R-CPD Esophageal Findings

The details of the following photos may support the R-CPD diagnosis, though they should not be considered diagnostic. Take note that all photos are non-channel scope images; that is, the scope is not able to insufflate (blow in) air. The significance: the esophagus is typically collapsed around endoscopes inserted into them and air is pumped in through a tiny channel in order to gently expand the esophagus so that its walls can be seen. Here, the air the patient cannot belch/evacuate is doing that work for us. And the esophagus remains open for extended time, the full duration of the examination. Four findings are being evaluated and compared with normal esophagoscopy images (also without insufflated air to make the comparison valid):

1) Reflux from the lower esophagus, suggesting damage to the lower esophageal sphincter from constant upward pressure trying unsuccessfully to belch.

2) What we call an “aortic shelf,” meaning that rather than an indentation of the medial circumference of the aorta, dilation of the esophagus drapes its mucosa across the upper surface of the esophagus, making a “horizontal shelf.” Keep in mind again that this is without insufflating any air.

3) Continuous patency with very infrequent, partial “clamping” down of the lumen or, often no closure at all, suggesting that there is sustained opening pressure of unbelchable air and/or that the contractile ability of the esophagus is reduced, in similar fashion to what happens to an overly-distended urinary bladder.

4) Upper esophageal dilation in a medial-lateral axis so that the upper esophagus becomes stretched in an exaggerated “oval” rather than a more gentle oval or even “circle.”

Emerging Esophageal Findings: Series of 5 photos

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Saliva bubbles in the lower esophagus.

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Saliva bubbles in the lower esophagus. Note that no air has been insufflated to obtain this view.
saliva wells up in the esophagus

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Approximately 0.5 second later, saliva wells up from below while the esophagus itself remains unchanged (Red dots in photos one and two mark identical reference points). Either abdominal wall or stomach wall compression lifts a column of stomach contents superiorly (retrograde) in the esophagus, explaining significant rates of GERD symptoms in this group, especially after treatment, which allows air to evacuate and might potentiate a higher rise of the material in the stomach/ lower esophagus.
pocket in the upper surface of the aorta

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Seen here is what almost appears like a pocket (arrow) at the upper surface of the aorta (A). Compare with the next photo.
aorta shelf

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The patient’s unburped air further expands the esophagus and makes more of a “shelf” of the upper surface of the aorta (A).
upper esophagus

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Now visualizing the upper esophagus, just below the cricopharyngeus muscle (UES): It appears that there is exaggerated lateral “stretch” of the esophagus. It cannot stretch posteriorly due to immovable spine (S) nor can it expand anteriorly due to the non-collapsible trachea (T). Consequently, it can only dilate laterally (arrows).

Abdominal Distention of R-CPD: Series of 3 photos

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x-ray of Gastric Air Bubble

Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

Dramatic Lateral Dilation of the Upper Esophagus: Series of 3 photos

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lateral dilation of the throat at C6 of the spine

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This photo is at the level of (estimated) C6 of the spine (at S). This person has known cervical arthritis, accounting for the prominence. Opposite the spine is the trachea (T). Note the remarkable lateral dilation (arrows) in this picture obtained with with no insufflated air using a 3.6mm ENF-VQ scope. It is the patient’s own air keeping the esophagus open for viewing.
air from below further dilates the upper esophagus

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At a moment when air from below further dilates the upper esophagus, the tracheal outline is particularly well-seen (T) opposite the spine (S). The “width” of the trachea indicated further emphasizes the degree of lateral dilation, which is necessary because spine and trachea resist anteroposterior dilation.
aortic shelf at the mid-esophagus

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Just for interest, at mid-esophagus, the familiar aortic “shelf” is seen. Again, this esophagus is being viewed with a 3.6 mm scope with only the patient own (un-burped) air allowing this view.

Dramatic dilation of the esophagus in a person with R-CPD due to buildup of swallowed air that he cannot belch to get rid of. : Series of 2 photos

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View of the mid-esophagus (1 of 2)

This view in the mid-esophagus was obtained with a 3.6mm scope without an air channel. The dilation is from the patient’s own unbelchable air. Note quite major lateral dilation of the esophagus, indicated by concentric dotted lines and arrows. Dilation is not possible in the direction of unyielding spine (S) and trachea (T).

View of the mid-esophagus (2 of 2)

A view that shows more clearly the indentation of trachea (T). Persons with this much dilation of esophagus often complain as much of chest pressure as they do abdominal bloating. This man has experienced “large” reduction of R-CPD symptoms after botulinum toxin injection into his upper esophageal sphincter (cricopharyngeus muscle).