Barium swallow diseases

PHARYNGEAL
 Diverticula
▪ Zenkers diverticulum
▪ Lateral pharyngeal puches
▪ Killian jamieson
diverticulum.
OESOPHAGEAL
 Webs
 Motility disorders.
 Diverticula
 Oesophageal rings
 GERD
 Oesophagitis
 Strictures
 Foreign body and trauma
 Benign tumours.
 Malignant neoplasms

 Impaired cricopharyngeus relaxation.
 Obstruction –elevation of pharyngeal pressure –
pulsion diverticula.
 Develops resulting in weakness in posterior
pharyngeal wall between horizontal and oblique
fibres in inferior constrictor muscle (Killian's
dehiscence).
 Collection at the midline posteriorly ,just above
cricopharyngeus protruding laterally, usually to
left, caudally shows enlargement.

 Protrusion of lateral pharyngeal wall through
thyrohyoid membrane at site of penetration
by laryngeal vessel and nerve branches.
 If a normal pouch becomes enlarged, it is
termed as lateral pharyngeal diverticulum.
 Glass blowers ,players of wind instruments.
 Lateral hypopharyngeal walls
 Bilateral.
 Retains little of bolus causing aspiration.

 Protrusion through the anterolateral
anatomical weak site of the cervical
esophagus below the cricopharyngeus
muscle
 Transient or permanent lateral cervical
oesophageal diverticulum.
 Food retention – overflow aspiration.

 Incidental finding
 Mc -Middle aged females.
 C/P: Dysphagia(Symptoms if lumen > 50%
compromised )
 Shelf like 1-2mm thick infoldings of mucosa
protrude into lumen from anterior wall of
cervical oesophagus.
 Semicircular.
 Multiple.
 Occasionally mid and lower.
 Best view - lateral

 Complete ring – oesophagus may balloon above the
web , a jet of barium may be seen passing through it.
 Sideropenic dysphagia (Plummer-Vinson syndrome)
 Iron deficiency anemia
 Esophageal web with dysphagia
 Increased incidence of carcinoma
 Epidermolysis bullosa, Bullous phemphigoid .
 Can be aging phenomenon,oesophageal reflux.
 Note:
 slight infolding of the mucosa anteriorly at the level of
cricoid cartilage is normal.
 Islands of ectopic gastric mucosa.

 10 oesophageal peristalsis
 Propels bolus through the esophagus
 Initiated by swallowing
 20 peristalsis
 Follows primary contraction and propels any
remaining bolus from thoracic esophagus
 Initiated by luminal distension or mucosal irritation.
 Tail end of peristaltic wave has the shape of the
inverted ‘V’ .
 Fast wave of relaxation followed by slow wave of
contraction.

1. 30 Contractions
2. Diffuse oesophageal spasm
3. Nutcracker oesophagus
4. Hypertrophic lower oesophageal sphincter.
5. Non specific oesophageal motility disorder.
6. Presbyoesophagus
 Motility varies from one swallow to next.
 Minimum of 5 single prone swallows.
 Radionuclide imaging
 Scintigraphy

 30 contractions are non propulsive and
uncoordinated and nonperistaltic.
 Lower two thirds of the oesophagus.
 Intermittent ripples along the wall of
oesophagus lasting only few seconds.
 Multiple simultaneous contraction rings .
 Cork screw appearance.
 2 or > 2 swallows out of the 5- abnormal.

 Episodes of abnormal motility occur without a
cause.
 Intermittent contractions of the mid and distal
esophageal smooth muscle, associated with
chest symptoms.
 Severe intermittent chest pain, dysphagia, food
impaction.
 24 hr oesophageal manometry is required.It
shows simultaneous nonpropulsive contractions
on at least 10% of swallows.

 Non-cardiac cause of chest pain attributed to
high amplitude distal esophageal peristalsis.
 Manometric diagnosis.
 10 peristaltic waves with pressure in excess of
180 mm of Hg.

 Hypertrophic lower oesophageal sphincter
 Manometric finding.
 Resting lower oesophageal sphincter > 40 mm of
Hg.
 Presbyoesophagus
 Elderly
 Diabetes
 Chest pain ,dysphagia.

 35- 50 yrs.
 Motor disorder
 Slow progression of dysphagia for both solids and
liquids.
 Increased incidence of carcinoma .
 By degeneration of neurones in auerbach’s
plexus.(between longitudinal and circular muscles)
 Failure of relaxation of lower oesophageal sphincter.
 Absent primary peristaltic waves
 Early – pronounced tertiary contractions (vigorous
achalasia)

 95% diagnostic accuracy
1. Early/Stage I
 Primary peristaltic waves absent with abnormal distal
peristalsis
 Only minimal narrowing of the GE junction
 Occasionally may see nonpropulsive peristaltic waves
in the esophageal body (“vigorous achalasia”
secondary to tertiary waves)
2. Progressive disease
 “Bird’s beak” appearance of GE junction
▪ Distal esophagus makes right angle before entering stomach

3. Hurst phenomenon
 With the patient upright, barium builds up to a point
where the hydrostatic pressure of the barium
overcomes the LES pressure
▪ Occasional “spurt” of barium through the GE junction as it is
intermittently forced open
 Dilated, aperistaltic esophageal body; may assume a
sigmoid shape
4. Severe disease
 Significant esophageal body dilatation with large
amounts of fluid/food retention
 Entire esophagus atonic in late stages

 Secondary achalasia
 Developed after the age of 50 yrs ,possibility
of underlying neoplasm.
 Direct invasion from carcinoma of stomach
,extrinsic invasion from tail of pancreas
,adjacent lymph nodes or mets from
bronchus or breast.

 Smooth muscle coat of the bowel damaged.
 Circular muscle affected.
 Lower two thirds.
 Barium study:
 dilatation of distal 2/3 of the oesophagus
 apparent shortening of length due to fibrosis
 dysmotility of lower oesophagus (normal peristalsis
above aortic arch)
▪ 10 and 20 contractions are absent.
▪ 30 contractions develop.
 gastro-oesophageal reflux due to reduced sphincter
tone

Figure 8. Scleroderma with a peptic stricture.
Luedtke P et al. Radiographics 2003;23:897-909
©2003 by Radiological Society of North America

 Pulsion diverticula are due to increased
intraluminal pressure.There are many pulsion
diverticula:
 Zenker's
 Killian-Jamieson
 Epiphrenic
 Midesophagus
 Aortopulmonary recess
 Motility is abnormal.

 lower
oesophagus near
the diaphragm.
 If large they can
narrow the
esophagus or
lead to
aspiration.

 The normal esophagus transiently protrudes into the
aortopulmonary window.
 Fixed protrusion is an inconsequential diverticulum.

 Traction diverticula are secondary to adjacent
disease.
 Most located in mid-esophagus.
 Result of fibrosis from adjacent tuberculous
lymph nodes

 A-Ring
 Muscular contraction at the junction of tubular and vestibular
esophagus
 No definite anatomic correlate
 B-Ring
 Mucosal ring at anatomic squamocolumnar junction (Z-line) Best or
only seen with vestibular distension
 Normally < 1 cm above diaphragm

 Pathological annular narrowing at the
gastroesophageal junction.
 Congenital ,inflammation and fibrosis
 Lower esophageal smooth-surfaced ringlike
constrictions 2–3-mm in height.
 > 20 mm wide, no obstruction
 < 13 mm wide, almost always intermittent obstruction
 13-20 mm wide, may obstruct
 Lumen of oesophagus < 13 mm(for dysphagia to
begin)
 Almost always located above a hiatal hernia.
 Demonstrated when oesophagus is distended during
prone barium swallow.

Figure 6. Schatzki ring.

Schatzki ring.
Levine M S , Rubesin S E Radiology 2005;237:414-427

 Gastroesophageal reflux (GERD) is the most
common cause of esophagitis.
 Excessive smoking, fatty meals ,drinking
alcohol or coffee –relaxation of lower
oesophageal strictures.
 Elderly ,scleroderma.
 Mucosal damage.
 Association between hiatus hernia and peptic
oesophageal sphincters.
 24 hr pH recording(<4)

 Earliest changes on endoscopy.
 Pronounced oedema , earliest changes of fine
mucosal nodularity seen on double contrast
barium swallow.
 Collapsed oesophagus shows thickened
longitudinal folds (>3mm) ~varices.
 Multiple fine ulcers – punctate or granular
appearance or larger discrete punched out
ulcers.

 Scarring produces permanent folds that
radiate from margins of ulcers.
 En profile – out pouchings can mimic
ulceration.
 Coarse transverse folds are different from
fine mucosal folds which are thought to result
from contraction of muscularis mucosa –
feline oesophagus.

 Severe scarring results in stricture formation.
 Mild stricturing – better seen on barium when
oesophagus is well distended with barium.
 Peptic stricture above hiatus hernia is
typically short , smooth lumen and tapered
margins.
 Long peptic strictures Z –E syndrome.

 Columnar metaplasia is the result of long-
standing reflux esophagitis.
 Most patients have reflux and a hiatus hernia.
 Mid or high esophageal ulcer.
 Mid or high esophageal web-like stricture
 Reticular mucosal pattern .

 Mc –infectious oesophagitis.
 Immunocompromised patients.
 Odynophagia,dysphagia ,haematemesis.
 Double contrast studies
 Mucosal plaques
 Plaques in long axis of oesophagus.
 Background mucosa appears normal.
 Granular or nodular mucosa.
 Deep marginal ulceration.
 Rarely track below the sloughing pseudomembrane.
 Fungal mass may protrude into the lumen.
 Perforation ,stricture and fistula formation rare.

Upright LPO spot image from double-contrast esophagography shows multiple discrete
plaquelike lesions (arrows) in the esophagus in a patient with Candida esophagitis.

 Immunocompromised.
 Acute self-limited disease.
 Mid oesophagus.
 Small mucosal vesicles that rupture to form
discrete punched-out ulcers.
 Small superficial ulcers against a background
of normal mucosa.
 Punctate, stellate, or ringlike configuration
and are often surrounded by radiolucent
mounds of edema.

Upright LPO spot image from double-contrast esophagography shows multiple small
superficial ulcers (arrows) in midesophagus of a patient with herpes esophagitis.

 Tetracycline and doxycycline.
 Small shallow ulcers in the upper or middle
esophagus and are indistinguishable from
those in herpes oesophagitis.
 Heal without scarring or strictures.

Upright LPO spot image from double-contrast esophagography shows two small superficial
ulcers as ring shadows (arrows) in midesophagus.

 Radiation dose of 5000 cGy or more to the
mediastinum.
 2–4 weeks after the initiation of radiation
therapy.
 Mucosa shows granular appearance due to
edema and inflammation .
 Ulceration and decreased luminal
distensibility.

 Radiation strictures 4–8 months after
completion of the therapy.
 Appear as smooth tapered areas of
concentric narrowing.

Upright LPO spot image from double-contrast esophagography shows radiation stricture as a
long segment of smooth tapered narrowing (arrows) in upper thoracic esophagus.

 The delicate, concentric and transiently
appearing folds of a feline esophagus should be
distinguished from the thicker, interrupted, fixed
folds indicative of longitudinal scarring from
reflux esophagitis.
 Horizontal striations due to muscularis mucosa
contractions .
 Normal in cats.
 Most often transient and insignificant .
 May be associated with gastroesophageal reflux
or esophagitis.

 Narrowing of the lumen.
 Single or multiple.

Figure 2. Peptic stricture.

 Foreign body impaction
 Mallory weiss tear.
 Oesophageal perforation

 Children
 Common level of the aortic arch, the left main
bronchus, and the gastroesophageal junction,
especially when there is a pre-existing stricture.
 Metallic and dense foreign bodies are obvious on
radiograph
 Mc -Unchewed meat bolus arrested at the site of
anatomical and pathological narrowing .
 Intraluminal filling defect may resemble
neoplasm.
 Post foreign body removal to r/o narrowing due
to hold up.

 Acute condition .
 Prolonged and forceful vomiting, coughing or
convulsions.
 Typically the mucous membrane at the
junction of the esophagus and the stomach
develops lacerations which bleed, evident by
bright red blood in vomitus, or bloody stools.
 Excessive alcohol ingestion.
 Resolves within 10 days without treatment.

 Uphill varices.
 Downhill varices.

 Portal hypertension with hepatofugal flow
through dilated esophageal collateral vessels to
the superior vena cava.
 May cause marked upper GI bleeding.
 Serpentine longitudinal filling defects in the
distal half of the thoracic portion of the
esophagus.
 Best -prone RAO position.
 High-density barium suspension or barium paste
to increase mucosal adherence.
 d/d :
 Varicoid carcinoma .
 Esophagitis with thickened folds.

Prone RAO spot image from single-contrast esophagography shows uphill esophageal
varices as serpiginous defects in lower esophagus.

 Superior vena cava obstruction with downward flow
via dilated esophageal collateral vessels to the portal
venous system and the inferior vena cava.
 Causes
 Central catheter–related thrombosis of SVC.
 CA lung or other metastatic tumors involving the
mediastinum.
 Lymphoma.
 Substernal goiter.
 Mediastinal radiation.
 Sclerosing mediastinitis
 Serpentine longitudinal filling defects confined to the
upper or middle part of the esophagus.

Upright LPO spot image from double-contrast esophagography shows downhill esophageal
varices as serpiginous defects in midesophagus above the level of the carina.

 Aberrant right subclavian artery.
 Aberrant left pulmonary artery.
 Double aortic arch.

 This is the most common thoracic arterial
anomaly and rarely causes symptoms.

 It indents the trachea dorsally and esophagus
ventrally as it extends between them.
 Narrowing of right bronchus can cause air
trapping or atelectasis.

 Diaphragmatic hiatus
 Sliding hiatus hernia
 Rolling hiatus hernia
 Congenital defects
 Bochdalek
 Morgagni hernias

 Most common.
 Predisposes to GE reflux.
 Phrenico –oesophageal ligaments stretching with age
or rupture of these ligaments.
 Small – reduces on standing
 Large – fixed .
 It is a pouch of stomach that protrudes 2 cm above
the hiatus.
 Three or more gastric folds passing from stomach
across hiatus and the Z line and area gastricae are
located above hiatus.
 Hiatus is wide > 3cm.

 Para oesophageal
 Cardia remains below the diaphragm and
fundus herniates through the hiatus or tear in
phrenico oesophageal membrane to lie on
the side of oesophagus.
 With progressive hiatal widening, increasing
protrusion and rotation of the stomach can
lead to gastric volvulus that can be
complicated by hemorrhage, obstruction,
strangulation, perforation.

 Mc benign mucosal tumor.
 Small sessile polyps with a smooth or slightly
lobulated contour.

 Mc benign submucosal tumor.
 Least common – GIST.
 Mucosal lesions are indicated by mucosal
irregularities.
 Submucosal intramural lesions produce
smooth filling defects.
 En profile : the margins often form close to a
right angle with the esophageal wall.

Upright LPO spot image from double-contrast esophagography shows leiomyoma as a
smooth submucosal mass (black arrows) in the midesophagus.

 Extrinsic lesions tend to form longer obtuse
angles if not fixed to the esophageal wall, and
their epicenter may be outside the
esophagus.

 Fibrovascular tissue with adipose tissue
covered by squamous epithelium.
 At the level of cricopharyngeus muscle.
 Pedunculated polyps are rare .
 Difficult to diagnose on esophagrams.
 Their movement during the examination
producing an inconstant position and shape
may be suggestive.
 The stalk is often difficult to identify.

Upright LPO spot image from double-contrast esophagography shows giant fibrovascular
polyp as smooth sausage-shaped mass (black arrows) expanding the lumen of the upper
thoracic esophagus.

 A foregut duplication cyst is a congenital
cyst.

 Early.
 Advanced .
 Early :
 Oesophageal carcinoma is limited to the mucosa,
submucosa with no lymph node metastases.
 Most are small ( Small esophageal carcinoma is
defined by the size of the lesion).
 So an early carcinoma may be small, but a
small carcinoma may be invasive or
metastatic and thus not an early carcinoma.

Upright LPO spot image from double-contrast esophagography shows early esophageal
cancer in profile as plaquelike lesion (black arrows) with flat central ulcer (white arrows) on
left lateral wall of the midesophagus.

Upright LPO spot image from double-contrast esophagography shows superficial spreading
carcinoma as focal area of mucosal nodularity (arrows) in midesophagus, without a discrete
mass.

 Advanced carcinoma has many gross
appearances:
 Polypoid
 Varicoid
 Infiltrative
 Ulcerative
 Superficial spreading
 Stricture
 Pseudoachalasia

Upright LPO spot image from double-contrast esophagography shows advanced infiltrating
carcinoma as irregular area of narrowing, with mucosal nodularity, ulceration, and shelflike
margins (arrows) in midesophagus.

Upright LPO spot image from double-contrast esophagography shows advanced esophageal
carcinoma as polypoid mass (white arrows) with a large area of ulceration (black arrows) on
the right posterolateral wall of the distal esophagus (small rounded defects abu...

Upright LPO spot image from double-contrast esophagography shows varicoid carcinoma as
lobulated submucosal lesion in the distal esophagus that could be mistaken for varices.

 An irregular, asymmetric stricture is highly suggestive of
carcinoma.
Smoothly tapered, symmetric strictures are characteristic
of a benign etiology, but malignant strictures can have
similar characteristics and mimic benign lesions.
 Distal esophageal malignancy may closely resemble
achalasia.
If esophageal motility is normal, achalasia can be
excluded.
If abnormal, however, subtle imaging features;
asymmetric, irregular, abrupt, or high narrowing, mucosal
abnormality, or fixed abnormality suggest diagnosis.

 Rare neoplasms also called carcinosarcomas.
 Bulky but nonobstructive .

 Rare primary melanomas of the esophagus
also tend to be bulky but not cause significant
obstruction.

1. David Sutton ;Textbook of radiology and
imaging ;Section 3 (GIT) – chapter 18.
2. The radiology assistant;Esophagus - Part I
3. The radiology assistant;Esophagus II :
Strictures, Acute syndromes, Neoplasms
andVascular impressions
4. Radiology;Diseases of the Esophagus:
Diagnosis with Esophagography

 Note :Radiographs have been described in
click to add notes.

Barium swallow diseases

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

Similaire à Barium swallow diseases

Similaire à Barium swallow diseases (20)

Dernier

Dernier (20)

Barium swallow diseases

Notes de l'éditeur