Short Esophagus with Esophagogastric or Marginal Ulceration

The chief purpose of this report is to describe the roentgen and esophagoscopic findings in 29 cases of short esophagus with peptic ulceration at the esophagogastric junction. Short descriptions of the symptomatology and the treatment of these cases will be included. The condition to be described is identical with that called by Allison, Johnstone, and Royce “short esophagus with peptic ulceration” (2). Allison later included this combination of short esophagus and marginal ulceration under “reflux esophagitis” (4). It has also been described under such other names as “peptic ulcer of the esophagus” (3, 6, 8, 11, 16) and “peptic ulceration of the esophagus with partial thoracic stomach” (12, 20, 21). It is difficult to choose a satisfactory designation for this entity, since there must remain at the present time considerable reservation as to its pathogenesis. The difficulty lies in the uncertainty as to whether the short esophagus demonstrable at the time of the examination is congenital or acquired. An additional confusing factor is the circumstance that, even though the final state may be in largest part acquired, congenital predisposing factors may be necessary. We shall describe the findings in our cases without making assumptions as to their pathogenesis. It must therefore be emphasized that the term “short esophagus” as used in this paper indicates that the esophagogastric junction is located above the esophageal hiatus of the diaphragm and that the esophagus is not redundant. The esophagus is seen to be short both on roentgen and on esophagoscopic examination, although neither of these diagnostic methods permits differentiation of congenital from acquired shortening. In a similar fashion, for convenience of description, the gastric pouch above the diaphragm, which must be present in every case of short esophagus, may be designated as a “hiatus hernia.” The use of the latter term to include both acquired and congenital pouches has a precedent, since in Åkerlund's basic contribution on hiatus hernias both congenital and acquired types were described (1). There have been three constant features in our series of cases: (a) The esophagus was short, i.e., the junction of the esophagus and the stomach, as determined by the nature of the lining epithelium, was above the esophageal hiatus of the diaphragm. (b) Free reflux or regurgitation of gastric contents into the gastric pouch above the diaphragm and from the pouch into the esophagus has been present. (c) Ulceration at the esophagogastric junction has been demonstrated. Before proceeding to a description of the roentgen and esophagoscopic findings, it is appropriate to state the criteria which were used to establish the presence of the features noted above. It is well known that the x-ray criteria for the identification of the esophagogastric junction are frequently equivocal.