This document discusses GI imaging techniques such as barium studies and fluoroscopy. It covers how different densities are visualized on x-rays and contrasts agents used. Various GI conditions are described such as gastroesophageal reflux disease (GERD), hiatal hernia, Barrett's esophagus, and esophageal motility disorders. Esophageal abnormalities, tumors, and diverticula are also summarized. The document provides an overview of what can be evaluated using barium and fluoroscopic imaging of the GI tract.

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