Details about radiology

2. GI Imaging

3. Densities
 X-ray allows visualization of different densities
-Air
-Fat
-Water
-Metal

4. Visualization of the Esophagus
 Different density required for visualization
i.e.: contrast

5. Contrast Agents
 Water Soluble
– Gastrografin
– Low-osmolality
 Inert
– Barium sulfate

6. Single vs. Double Contrast
 Improved mucosal visualization

7. Fluoroscope
 Real-time
x-ray video
 Multiple sequential
images
 Spot films

8. Barium Studies
 (Video) Esophogram
 Barium Swallow
 UGI series
 Modified Barium
Swallow

9. Gastroesophageal
Reflux

10. GERD & Barium
 Visualization of
refluxing barium
 Patient position
 Valsalva
 Usefulness is
arguable

11. GERD Secondary Signs
 Hiatal Hernia (HH)
 Cricopharyngeus muscle spasm
 Reflux esophagitis
 Benign stricture
 Barrett’s esophagus
 Aspiration pneumonia

12. Hiatal Hernia
 Extension of stomach into chest through
esophageal hiatus
 2 types:
– Sliding 95%
– Para-esophageal 5%
 Not associated with GERD
 May be more prominent when supine

14. Cricopharyngeous Muscle
 Posterior wall of pharyngoesophageal
junction
 Normally relaxes with swallowing to allow
passage of food
 Incomplete relaxation can be seen as
protective mechanism in GER patients
 Smooth impression at C5-6 level

15. Cricopharyngeous Muscle
Spasm

16. Reflux Esophagitis
 Begins distally
 Thickened folds
 May have associated
linear ulcers

17. Benign Stricture
 Distal or mid-esophagus
 Smooth walls
 May be partially distensible

18. Barrett’s Esophagus
 In approx. 10% of untreated reflux patients
 Metaplasia of normal squamous epithelium
to a gastric columnar epithelium
 Nodular or granular mucosa
 Look for focal ulceration, stricture, and
cancer (15% or 30x increase)

19. Barrett’s Esophagus

20. Aspiration Pneumonia
 Appearance will vary with amount of
aspirate, patient position, reaction to
aspiration
 Often bilateral, associated atalectasis
 Posterior and basal areas more common

21. Aspiration Pneumonia

22. Aspiration

23. Esophageal Cancer

24. Detection
 Barium studies are not as sensitive as
endoscopy, but more readily available
 Suspect cases referred on to endoscopy
 CT, MRI not suitable for screening

25. Barium Swallow Patterns
1. Annular constricting
 Most common
 Many variations
2. Polypoid mass
3. Infiltrative
 In submucosa, may simulate benign stricture
4. Ulcerated mass

26. Esophageal
Cancer

27. Esophago-
bronchial
fistula

28. Tumor Staging
 CT most commonly used
 Endoscopic ultrasound in some centers

29. Computed Axial Tomography

30. Computed Axial Tomography

31. CT Staging
 Wall thickness
 Infiltration of paraesophageal fat planes
 Regional invasion (trachea, pleura,
pericardium, vertebrae etc…)
 Lymphadenopathy
 Distant Metastases

32. Normal CT

33. Invasive Cancer

34. Endoscopic Ultrasound
 Smaller lesions
 Assess wall involvement

35. Esophageal Motility

36. Normal Motility
 Best seen prone
 3 phases:
– Oral, pharyngeal, esophageal

37. Esophageal Phase
 Primary wave:
– Initiated by swallowing reflex
 Secondary Wave:
– As response to esophageal distension

38. Normal Swallow

39. Abnormal Motility
 Non-specific finding
 Seen in reflux esophagitis, radiation injury,
caustic ingestion, myxedema, diabetes
mellitus…

40. Corkscrew esophagus
 Tertiary esophageal waves
– Non-propulsive
– Corkscrew or beaded
appearance

41. Scleroderma
 Fibrosis of smooth muscle
 Dilated esophagus with widely patent GEJ
 Resultant reflux
 Reflux esophagitis => ulceration =>
stricture (mild) => Barrett’s => neoplasm

42. Scleroderma

43. Achalasia
 Diffusely decreased or absent peristalsis
 Lower esophageal sphincter fails to relax
 Smooth, tapered distal esophageal
narrowing
 Some passage of food in upright position

44. Achalasia

45. Neuromuscular Disorders
 Most common => stroke
 Parkinsonism, Alzheimer’s, multiple
sclerosis, CNS neoplasms, traumatic injury
 Modified barium swallow

46. Zenker’s Diverticulum

47. Zenker’s
 Herniation at posterior midline above UES
 Horizontal & oblique fibers of inferior
constrictor muscles => Killian’s dehiscence
 Associated incomplete cricopharyngeus
muscle relaxation
 Neck at superior aspect of sac
 Midline, but lateral extension with growth

48. Zenker’s Diverticulum

49. Zenker’s Diverticulum