Shaggy esophagus | Radiology Signs

Answer:

Shaggy esophagus is caused by severe Candida esophagitis, an opportunistic fungal infection of the esophageal mucosa most commonly due to Candida albicans, typically seen in immunocompromised patients such as those with HIV/AIDS, diabetes, or on immunosuppressive therapy. It manifests radiologically as a grossly irregular, shaggy contour of the esophageal lumen due to innumerable coalescent pseudomembranes, raised plaques, and ulcers. Rarely, advanced infiltrating esophageal carcinoma can produce a similar irregular contour and must be considered as a mimic.

Why is it called so?

It is called “shaggy esophagus” because the barium-coated esophageal mucosa appears irregular and frayed, resembling a shaggy or unkempt surface, due to the presence of numerous plaques, pseudomembranes, and ulcerations projecting into the lumen.

Pathophysiology

Candida organisms colonize and invade the esophageal epithelium, leading to formation of raised mucosal plaques composed of necrotic epithelial debris, inflammatory cells, and fungal hyphae. These plaques and associated ulcers create multiple filling defects and irregular mucosal contours on barium esophagography. In severe or fulminant cases, the plaques coalesce and are interspersed with ulcers, resulting in a markedly irregular, “shaggy” appearance of the esophageal wall with barium trapped between lesions.

Alternative names: None.

Other associated named signs: Foamy esophagus (esophageal stasis with fungal infection) and the “cobblestone” or “snakeskin” appearance on double-contrast esophagography; esophageal intramural pseudodiverticulosis (narrow, flask-shaped dilations of excretory ducts) can co-exist with Candida esophagitis.

References

1. Davenport AA, Chen EY, Rappaport DC. The “shaggy esophagus”. Abdom Radiol (NY). 2019.