained to rule out other conditions 1

3. High-Resolution Manometry (HRM):

   • Indicated to assess esophageal motility and peristalsis 1
   • Should include both liquid and solid swallows to better reproduce symptoms 1
   • Can identify specific motility disorders that may not be apparent on imaging alone 1

4. pH Monitoring/Impedance Testing:

   • Consider if GERD is suspected as contributing to the finding 1
   • Helps distinguish between primary motility disorders and secondary changes due to reflux 3

Management Recommendations

1. Initial Management:

   • Complete the recommended barium swallow study 1
   • Proceed with endoscopy with multiple biopsies regardless of endoscopic appearance 1, 4

2. If Motility Disorder Identified:

   • Treatment depends on the specific disorder diagnosed 1
   • For achalasia or spasm: consider pneumatic dilation, which has shown good results 5
   • For GERD-related dysmotility: H2-blockers or PPI therapy may restore normal peristalsis 2

3. If Eosinophilic Esophagitis Identified:

   • Combination of dilation and anti-inflammatory therapy (topical steroids) 4
   • Stop PPIs for 3 weeks before diagnostic endoscopy to avoid false-negative results 4

4. If Structural Abnormality Found:

   • Dilation may be required for stenosis, using balloon dilators or wire-guided bougies 4
   • For very narrow stenosis, limit initial dilation to 10-12 mm in diameter 4
   • Perform weekly or biweekly dilations until a diameter of ≥15 mm is achieved 4

Important Considerations

• The absence of distal esophageal mass or wall thickening is reassuring against malignancy, but does not rule out other significant pathology 1, 6

• Focal wall thickening on CT can be seen in benign conditions such as diffuse esophageal spasm 7

• Early diagnosis and treatment of conditions like eosinophilic esophagitis is crucial to prevent complications such as fibrosis and stenosis 4

• Patients with persistent dysphagia despite normal endoscopic findings should undergo comprehensive esophageal physiological testing 1

• Solid swallows during manometry should be considered to better replicate symptoms, as liquid swallows alone may miss clinically relevant dysfunction 1