This document summarizes various pathologies that can be seen on a barium swallow exam. It describes abnormalities of the upper and lower esophageal sphincters, including cricopharyngeal achalasia. It also discusses esophageal peristalsis abnormalities like tertiary contractions and diffuse esophageal spasm. Other topics covered include achalasia, esophageal rings, diverticula, hernias, esophagitis, Barrett's esophagus, infectious esophagitis, acute esophageal syndromes, leiomyomas, malignant tumors, varices, foreign bodies, and complications. Images are provided to illustrate many of the pathologies.

1. BARIUM SWALLOW
PATHOLOGIES
DR. SABHILASH SUGATHAN

3. UPPER ESOPHAGEAL SPHINCTER
• Primarily formed by
cricopharyngeal muscle.
• Located at the C5-C6 level
• Normally relaxes with bolus
• No relaxation: with symptoms
termed -- cricopharyngeal
achalasia
Feeling of lump in throat. Persistent indentation (arrow) by cricopharyngeus muscle that does not relax as bolus progresses
caudally

4. LOWER ESOPHAGEAL SPHINCTER
•Distal 2-4 cm esophageal high
pressure zone defined by manometry.
Corresponds to vestibule on
esophagram.
•Bulbous distention of the distal
esophagus is called the vestibule.
This distention is best demonstrated by
breath holding in inspiration or a
Valsalva maneuver.
•Do not mistake this for a hiatal hernia.

5. ESOPHAGEAL PERISTALSIS
Normal:
• Primary contraction: Propels bolus through the esophagus
• Secondary contraction: Follows primary contraction and propels any remaining
esophagus
Abnormal:
• Tertiary contractions, presbyesophagus: Nonpropulsive contractions
• Diffuse esophageal spasm
• Nutcracker esophagus
• Decreased peristalsis resulting from achalasia, scleroderma, dermatomyositis,
and secondary to many other diseases

6. TERTIARY CONTRACTIONS:
NONPROPULSIVE CONTRACTIONS
• On the left tertiary contractions on first
swallow (left).
• Normal primary contraction on next
swallow (right).

7. DIFFUSE OESOPHAGEAL SPASM
• “corkscrew” “rosary bead"
esophagus
• The esophageal muscle is
hypertrophied, but
histologically normal

8. ACHALASIA CARDIA
• Barium swallow showing dilatation of the esophageal
body
• With short segment stricture.
• A “bird- beak " like tapering of the esophagus at the
GE junction.
• impaired relaxation of the lower esophageal
sphincter.
• This appears to be due to loss/destruction of neurons in
the Auerbach/myenteric plexus.
• Obstruction of the distal esophagus from other non-
functional etiologies, notably malignancy(Distal
carcinoma), may have a similar presentation and has
been termed "secondary achalasia" or
"pseudoachalasia".

10. LOWER ESOPHAGEAL RINGS
A-Ring
• Muscular contraction at the junction of tubular and vestibular esophagus
•B-Ring
• Mucosal ring at anatomic squamocolumnar junction (Z-line)
• Best or only seen with vestibular distension
• May cause episodic dysphagia if esophagus is narrowed, then termed a Schatzki
ring
• usually associated with a hiatus hernia.

11. A-RING
• Esophageal A-ring due to muscular
contraction. It varies during examination and
may not persist.

12. B-RING - SCHATZKI RING
• 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.

13. OESOPHAGEAL WEB
•Esophageal webs refer to an esophageal constriction caused by a thin mucosal
membrane projecting into the lumen.
•More commonly occur in the cervical oesophagus near cricopharyngeus muscle
than in the thoracic oesophagus.
• They typically arise from the anterior wall
Associations
• Plummer-Vinson syndrome
• GORD/GERD (especially a distal oesophagus web)
• external beam radiation.

14. Multiple smooth tapered concentric narrowing
of the cervical esophagus in keeping with
esophageal webs.
• Plummer-Vinson syndrome
with jet effect

15. DIVERTICULA
Pulsion diverticula are due to increased intraluminal pressure. There are many pulsion diverticula:
• Zenker's
• Killian-Jamieson
• Epiphrenic
• Midesophagus
• Aortopulmonary recess
•.

16. ZENKER’S DIVERTICULUM
• A Zenker's diverticulum is a
pulsion hypopharyngeal false
diverticulum with only mucosa
and submucosa protruding
through triangular posterior
wall weak site (Killian's
dehiscence) between horizontal
and oblique components of
cricopharyngeus muscle.
• due to elevated upper
esophageal pressure

18. KILLIAN JAMIESON DIVERTICULUM
• Killian-Jamieson
diverticulum is a pulsion
diverticulum, that protrudes
through a lateral anatomic
weak site of the cervical
esophagus below the
cricopharyngeus muscle.
• AP view shows
diverticulum (arrow)
originating laterally.
• Lateral view confirms
diverticulum does not
originate posteriorly as a
Zenkers diverticulum
would.

19. EPIPHRENIC DIVERTICULUM
• These pulsion diverticula are
classified by their location near the
diaphragm.

20. AORTOPULMONARY WINDOW DIVERTICULUM
• The normal esophagus transiently
protrudes into the aortopulmonary window.

21. HIATUS HERNIA
• High abdominal pressure is required to
demonstrate.
• Barium meal in Trendlenberg position.
Displacement of the cardio-esophageal junction
above the esophageal hiatus . Part of the
stomach is present in the chest
• Reflux of barium into the esophagus

22. SLIDING HERNIA

23. PARA-ESOPHAGEAL HERNIA
gas filled gastric fundus (asterisk)
protrudes through hiatus but GE junction
(arrow) is below diaphragm.

24. MIXED HERNIA
• 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.

25. ESOPHAGITIS

26. GASTRO ESOPHAGEAL REFLUX
• SIPHON TEST
• Fill the stomach with 50% barium(150-200ml)
• Follow this 1-2 mouthful of water to remove traces of barium in esophagus
• Pt in supine with left side raised 15% up
• Keep one mouthful of water in pt mouth
• Ask pt to swallow water-a jet of barium will shoot into water column as it enter GO
junction
• Alternatively with full stomach, ask pt to roll side to side • Reflux will be seen

27. 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

28. BARRETT’S OESOPHAGUS
• 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
The reticular mucosa is
characteristic of Barrett's
columnar metaplasia, especially
with the associated web like
(arrow) stricture.

29. FELINE OESOPHAGUS
• The appearance is almost always
associated with active gastro-
esophageal reflux and is thought to be
due to contraction of the muscularis
mucosae with resultant shortening of
the esophagus and 'bunching up' of the
mucosa in the lumen .
• Feline esophagus also known
as esophageal shiver, refers to the
transient transverse bands seen in the
mid and lower esophagus on a double-
contrast barium swallow.
• Transient horizontal ridges throughout
the esophagus (they disappear with a
subsequent swallow).

30. INFECTIOUS ESOPHAGITIS

31. CANDIDA ESOPHAGITIS
• A patient with an infectious esophagitis due to
candida.
• The barium study shows numerous fine erosions
and small plaques due to Candida albicans in
albicans in immunocompromised patient.

32. CROHN'S ESOPHAGITIS
• There is a granulomatous
esophagitis with aphthous
ulcers (arrows).

33. CYTOMEGALOVIRUS ESOPHAGITIS.
• giant ulcers

34. CYTOMEGALOVIRUS ESOPHAGITIS
• Cytomegalovirus esophagitis in a
patient with AIDS
• Double contrast esophagram shows a
large flat ulcer in profile (large arrows)
in the midesophagus with a cluster of
small satellite ulcers (small arrows)
•

35. T.B esophagitis. Eosinophilic esophagitis
irregular sinus
tract from
proximal
esophagus
(arrow).
corrugated margins
(arrows) due to
ring-like
indentations

36. Acute esophageal syndromes

37. BOERHAAVE SYNDROME:
•Boerhaave's syndrome is rupture of the esophageal wall.
•It is most often caused by excessive vomiting
•Perforation is almost always on the left side of distal esophagus
•Boerhaave's syndrome is a transmural or full-thickness perforation
of the esophagus, distinct from MalloryWeiss syndrome, a non-
transmural esophageal tear also associated with vomiting.

38. This image is of a patient with Boerhaave syndrome.
Chest radiographs show pneumomediastinum (arrows).
Esophagram with extravasated water soluble contrast material in left
hemithorax (asterisk)

39. MALLORY-WEISS TEAR
•A Mallory-Weiss tear results from 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.
•It may occur as a result of excessive alcohol ingestion.
•This is an acute condition which usually resolves within 10 days
without special treatment.

40. a patient with a Mallory-Weiss tear.
Spot films show barium (arrows) in linear mucosal tear near
gastroesophageal junction.

41. Leiomyomas are the most common
benign esophageal neoplasm and are
often large yet nonobstructive.
Gastrointestinal stromal tumors (GIST)
are least common in the esophagus.
LEIOMYOMAS
The barium study demonstrates a lobulated mass (arrow) that does not
obstruct despite its large size.

42. MALIGNANT

43. CA ESOPHAGUS
• Classical finding in carcinoma-rat tail
appearance

44. • A segmental narrowing with an
irregular margin and shouldering
appearance at the distal half of the
esophagus suggests tumoral
infiltration.
• Evidence of prior sternotomy is
noted.

45. GASTRIC CARDIA CANCER INVADING THE
DISTAL ESOPHAGUS (BARIUM SWALLOW)
• Severe stricture with shouldering
appearance is present at the distal
portion of the esophagus and gastric
cardia that causes pre-stricture dilatation
and contrast media stasis compatible
with esophageal pseudoachalasia.

46. ESOPHAGEAL VARICES
• Varices are best demonstrated in
mucosal relief study after using
Buscopan/ valsalva maneuver.
• Mild dilatation of the esophagus with
multiple persistent filling defects in
the lower third of the esophagus
and/or longitudinal furrows.

48. DYSPHAGIA LUSORIA
• The oesophagus may be compressed by a
congenitally aberrant right subclavian artery.
• If this is symptomatic a diagnosis of
dysphagia lusoria is made
• Here it is seen as oblique tubular extrinsic
compression in upper oesophagus.

49. • To detect the level of obstruction in case of radiolucent foreign body in
esophagus,marsh mellow coated with barium is swallowed
• Passage of marsh mellow will be
hindered
• at the level of obstruction
• Barium swallow shows irregular
areas of narrowing and dilatation ----
“Shish kebab”
FOREIGN BODY IMPACTION

50. COMPLICATION
• Leakage of barium from unsuspected
perforation

51. ASPIRATION

52. THANKYOU

53. SCHATZKI RINGS
• A Schatzki ring, also called a Schatzki-Gary ring, is a symptomatic, narrow
esophageal B-ring occurring in the distal esophagus and usually associated with
a hiatus hernia.
• The pathogenesis of the Schatzki ring is unclear with conflicting hypotheses that
include redundant pleats of mucosa, congenital abnormalities and modified peptic
strictures. Interestingly, there is a reduced incidence of Barrett esophagus in patients
with a Schatzki ring.
• Depending on its luminal diameter, an esophageal B-ring may be symptomatic or
asymptomatic :
• <13 mm: almost always symptomatic
• 13-20 mm: sometimes symptomatic
• >20 mm: rarely symptomatic
• When it is symptomatic, it is termed a "Schatzki ring"

56. 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.

57. Granular cell myoblastomas, an uncommon
benign tumor.
Fibrovascular polyp