Barium swallow

1. Barium swallow-
oesophago pharyngogram
K Mohamed Rafi

2. INDICATIONS
• Dysphagia
• Odynophagia
• Esophagitis
• Esophageal tracheal fistula
• Foreign Bodies
• Carcinoma of the esophagus

3. EQUIPMENT USED
• Conventional
fluoroscopy unit (real
time image).
-image intensifier
-spot film device
-television fluoroscopy
-fluoroscopic couch
Special "feeding"
equipment may be
required, i.e. straws and
feeding cups.

4. ACCESSORIES USED
• Anatomical markers –right or left
• Cassettes (17X14)
• Footrest (patient tilted towards erect
position).
• Hand grips ,shoulder supports
• Lead aprons, gloves, glasses, and thyroid
shield.

5. PATIENT PREPARATION
• CLINICAL
-Patient Identification
-Check pregnancy state
-implied consent or signed
-Because the esophagus is empty most of the time, patients
need no preparation for an esophagram unless an upper
GI series is to follow. When combined with an upper GI, or
if the primary interest is the lower esophagus, preparation
for the UGI takes precedence.
PHYSICAL
-Patient is asked to remove any jewelry or other objects that
may interfere with the procedure.

6. Contrast Agents
• Water Soluble
– Gastrografin
– Low-osmolality
• Inert
– Barium sulfate

7. Barium sulphate
• Barium sulphate (insoluble ,stable and inert i.e. passes
through the patient unchanged causing little discomfort other
than constipation.
• Thick barium is used.
It is more difficult to swallow but is well suited for use in the
esophagus because it descends slowly and tends to coat the
mucosal lining.

8. TROLLEY SETUP
(TOP SHELF)
Equipment must be
hygienically clean
• 1 jug of water
• Clean glasses-2
• Barium
• Spoons
• Tissue paper
• straw
LOWER SHELF (unsterile)
• Emergency drugs

9. Types
• Single contrast
• Double contrast
• Mucosal relief

10. Basic Positions
• RAO (35° to 40°)
• Lateral
• AP (PA)
• LAO

11. RAO (35° to 40°) Esophagram
Pathology Demonstrated:
• Strictures, foreign bodies, anatomic anomalies, and
neoplasms of the esophagus are shown.
Shielding
• Place lead shield over patient's pelvic region to protect
gonads.
Patient Position
• Position patient recumbent or erect. Recumbent is
preferred because of more complete filling of the
esophagus (caused by the gravity factor with the erect
position).

12. Central Ray
• CR perpendicular to IR
• CR to level of T5 or T6 (2 to 3 inches [5 to 7.5
cm] inferior to jugular notch)
• Minimum SID of 40 inches (100 cm)

13. Technical factors
• Moving or stationary grid
• 100 to 125 kV range
• 14 x 17 image receptor(15*12)

14. Part Position
•Rotate 35° to 40° from a prone position, with the right
anterior body against the IR or table.
Place right arm down with left arm flexed at elbow and
up by the patient's head, holding cup of barium, with a
straw in patient's mouth.
Flex left knee for support.
Align midline of thorax in the oblique position to midline
of IR and/or table.
Place top of IR about 2 inches (5 cm) above level of
shoulders to place center of IR at central ray (CR)

15. Respiration
• Suspend respiration and expose on expiration
• Note 1: Thick barium—Two or three spoonfuls of thick
barium should be ingested and the exposure made
immediately after the last bolus is swallowed. (Patient
generally does not breathe immediately after a
swallow.)
• Note 2: Thin barium—For complete filling of the
esophagus with thin barium, the patient may have to
drink through a straw, with continuous swallowing and
exposure made after three or four swallows without
suspending respiration (using as short an exposure
time as possible).

17. Radiographic Criteria
• Structures Shown: Esophagus should be visible between the
vertebral column and heart.
• Position: Adequate rotation of body projects esophagus between
vertebral column and heart. If esophagus is situated over the spine,
more rotation of the body is required. • Entire esophagus is filled or
lined with contrast media. • Upper limbs should not superimpose
the esophagus.
• Collimation and CR: Collimation margins are seen laterally on
radiograph. CR is centered at level of T5 or T6 to include the entire
esophagus.
• Exposure Criteria: Appropriate technique is used to clearly visualize
borders of the contrast media—filled esophagus; sharp structural
margins indicate no motion.

18. Lateral
Part Position
• Place patient's arms over the head, with the
elbows flexed and superimposed.
• Align midcoronal plane to midline of IR
and/or table.
• Place shoulders and hips in a true lateral
position.
• Place top of IR about 2 inches (5 cm) above
level of shoulders, to place center of IR at CR.

20. Optional swimmer's lateral position
Optional swimmer's lateral position
• Allows for better demonstration of the upper
esophagus without superimposition of arms and
shoulders.
• Position hips and shoulders in true lateral
position; then separate shoulders from
esophageal region by placing upside shoulder
down and back, with arm behind back. Place
downside shoulder and arm up and in front to
hold cup of barium.

22. Radiographic Criteria
Structures Shown: • Entire esophagus is seen between
thoracic spine and heart.
Position: • True lateral is indicated by direct superimposition
of posterior ribs. • The patient's arms should not
superimpose the esophagus. • Entire esophagus is filled or
lined with contrast media.
Collimation and CR: • Collimation margins are seen laterally
on radiograph. • CR is centered at level of T5 or T6 to
include the entire esophagus.
Exposure Criteria: • Appropriate technique is used to clearly
visualize borders of the contrast media–filled esophagus. •
Sharp structural margins indicate no motion

23. AP (PA) PROJECTION
Pathology Demonstrated
• Strictures, foreign bodies, anatomic
anomalies, and neoplasms of the esophagus
are shown

24. Patient Position
• Position patient recumbent or erect (recumbent preferred).
• Part Position
• • Align MSP to midline of IR and/or table.
• • Ensure that shoulders and hips are not rotated.
• • Place right arm up to hold cup of barium.
• • Place top of IR about 2 inches (5 cm) above top of shoulder, to
place CR at center of IR.
Central Ray
• • CR perpendicular to IR
• • CR to MSP, 1 inch (2.5 cm) inferior to sternal angle (T5-6) or
approximately 3 inches (7.5 cm) inferior to jugular notch
• • Minimum SID of 40 inches (100 cm) or 72 inches (183 cm) if
erect

26. Radiographic Criteria
Structures Shown: The entire esophagus is filled with
barium.
Position: • No rotation of the patient's body is evidenced
by the symmetry of the sternoclavicular (SC) joints.
Collimation and CR: • Collimation margins are seen
laterally on radiograph. • CR is centered at level of T5
or T6 to include the entire esophagus.
Exposure Criteria: • Appropriate technique is used to
visualize the esophagus through the superimposed
thoracic vertebrae. • Sharp structural margins indicate
no motion

27. LAO POSITION:
Part Position
• •Rotate 35° to 40° from a PA, with the left anterior body against IR or
table.
• Place left arm down by the patient's side, with right arm flexed at
elbow and up by the patient's head.
• Flex right knee for support.
• Place top of cassette about 2 inches (5 cm) above level of shoulders, to
place CR at center of IR.
Central Ray
• CR perpendicular to IR
• CR to level of T5 or T6 (2 to 3 inches [5 to 7.5 cm] inferior to jugular
notch)
• Minimum SID of 40 inches (100 cm) or 72 inches (180 cm) if erect

29. RADIATION PROTECTION
• Minimise fluoroscopy time and current.
• Collimate X-ray beam to minimise size.
• Shield sensitive organs when possible.
• Use spot film photofluoroscopy with modern image
intensifier instead of radiography whenever
appropriate.
• Use of lead shields for both radiographer and patient.

30. COMPLICATIONS
• Aspirations of barium mixture
• Leakage of barium from a unsuspected
perforation

31. Anatomy and embryology
• The esophagus develops from the cranial portion of the foregut and
is recognizable by the third week of gestation.
• Much of the alimentary canal originates as a tube of endoderm
enclosed in splanchnopleuric mesoderm.
• Its external surface faces the embryonic coelom, and the
endodermal lining forms the epithelium of the canal and also the
secretory and ductal cells of various glands which secrete into the
lumen, including the pancreas and liver.
• The splanchnopleuric mesoderm forms the connective tissue,
muscle layers, blood vessels and lymphatics of the wall, and its
external surface becomes the visceral mesothelium or serosa (p.
41).

32. Anatomy and embryology
• There is no serosa surrounding the cervical and
thoracic portions of the gut, or where the hindgut
traverses the pelvic floor: in these sites the gut
tube is surrounded by a connective tissue
adventitia.
• Neural elements invade the gut from neural crest
tissue The smooth muscle of the muscularis
externa layers of the alimentary canal is
supplemented with striated muscle both cranially
(from the branchial arches) and caudally

33. Anatomy and embryology
 The normal esophagus is a hollow, highly distensible muscular tube
that extends from the epiglottis in the pharynx, at about the level of
the C6 vertebra, to the gastroesophageal junction at the level of the
T11 or T12 vertebra.
 Measuring between 10 and 11 cm In the newborn, it grows to a
length of about 25 cm in the adult.
 For the endoscopist, the esophagus is recorded as the anatomic
distance between 15 and 40 cm from the incisor teeth, with the
gastroesophageal junction located at the 40-cm point.
 Several points of luminal narrowing can be identified along its
course—proximally at the cricoid cartilage, midway in its course
alongside the aortic arch and at the anterior crossing of the left
main bronchus and left atrium, and distally where it pierces the
diaphragm.

35. Histology

37. Myenteric plexus-mesh likeapperaerna
in stainnig

38. IMAGING ANATOMY
• Pharynx
o Nasopharynx
– • From base of skull to tip of soft palate
o Oro (mesopharynx)
– • From soft palate to hyoid bone
o Hypo (laryngopharynx)
– • From hyoid to bottom of cricopharyngeus
muscle

39. Esophagus
• Divided into 3 subdivisions
• The cervical esophagus
• Thoracic esophagus
• Abdominal esophagus

40. Lateral view:
• Epiglottis (red arrow).
• Post cricoid impression
(yellow arrows).Sub
mucosal venous plexus
over cricoid cartilage
produces inconstant
indentation of the anterior
esophageal wall
• Cricopharyngeous
impression (white arrow).
Extrinsic impression on
posterior esophagus by
contracted muscle.

41. Cricopharyngeal achalasia
• Cricopharyngeal
achalasia in 46-year-old
woman. Feeling of lump
in throat. Persistent
indentation (arrow) by
cricopharyngeus muscle
that does not relax as
bolus progresses
caudally

42. Cricopharyngeal achalasia

43. AP-view:
• Small lateral pharyngeal
pouches(arrows):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 a
lateral pharyngeal
diverticulum.

44. Barium Swallow, Single Contrast
Main Indication:
Dyshagia

45. Identation of A.A
Single Contrast
Indentation of
L.main bronchus
Double Contrast

46. Barium Swallow, Single Contrast
Double Contrast
Heart

47. Dysphagia lusoria –RT AA

48. Dysphagia lusoria

49. Dysphagia lusoria –Ab. Lt pul a.

51. Double aortic arch

52. Varices
• One of the few potential sites for communication between the
intra-abdominal splanchnic circulation and the systemic venous
circulation is through the esophagus. When portal venous blood
flow into the liver is impeded by cirrhosis or other causes, the
resultant portal hypertension induces the formation of collateral
bypass channels wherever the portal and systemic systems
communicate.
• Portal blood flow is thereby diverted through the coronary veins of
the stomach into the plexus of esophageal subepithelial and
submucosal veins, thence into the azygos veins and the superior
vena cava. The increased pressure in the esophageal plexus
produces dilated tortuous vessels called varices
• Patients with cirrhosis develop varices at a rate of 5% to 15% per
year, so that varices are present in approximately two thirds of all
cirrhotic patients. They are most often associated with alcoholic
cirrhosis.

54. ESOPHAGEAL VARICES :
The characteristic radiographic appearance
1. Serpiginous filling defects which
appear as round or oval filling defects
resembling the beads of a rosary( dilated
venous structures) ( arrowhead).
2. Changes size and appearance with
variations in intrathoracic pressure and
collapse with esophageal peristalsis and
distension.
3. Varices related to portal
hypertension are most commonly
demonstrated in the lower third of the
esophagus.
4. In portal hypertension ; common
accompanying gastric varices(arrow).

55. Barium Swallow, Single Contrast
Ampulla
Normal Varient
Fundus
Body

56. Z LINE

57. • Upper esophageal sphincter
o At pharyngoesophageal junction
o Formed primarily by cricopharyngeus
muscle
• Lower esophageal sphincter
–o Defined by manometric evidence of high
resting tone or pressure

58. Normal gastro esophageal junction
• At the gastro
esophageal junction
smooth, uniform folds
in gastric fundus
converge on very distal
esophagus (arrow).

59. Swallowing
• During the process of swallowing, or deglutition,
the tongue pushes a bolus of food into the throat
(1). The nasopharynx is reflexively blocked, (2),
respiration is inhibited, the vocal chords close
and the epiglottis seals off the trachea (3) while
the upper esophageal sphincter opens (4).
• A peristaltic wave forces the bolus into the
oesophagus (5,).
• If the bolus gets stuck, stretching of the affected
area triggers a secondary peristalticwave.

63. Peristalsis
• Primary peristalsis
– o Initiated by swallowing
– o Normal is a continuous aboral esophageal contraction wave,
lasting 6-8 seconds, that propels the bolus to the stomach
• o Best evaluated by individual swallows of barium with
patient in the prone oblique position
• Secondary peristalsis
– o Similar aboral contraction wave, but initiated by esophageal
distention or gastric reflux, rather than by swallowing
• Tertiary peristalsis
– o Nonperistaltic, disorganized contractions
– o May be intermittent, weak, asymptomatic
– o May be persistent, repetitive, strong and produce dysphagia

65. Corkscrew esophagus
• Tertiary esophageal waves
– Non-propulsive
– Corkscrew or beaded
appearance

66. Feline 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.
• Normal in cats
• The characteristics of a feline esophagus are:
• Horizontal striations due to muscularis mucosa contractions
• Most often transient and insignificant. May be associated with
gastroesophageal reflux or esophagitis

67. Feline

69. Nut cracker

70. Sphincter
• Although the pressure in the esophageal lumen is negative
compared with the atmosphere, manometric recordings of
intraluminal pressures have identified two higher-pressure
areas that remain relatively contracted in the resting phase.
• 3-cm segment in the proximal esophagus at the level of the
cricopharyngeus muscle is referred to as the upper
esophageal sphincter (UES).
• The 2- to 4-cm segment just proximal to the anatomic
gastroesophageal junction, at the level of the diaphragm, is
referred to as the lower esophageal sphincter (LES).
• Both "sphincters" are physiologic, in that there are no
anatomic landmarks that delineate these higher-pressure
regions from the intervening esophageal musculature.

71. Upper esophageal sphincter
• Upper esophageal sphincter
• Primarily formed by cricopharyngeal muscle.
• Located at the C5-C6 level
• Normally relaxes with bolus
• Abnormalities
• Delayed relaxation
• Early closure
• No relaxation: with or without symptoms; if
symptomatic, termed cricopharyngeal achalasia

72. Lower esophageal sphincter
• Drugs and many types of food and drink affect lower
esophageal sphincter and can lead to reflux.
• Glucagon relaxes the lower esophageal sphincter when used
for air-contrast upper gastrointestinal examination.
• Bulbous distention of the distal esophagus is called the
vestibule and corresponds to the manometrically defined
lower esophageal sphincter.
• This distention is best demonstrated by breath holding in
inspiration or a Valsalva maneuver
• Do not mistake this for a hiatal hernia.

73. Lower esophageal sphincter
• o Phrenic ampulla, esophageal vestibule
• "A"ring
• o Sporadically imaged indentation of esophageal lumen
at the cephalic end of the lower esophageal sphincter
(the "tubulo-vestibular junction")
• "B"ring
• o Transverse mucosal fold marking the esophagogastric
junction and often corresponding to the mucosal
junction between squamous + columnar epithelium

74. Lower esophageal sphincter
• The lower esophageal sphincter opens at the
start of deglutition due to a vagovagal reflex
(receptive relaxation) mediated by VIP-
andNO-releasing neurons
• Otherwise, the lower sphincter remains closed
to prevent the reflux of aggressive gastric
juices containing pepsin and HCl.

75. Lower esophageal sphincter

77. • Esophageal motility is usually checked by
measuring pressure in the lumen, e.g., during
a peristaltic wave
• The resting pressure within the lower
sphincter is normally 20–25 mmHg. During
receptive relaxation, esophageal pressure
drops to match the low pressure in the
proximal stomach indicating opening of the
sphincter.

78. • In achalasia, receptive relaxation fails to
occur and food collects in the esophagus.
• Accentuated “B” ring is called Schatzki ring

79. Schatzki ring
Schatzki ring on an erect,
double-contrast barium
esophagogram. Image
demonstrates a thin,
ringlike narrowing (arrows)
in the lower esophagus just
above a hiatal hernia.
• Prone, single-contrast barium
esophagogram demonstrating a thin,
ringlike narrowing (arrows) in the lower
esophagus just above a hiatal hernia. This
view is most sensitive for detecting lower
esophageal rings, provided adequate
esophageal distention is achieved.

80. Normal B ring Schatzki ring

81. Rings ?????

82. Webs
• Esophageal web
• 10% incidence at autopsy Can be
congenital or acquired
• Most in hypopharynx and proximal
esophagus
• Majority protrude from anterior
esophageal wall
• Symptoms if lumen > 50%
compromised

83. WEBS
• Esophageal mucosal webs are uncommon ledge like protrusions of the
mucosa into the esophageal lumen. These are semicircumferential,
eccentric, and most common in the upper esophagus.
• Well-developed webs rarely protrude more than 5 mm into the lumen,
with a thickness of 2 to 4 mm. The webs consist of squamous mucosa and
a vascularized submucosal core. Webs can be congenital in origin, or they
may arise in association with long-standing reflux esophagitis, chronic
graft-versus-host disease (GVHD), or blistering skin diseases.
• When an upper esophageal web is accompanied by an iron-deficiency
anemia, glossitis, and cheilosis, the condition is referred to as the
Paterson-Brown-Kelly or Plummer-Vinson syndrome, with an attendant
risk for postcricoid esophageal carcinoma.

84. Plummer-Vinson syndrome
• Sideropenic dysphagia (Plummer-
Vinson syndrome)
• Iron deficiency anemia
• Esophageal web with dysphagia
• Increased incidence of carcinoma

85. • AP and Lateral
views show
short, thin web
(arrows)with
minimal
intraluminal
extension.

86. • On the left
images of a
42-year-old
woman with
• dysphagia
due to web.
• There is >50%
luminal
narrowing

87. RINGS
• Esophageal rings are concentric plates of
tissue protruding into the lumen of the distal
esophagus. One occurring above the squamo
columnar junction of the esophagus and
stomach is common

88. Lower oesophageal ring

89. LES
GERD achalasia

90. Achalasia cardia
• The term achalasia means "failure to relax" and in the present
context denotes incomplete relaxation of the lower esophageal
sphincter in response to swallowing.]
• This produces functional obstruction of the esophagus, with
consequent dilation of the more proximal esophagus.
• Manometric studies show three major abnormalities in achalasia:
(1) aperistalsis,
(2) partial or incomplete relaxation of the lower esophageal
sphincter with swallowing, and
(3) increased resting tone of the lower esophageal sphincter. It
is now generally accepted that in primary achalasia there is loss of
intrinsic inhibitory innervation of the lower esophageal sphincter and
smooth muscle segment of the esophageal body.

92. • Secondary achalasia may arise from
pathologic processes that impair esophageal
function
• The most serious aspect of this condition is
the hazard of developing esophageal
squamous cell carcinoma, reported to occur in
about 5% of patients and typically at an earlier
age than in those without achalasia

96. Inflammation and Infection
• Gastroesophageal reflux (GERD) is the most
common cause of esophagitis

97. DEMONSTRATION OF ESOPHAGEAL
REFLUX
• The diagnosis of possible esophageal reflux or
regurgitation of gastric contents may occur
during fluoroscopy or an esophagram. One or
more of the following procedures may be
performed to detect esophageal reflux:
1.Breathing exercises
2.The water test
3.Compression paddle technique
4.The toe-touch maneuver

98. • Various breathing exercises are designed to
increase both intrathoracic and intraabdominal
pressures. The most common breathing exercise
is the Valsalva maneuver. The patient is asked to
take a deep breath and, while holding the breath
in, to bear down as though trying to move the
bowels. This maneuver forces air against the
closed glottis. A modified Valsalva maneuver is
accomplished as the patient pinches off the nose,
closes the mouth, and tries to blow the nose. The
cheeks should expand outward as though the
patient were blowing up a balloon

99. • A Mueller maneuver also can be performed as
the patient exhales and then tries to inhale
against a closed glottis.
• With both methods, the increase in
intraabdominal pressure may produce the
reflux of ingested barium that would confirm
the presence of esophageal reflux. The
radiologist carefully observes the
esophagogastric junction during these
maneuvers.

100. • The water test is done with the patient in the supine
position and turned up slightly on the left side. This slight
left posterior oblique (LPO) position fills the fundus with
barium. The patient is asked to swallow a mouthful of
water through a straw. Under fluoroscopy, the radiologist
closely observes the esophagogastric junction. A positive
water test occurs when significant amounts of barium
regurgitate into the esophagus from the stomach

101. • compression paddle can be placed under the
patient in the prone position and inflated as
needed to provide pressure to the stomach
region. The radiologist can demonstrate the
obscure esophagogastric junction during this
process to detect possible esophageal reflux

102. • The toe-touch maneuver
also is performed to
study possible
regurgitation into the
esophagus from the
stomach. Under
fluoroscopy, the cardiac
orifice is observed as the
patient bends over and
touches the toes.
Esophageal reflux and
hiatal hernias sometimes
are demonstrated with
the toe-touch maneuver.

103. Although the procedures described in
are still performed, they are
unphysiogical , most cases of
esophageal reflux are confirmed
through endoscopy.

104. REFLUX ESOPHAGITIS

106. Gastroesophageal reflux
• Spontaneous reflux extends to level of
aortic arch.
• Spontaneous gastro esophageal
reflux has been demonstrated
in up to 1/3 of patients with
reflux esophagitis.
• In addition many asymptomatic
patients have spontaneous
reflux so that reflux during an
esophagram is not sensitive or
specific for relating symptoms
to reflux.

107. • Irregular stricture
(arrowhead) and
erosions (arrows)
due to GERD.

108. • Those with severe reflux esophagitis are likely
to have a sliding hiatal hernia

109. Hiatal Hernia
• In hiatal hernia, separation of the diaphragmatic crura and
widening of the space between the muscular crura and the
esophageal wall permits a dilated segment of the stomach to
protrude above the diaphragm.
• Two anatomic patterns are recognized : the axial, or sliding,
hernia and the nonaxial, or paraesophageal, hernia.
• The sliding hernia constitutes 95% of cases; protrusion of the
stomach above the diaphragm creates a bell-shaped dilation,
bounded below by the diaphragmatic narrowing
• In paraesophageal hernias, a separate portion of the stomach,
usually along the greater curvature, enters the thorax through
the widened foramen.

112. Hiatal Hernia
• Those with severe reflux esophagitis are likely
to have a sliding hiatal hernia. Other
complications affecting both types of hiatal
hernias include mucosal ulceration, bleeding,
and even perforation. Paraesophageal hernias
rarely induce reflux, but they can become
strangulated or obstructed

113. • Air-contrast
esophagram
shows thick
esophageal
mucosal folds
(arrows) and an
ulcer
(arrowhead)
due to GERD.
• Single contrast
esophagram
shows stricture
(arrow)and
sliding hiatus
hernia

114. HAITUS HERNIA ??????

115. Diverticula
• Classification of esophageal diverticula based on
mechanism of formation
• Traction type (true diverticula): Herniation of all layers
(mucosa, submucosa & muscularis propria)
Traction diverticulum: Acquired condition due to
subcarinal or perihilar granulomatous lymph node
pathology
• Pulsion type (pseudodiverticula): Mucosal, submucosal
herniation & lack of muscle

116. Diverticula
• Pulsion diverticula are due to increased intraluminal
• pressure. There are many pulsion diverticula:
• Zenker's
• Epiphrenic
• Midesophagus
• Aortopulmonary recess
• Traction diverticula are secondary to adjacent disease.
• Most located in mid-esophagus.

117. Zenker's diverticulum
• A Zenker's diverticulum is a pulsion hypo pharyngeal false
diverticulum with only mucosa and sub mucosa protruding through
triangular posterior wall weak site (Killian's dehiscence) between
horizontal and oblique components of cricopharyngeus muscle.
• The etiology is controversial and is probably due to elevated upper
esophageal pressure, cricopharyngeus dysfunction and reflux.
• The clinical presentation can be dysphagia, regurgitation, aspiration
or a mass or air-fluid level on neck or chest radiographs.
• The esophagram shows collection with midline posterior origin just
above cricopharyngeus protruding lateral, usually to left, and
caudal with enlargement.

121. EPIPHRENIC DIVERTICULUM
• Arises in the distal of
the esophagus, just
above diaphragm
• Pulsion diverticulum
(arrow) that probably
related to
incoordination of
esophageal peristalsis
and relaxation of the
lower esophageal
sphincter
EPIPHRENIC DIVERTICULUM

122. Pseudodiverticulosis
• Dilated mural
glands or pseudo
diverticulosis, is
usually
associated with
histologic or
endoscopic signs
of inflammation,
and many
patients have
strictures due to
GERD.

123. GERD ?????

124. BARRETT ESOPHAGUS
• Barrett esophagus is a complication of long-standing
gastroesophageal reflux, occurring in up to 10% of patients
with persistent symptomatic reflux disease, as well as in
some patients with asymptomatic reflux.
• Barrett esophagus is defined as the replacement of the
normal distal stratified squamous mucosa by metaplastic
columnar epithelium containing goblet cells.
• Prolonged and recurrent gastroesophageal reflux is thought
to produce inflammation and eventually ulceration of the
squamous epithelial lining.
• Healing occurs by ingrowth of stem cells and re-
epithelialization.

125. Barrett's esophagus
• Barrett's esophagus with
reticular mucosa and web-like
(arrow) stricture
• salmon-pink, velvety mucosa
between the smooth, pale pink
esophageal squamous mucosa
and the more lush light brown
gastric mucosa

126. Barrett's esophagus
• Barrett's esophagus (columnar metaplasia) is the
result of long-standing reflux esophagitis.
• The diagnosis is strongly suggested by:
– Mid or high esophageal ulcer
– Mid or high esophageal web-like stricture
– Reticular mucosal pattern

127. Barrett's esophagus
• Barrett's esophagus
with
adenocarcinoma.
• There are abnormal
distal mucosal folds.
• The upper margin
of adenocarcinoma
makes right angle
with esophageal
wall (arrow)
indicating a mural
lesion in patient
with GERD and
Barrett's esophagus.

128. Glycogen acanthosis
• Glycogen plaques are
frequently seen at
endoscopy.
• The reported incidence at
endoscopy is 5 to 15% of all
patients.
• These benign epithelial
collections of glycogen
produce small mucosal
nodules.
• Nodules are smooth and
well-defined. This may be a
degenerative process and
produces no symptoms.

129. ESOPHAGITIS
• Injury to the esophageal mucosa with subsequent
inflammation is a common cause
• There are many presumed contributory factors:
• Decreased efficacy of esophageal antireflux mechanisms
• Inadequate or slowed esophageal clearance of refluxed
material
• The presence of a sliding hiatal hernia
• Increased gastric volume, contributing to the volume of
refluxed material
• Impaired reparative capacity of the esophageal mucosa by
prolonged exposure to gastric juices

130. Esophageal ulceration
• • Common
• o Reflux esophagitis
• o Candida esophagitis
• o Herpes esophagitis
• o Drug-induced
esophagitis
• Uncommon
o Radiation esophagitis
o Caustic esophagitis
o Tuberculous esophagitis
o Cytomegalovirus esophagitis
o HIV esophagitis
o Crohn disease
o Nasogastric intubation
o Alkaline reflux esophagitis
o Behcet disease
o Epidermolysis bullosa dystrophica
o Benign mucous membrane
pemphigoid

131. Candida esophagitis
• The barium study shows numerous
fine erosions and small plaques due
to Candida albicans immuno
compromised patient.

132. Cytomegalovirus esophagitis
• AIDS patient with an
infectious esophagitis
due to Cytomegalovirus.
• Such giant ulcers can
also be due to HIV
alone.

133. Herpes oesophagitis

134. Crohn's esophagitis
• There is a
granulomatous
esophagitis with
aphthous ulcers
• This is an uncommon
manifestation of
Crohn's disease.
• The figure on ther right
shows the more
common colonic
aphthous ulcers.

135. HIV OESOPHAGITIS

136. TB esophagitis
• There is an irregular sinus
tract from proximal
esophagus Chest radiograph
shows enlarged lymph
nodes widening
mediastinum due t0primary
tuberculosis.

137. : CORROSIVE ESOPHAGITIS
• Most severe corrosive injuries are caused by alkalis
• Barium study is unnecessary during acute phase.
• Radiographic findings;
1. Diffuse superficial or deep ulceration
involving long portion of the distal
esophagus
2. Abnormal motility
3. Fibrotic healing results in a long
esophageal stricture ( arrow) that
extends down to the cardioesophageal
junction.
barium was aspirated into left main
bronchus

138. : CORROSIVE ESOPHAGITIS

139. Eosinophilic esophagitis
• There is diffuse distal
narrowing and
corrugated margins
(arrows) due to ring-like
indentations, that are
characteristic of
eosinophilic
esophagitis.

140. Eosinophilic esophagitis
• This diagnosis may be suggested by peripheral
eosinophilia and confirmed by > 20 eosinophil's per HPF
on biopsy.
• Patients often have dysphagia and allergies.
• Imaging finding include diffuse narrowing, strictures,
and a ringed appearance similar to transverse (feline
esophagus) folds that are transient or associated with
reflux.
• Steroid therapy is often curative

141. LYMPH NODE LEOMYOSARCOMA

142. Major radiographic findings: CARCINOMA
EARLY STAGE
- Flat plaque-like lesion or small
polypoid lesion) on one wall of
the esophagus

143. : Major radiographic appearances :
ADVANCED STAGE
• A. Large Polypoid ( often
fungating ) filling defect
(arrow) with overhanging
edge (arrow)
• B. Large ulcer niche (
arrow) within a bulging
mass (ulcerated mass)
(arrow)

144. Major radiographic appearances
•
Advanced stage
• A. Encircling mass with
irregular luminal
narrowing (pink arrow)
and shelf like margins
(black arrow)
• B. Nodular thickened
folds (varicoid type)
(black arrow); Extension
of the tumor
(pink arrow)

145. PSEUDO-ACHALASIA caused by direct
spread to the distal esophagus from gastric
carcinoma
Radiographic findings :
1. Irregularly, narrowed and
nodular( arrowhead),
sometimes ulcerated
(arrow), lesion at distal
esophagus
2. Rapid transition between
normal and abnormal part.
3. Dilatation of proximal
esophagus.

147. RISK FACTORS FOR CARCINOMA OF THE ESOPHAGUS
Esophageal Disorders
• Long-standing esophagitis ,Achalasia
• Plummer-Vinson syndrome (esophageal webs, microcytic hypochromic anemia,
atrophic glossitis)
• Alcohol consumption Tobacco abuse
• Deficiency of vitamins (A, C, riboflavin, thiamine, pyridoxine) Deficiency of trace
metals (zinc, molybdenum)
• Fungal contamination of foodstuffs High content of nitrites/nitrosamines
• Genetic Predisposition Tylosis (hyperkeratosis of palms and soles)

149. • Abnormal Gastro
Esophageal Junction:
Barium outlines thick,
irregular mucosal folds
(asterisks). Fundal
adenocarcinoma invades
esophagus (arrows)

150. Foreign bodies
• Of which patients may ingest a variety, include a bolus of food,
metallic objects, and other materials lodging in the esophagus.
Their locations and dimensions may be determined during the
esophagram.
• Radiolucent foreign bodies, such as fish bones, may require the use
of additional materials and techniques for detection
• Cotton or bread may be shredded and placed in a cup of barium
and drunk by the patient. The intent of this technique is to allow a
tuft of the cotton to be suspended by the radiolucent foreign body
and visible during fluoroscopy.
• Although this technique has been used for decades, most
gastroenterologists prefer the use of endoscopy to isolate and
remove these foreign bodies.

152. Chest radiograph depicts deviation of the trachea to the right in an
18-month-old female infant with upper respiratory congestion lasting
3 months

153. Esophagram demonstrates irregularity of the contrast material column along
the right lateral aspect of the esophagus. These findings suggest the presence
of a nonradiopaque foreign body.

154. Congenital Anomalies
• Ectopic tissue rests are not uncommon in the
esophagus. The most common is ectopic
gastric mucosa in the upper third of the
esophagus ("inlet patch"), occurring in up to
2% of individuals. Sebaceous glands or ectopic
pancreatic tissue are much less frequent. The
acid secretions of the ectopic gastric mucosa
or pancreatic enzymatic secretions can
produce localized inflammation and
discomfort.

155. Congenital
Disorder Clinical Presentation and Anatomy
Stenosis Adult with progressive dysphagia to solids and
eventually to all foods; a lower esophageal
narrowing, which is usually the result of
chronic inflammatory disease, including
gastroesophageal reflux
Atresia, fistula Newborn with aspiration, paroxysmal
suffocation, pneumonia; esophageal atresia
(absence of a lumen) and tracheoesophageal
fistula may occur together
Webs, rings Episodic dysphagia to solid foods; a
(presumably) acquired mucosal web or
mucosal and submucosal concentric ring
partially occluding the esophagus
Diverticula Episodic food regurgitation, especially
nocturnal, sometimes pain is present; an
acquired outpouching of the esophageal wall
page 549

156. ATRESIA AND FISTULAS
• In atresia, a segment of the esophagus is represented by only a thin, non
canalized cord, with a proximal blind pouch connected to the pharynx and
a lower pouch leading to the stomach.
• Atresia is most commonly located at or near the tracheal bifurcation. It
rarely occurs alone, but is usually associated with a fistula connecting the
lower or upper pouch with a bronchus or the trachea. Associated
anomalies include congenital heart disease, neurologic disease,
genitourinary disease, and other gastrointestinal malformations. Atresia
sometimes is associated with The presence of a single umbilical artery.
• Aspiration and paroxysmal suffocation from food are obvious hazards;
pneumonia and severe fluid and electrolyte imbalances may also occur.

157. Tracheo oesophageal fistula

158. Thank you for
this opportunity

159. Image Gallery

164. web

173. Mucosal herniation through an area of anatomic
weakness in the region of cricopharyngeal muscle
(Killian dehiscence)

174. zenkers

176. Pulsion diverticula-Outpouching or sac-like protrusion of
one or more layers of esophageal wall

178. Caused by dilation of excretory ducts of deep
mucous glands

181. Boeerheve syndrome

183. Fibrovascular polyp-Giant, smooth, sausage-shaped,
intraluminal, expansile mass

184. Carcinoma

186. Thank you for
this opportunity

188. Mucosal relief
• Spot film hear
demonstrate
presence of
esophageal varies.
And this is best
seen if patient is
performing Valsalva
maneuver on
exposure.