AP view shows diverticulum (arrow) originating laterally.Lateral view confirms diverticulum does not originate posteriorly as a Zenkersdiverticulum would.
Barium swallow shows circumferential radiolucent ring in upper esophagus. Proximal dilatation and jet phenomenon (Barium spurting through the ring on fluoroscopy) indicate partial obstruction.
AP and Lateral views show short, thin web (arrows) with minimal intraluminal extension.
On the left images of a 42-year-old woman with dysphagia due to web.There is > 50% luminal narrowing
On the left tertiary contractions on first swallow (left). Normal primary contraction on next swallow (right).These tertiary contractions are non-propulsive, transient, and intermittent contractions that are inconstant in location and not accompanied by symptoms, usually in older patients.
Single-contrast prone right anterior oblique esophagram shows diffuse esophageal spasm with marked nonperistaltic contractions (black arrows) and short segment of tapered narrowing in distal esophagus (small white arrow) due to incomplete opening of lower esophageal sphincter. Large white arrow denotes small hiatal hernia.
Sometimes transient tertiary contractions may simulate diverticula.On the left images of a patient with tertiary contractions, that during the examination look like diverticula.
Diffuse esophageal spasm. Patient experienced chest pain during examination
Secondary achalasia in a case with Chagas' disease. Note the esophageal dilation and aperistalsis with a large amount of residual food present. (With permission from .)
Secondary achalasia due to chronic idiopathic intestinal pseudo-obstruction. There is abnormal esophageal motility and radiographic appearance indistinguishable from primary achalasia. (With permission from .)
Scleroderma with oesophageal cancer and peptic stricture
LEFT: Small diverticulum (arrow) in asymptomatic patient RIGHT: Large diverticulum (arrow) in patient with aspiration
On the left small aortopulmonarydiverticula (arrows), that are incidental findings in two patients
On the far left a traction diverticulum (arrow) due to hilar granulomatous disease. Calcified adenopathy (asterisk). In the middle a pulsion diverticulum (arrow) due to high intraluminal pressure.On the right multiple pulsiondiverticula (arrows) that preceded Heller myotomy for achalasia.
On the left a traction diverticulum (arrows) secondary to post primary TB.It simulates a cavitary lung lesion on the chest radiograph.
Esophageal ring due to muscular contraction. It varies during examination and may not persist.
Esophageal A-ring due to muscular contraction. It varies during examination and may not persist.Non-persistent ring at the apex of a sliding hiatus hernia.
The appearance does not change during the examination. On the left a patient with a 'B' ring (arrows) several cm above diaphragm at the apex of sliding hiatus hernia.Note unchanged appearance on these two images.
On the left a 52-year-old man with episodic dysphagia.The image on the far left does not show a abnormality, but distal esophagus not distended .With dilation of the distal esophagus, a 13 mm wide Schatzki B-ring (arrows) that caused intermittent obstruction is demonstrated at the apex of a hiatus hernia (arrowhead).
On the left a 71-year-old man with chest pain after fast food lunch.Distal obstructing filling defect (arrow) is a piece of meat that passed into stomach during study.Follow-up esophagram shows Schatzki B-ring (arrows) that caused obstruction.
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
On the left Irregular stricture (arrowhead) and erosions (arrows) due to GERD.
Barrett's esophagus with reticular mucosa and web-like (arrow) stricture
on the left a patient with a Barrett's esophagus with an 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.
The barium stury shows numerous fine erosions and small plaques due to Candida albicans in immunocompromised patient.
On the left an AIDS patient with an infectious esophagitis due to Cytomegalovirus.Such giant ulcers can also be due to HIV alone.
There is a granulomatousesophagitis with aphthous ulcers (arrows).This is an uncommon manifestation of Crohn's disease.The figure on ther right shows the more common colonic aphthous ulcers.
There is an irregular sinus tract from proximal esophagus (arrow).Chest radiograph shows enlarged lymph nodes widening mediastinum due to primary tuberculosis.
On the far left a stricture (arrow) with irregular mucosal folds at stricture site on air-contrast view. This patient had Barrett's esophagus. Mid esophageal strictures and ulcers are suspicious for Barrett's esophagus.The two images on the right show a Barrett's esophagus with an irregular stricture due to adenocarcinoma.
On the left a long, symmetric tapered benign stricture months after radiotherapy.
On the left images of a patient with a benign stricture high in the esophagus (arrow). There is bilateral lower lobe lung consolidation due to repeated aspiration.
On the left a high stricture (arrow) following caustic ingestion
On the left a patient with benign pemphigoid.Mucosal bullae have led to multiple strictures (arrows).
On the left a patient with benign epidermolysisbullosa.Multiple strictures (arrows) are a residual of mucosal bullous disease.Extensive bullous skin disease has led to webbed fingers and contractions
Corrosive ingestion can result in multiple strictures.
Spot films show barium (arrows) in linear mucosal tear near gastroesophageal junction. Tears may be in distal esophagus, gastric fundus, or extend across the GE junction.
Downhill varices in a patient with a superior vena cava obstruction
The artery extends up and to the right producing a dorsal diagonal impression on the esophagus (arrows). The CT demonstrates that the aberrant artery (arrow) is last vessel from arch and extends dorsal to trachea and esophagus.
Aberrant left pulmonary artery: aberrant artery extends between trachea and esophagus indenting both (arrows)
On the left initially, GE junction is below the esophageal hiatus. Later, stomach protrudes through hiatus. Neither the hernia or stricture (arrow) due to reflux esophagitis were visible early in the examination.
On the far left gas filled gastric fundus (asterisk) protrudes through hiatus but GE junction (arrow) is below diaphragm.Next to it a paraesophageal hernia with most of 'upside down' stomach in chest with greater curvature (arrows) flipped up.
Distal esophagus is adjacent to the herniated gastric fundus, but unlike a paraesophageal hernia, the gastroesophageal junction (arrow) is above rather than below the diaphragm.
On the chest film an abnormal opacity is seen behind the heart (arrow). The barium study demonstrates a lobulated mass (arrow) that does not obstruct despite its large size.
On radiograph, tumor (arrows) protrudes into azygoesophageal recess. On esophagram, the inferior margin of this intramural lesion forms close to a right angle (arrow) with esophageal wall.
A calcified esophageal mass is almost always a leiomyoma. On the left a patient with a calcified esophageal lesion (arrows) protrudes into azygoesophageal recess on radiograph. Lesion (arrow) on CT and surgical specimen radiograph showing calcification.
The findings on the barium study are non-specific. Lesion (arrows) is visible behind the heart on radiograph. Esophageal narrowing (arrows) is caused by duplication.
In the case on the left it displaces hypopharynx and opacified esophagus (arrow) posteriorly and trachea and larynx (asterisk) anteriorly.
On the left a patient with an early esophageal carcinoma. Lesion is not visible on single contrast esophagram. Air-contrast esophagram shows surface irregularity (arrows) indicating a mucosal lesion. This was both a small lesion and a pathologically early squamous carcinoma.
LEFT: Small polypoid carcinoma. RIGHT: Large polypoid lesion.
Esophageal carcinoma with ulcerations (arrows) and sharp right angle junction with esophageal wall (arrowheads)
Unchanging appearance of filling defects indicate tumor rather than varices. Note sharp upper margin of lesion and ulceration (arrows)
LEFT: Varicoid carcinoma. Long lobulations simulate varices but did not vary during fluoroscopy. Note large irregular folds and soft tissue mass (arrow) of gastric fundus RIGHT: Superficial spreading carcinoma. superficial spreading carcinoma. Extensive superficial spread involves distal esophagus. This appearance can be seen with both early and advanced lesions.
LEFT: Long irregular distal stricture due to carcinoma.RIGHT: Distal narrowing is not tapered and more proximal than achalasia. Irregularity (arrow) at narrowed site is subtle but persistentLeft : carcinoma with stricture. Right : carcinoma with stricture resembling achalasia.
On the left a patient with a leiomyosarcoma of the esophagus. Margin (arrows) of bulky lesion visible on chest radiograph. Lateral view of esophagram shows marked irregularity and esophageal narrowing (arrows).
Impaired cricopharyngeus relaxation.
Obstruction –elevation of pharyngeal pressure –
Develops resulting in weakness in posterior
pharyngeal wall between horizontal and oblique
fibres in inferior constrictor muscle (Killian's
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
Retains little of bolus causing aspiration.
Protrusion through the anterolateral
anatomical weak site of the cervical
esophagus below the cricopharyngeus
Transient or permanent lateral cervical
Food retention – overflow aspiration.
Mc -Middle aged females.
C/P: Dysphagia(Symptoms if lumen > 50%
Shelf like 1-2mm thick infoldings of mucosa
protrude into lumen from anterior wall of
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.
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
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
1. 30 Contractions
2. Diffuse oesophageal spasm
3. Nutcracker oesophagus
4. Hypertrophic lower oesophageal sphincter.
5. Non specific oesophageal motility disorder.
Motility varies from one swallow to next.
Minimum of 5 single prone swallows.
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
Intermittent contractions of the mid and distal
esophageal smooth muscle, associated with
Severe intermittent chest pain, dysphagia, food
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.
10 peristaltic waves with pressure in excess of
180 mm of Hg.
35- 50 yrs.
Slow progression of dysphagia for both solids and
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
95% diagnostic accuracy
1. Early/Stage I
Primary peristaltic waves absent with abnormal distal
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
4. Severe disease
Significant esophageal body dilatation with large
amounts of fluid/food retention
Entire esophagus atonic in late stages
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.
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
Pulsion diverticula are due to increased
intraluminal pressure.There are many pulsion
Motility is abnormal.
If large they can
The normal esophagus transiently protrudes into the
Fixed protrusion is an inconsequential diverticulum.
Traction diverticula are secondary to adjacent
Most located in mid-esophagus.
Result of fibrosis from adjacent tuberculous
Muscular contraction at the junction of tubular and vestibular
No definite anatomic correlate
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
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
Almost always located above a hiatal hernia.
Demonstrated when oesophagus is distended during
prone barium swallow.
Gastroesophageal reflux (GERD) is the most
common cause of esophagitis.
Excessive smoking, fatty meals ,drinking
alcohol or coffee –relaxation of lower
Association between hiatus hernia and peptic
24 hr pH recording(<4)
Earliest changes on endoscopy.
Pronounced oedema , earliest changes of fine
mucosal nodularity seen on double contrast
Collapsed oesophagus shows thickened
longitudinal folds (>3mm) ~varices.
Multiple fine ulcers – punctate or granular
appearance or larger discrete punched out
Scarring produces permanent folds that
radiate from margins of ulcers.
En profile – out pouchings can mimic
Coarse transverse folds are different from
fine mucosal folds which are thought to result
from contraction of muscularis mucosa –
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
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.
Double contrast studies
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.
Acute self-limited disease.
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.
Radiation dose of 5000 cGy or more to the
2–4 weeks after the initiation of radiation
Mucosa shows granular appearance due to
edema and inflammation .
Ulceration and decreased luminal
Radiation strictures 4–8 months after
completion of the therapy.
Appear as smooth tapered areas of
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
Horizontal striations due to muscularis mucosa
Normal in cats.
Most often transient and insignificant .
May be associated with gastroesophageal reflux
Narrowing of the lumen.
Single or multiple.
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
Mc -Unchewed meat bolus arrested at the site of
anatomical and pathological narrowing .
Intraluminal filling defect may resemble
Post foreign body removal to r/o narrowing due
to hold up.
Acute condition .
Prolonged and forceful vomiting, coughing or
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.
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
Best -prone RAO position.
High-density barium suspension or barium paste
to increase mucosal adherence.
Varicoid carcinoma .
Esophagitis with thickened folds.
Superior vena cava obstruction with downward flow
via dilated esophageal collateral vessels to the portal
venous system and the inferior vena cava.
Central catheter–related thrombosis of SVC.
CA lung or other metastatic tumors involving the
Serpentine longitudinal filling defects confined to the
upper or middle part of the esophagus.
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
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.
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,
Mc benign mucosal tumor.
Small sessile polyps with a smooth or slightly
Mc benign submucosal tumor.
Least common – GIST.
Mucosal lesions are indicated by mucosal
Submucosal intramural lesions produce
smooth filling defects.
En profile : the margins often form close to a
right angle with the esophageal wall.
Extrinsic lesions tend to form longer obtuse
angles if not fixed to the esophageal wall, and
their epicenter may be outside the
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.
A foregut duplication cyst is a congenital
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.
An irregular, asymmetric stricture is highly suggestive of
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
If esophageal motility is normal, achalasia can be
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
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
4. Radiology;Diseases of the Esophagus:
Diagnosis with Esophagography
Note :Radiographs have been described in
click to add notes.