Corkscrew oesophagus | Radiology Signs

Answer:

A corkscrew oesophagus is the serpiginous, compartmentalised appearance produced when multiple simultaneous, non-propulsive tertiary contractions indent the barium column, dividing it into a series of sacculations along a spiral course. The same appearance is called the rosary bead oesophagus. It was historically equated with diffuse (now distal) oesophageal spasm, but it is a description of disordered motility rather than a diagnosis, and it occurs equally in type III (spastic) achalasia. Under the Chicago Classification v4.0, high-resolution manometry makes the distinction: distal oesophageal spasm has a normal median integrated relaxation pressure with at least 20% premature contractions (distal latency under 4.5 s), whereas type III achalasia has an abnormal median IRP with 100% absent peristalsis. Jackhammer (hypercontractile) oesophagus is separate again, defined by distal contractile integral above 8000 mmHg·s·cm with normal IRP and latency. Barium therefore screens and demonstrates; manometry classifies.

Why is it called so?

The barium column is thrown into a series of tight spiralling curves resembling the helix of a corkscrew.

Pathophysiology

Loss of the normal inhibitory innervation of the distal oesophageal smooth muscle, attributed to impaired nitric oxide-mediated deglutitive inhibition, allows contractions to occur simultaneously along a long segment instead of sequentially from proximal to distal. Because these contractions are neither ordered nor propulsive, they indent the lumen at multiple levels at once and trap barium in the intervening segments, producing discrete compartments. The muscle in the affected segment is often hypertrophied, which accentuates the indentations and accounts for the thickened distal oesophageal wall seen on CT and endoscopic ultrasound.

Alternative names: Rosary bead oesophagus, curling oesophagus, nutcracker-type spastic appearance (descriptive only)

Other associated named signs: Bird beak sign of achalasia, feline oesophagus of transverse folds, and the corkscrew sign of midgut volvulus, a separate and unrelated entity

References

1. Prabhakar A, Levine MS, Rubesin S, Laufer I, Katzka D. Relationship between diffuse esophageal spasm and lower esophageal sphincter dysfunction on barium studies and manometry in 14 patients. AJR Am J Roentgenol. 2004;183(2):409-13. PMID: 15269034.