diagnostic modalities used for esophageal pathology

1. Diagnostic Modalities
For
Esophageal Diseases
Dr SD Sanyal

2. Modalities
1. Barium swallow
2. Esophagoscopy
3. Esophageal manometry/ Impedance
manometry
4. Ambulatory pH monitoring
5. Impedence pH monitoring
6. Endoscopic esophageal ultrasound
7. Bilitec 2000

3. Anatomy
• The oesophagus begins at the upper
oesophageal sphincter at the level of C6 and
finishes at lower oesophageal sphincter at T11
and is approx 25 cm

4. Constrictions

5. Barium Swallow

6. • Imaging procedure used to examine upper GI
tract,which include the esophagus and to a
lesser extent the stomach.
• Contrast : Barium sulphate

7. Indications
• Dysphagia
• Heart burn, retrosternal pain, regurgitation &
odynophagia.
• Hiatus hernia
• Reflux oesophagitis
• Stricture
• Esophageal carcinoma.

8. Indications
• Motility disorders:
i. Achalasia
ii. DES
• Pressure from Extrinsic lesions.
• Assessment of abnormality of:
• i. Zenkers diverticulum
• ii. Cricoid webs
• iii. Cricopharyngeal Achalasia.

9. Contraindications
• Suspected mediastinal/pleural/peritoneal leak
• Tracheo-esophageal fistula

10. Contrast Agent
• 100% BARIUM SULPHATE PASTE
• 80% BARIUM SULPHATE SUSPENSION
• 30% BARIUM SULPHATE SUSPENSION FOR
HIGH KV TECHNIQUE
• 200-250% HIGH DENSITY,LOW VISCOSITY FOR
DOUBLE CONTRAST STUDY

11. Views
• SOFT TISSUE NECK – AP & LAT – SCOUT
• NECK-AP & LATERAL
• THORAX-RAO VIEW

12. Types of Study
• Air esophagogram
• Full coloumn
• Mucosal relief

13. Scout film

14. RAO view

15. Preparation
• NPO
• Check for contrast related allergy
• Pregnancy
• Pre-procedure counselling

16. Technique
• PHARYNX
- One mouthful contrast bolus with high
density(250% w/v).
- Patient is asked to swallow once and stop
swallowing there after.
- This is to get optimum mucosal coating.
- Frontal and lateral view x-ray taken

17. Technique
• ESOPHAGUS
- Single contrast
- Multiple mouthfuls of 80% w/v barium
suspension
- Prone swallow to assess esophageal
contraction.
- Useful in esophageal
compression/disordered motility

18. Technique
• Double contrast
- Contrast high density,low viscosity(200-250%).
- 15-20 ml
- Effervescent powder given with another
mouthful of barium.
- In erect posture
• Pre-procedure administration of anti-spasmodic

19. Images

20. Air Contrast

21. Relief Contrast

22. Full Coloumn

23. Normal Indentations

24. Ca Esophagus

25. Achalasia cardia

26. DES

27. Webs

28. Hiatus Hernia

29. Gastro-esophageal Reflux

30. Gastro-esophageal Reflux

31. Esophageal Stricture

32. Barrett’s Esophagus

33. Zenker’s Diverticulum

34. Killian’s Dehiscence

35. Candida Esophagitis

36. Feline Esophagus

37. Esophagoscopy

38. • It is a modality to visualise the esophagus b/w
the:
- Upper esophageal sphincter
&
- GEJ
• Mostly performed as a part of esophago
gastroscopy

39. Types
- Based on the scope used:
• Rigid
• Flexible

40. Types
• Chromoendoscopy
• Magnification endoscopy
• Narrow band imaging
• Optical coherence tomograph spectroscopy
using:
- reflectance
- absorption
- light-scattering
- fluorescence
- Raman detection methods

41. Routes
• Trans-oral
• Trans-nasal

42. Indications
• Food bolus/ foreign body impaction
• Evaluation and management
of GERD, including noncardiac chest pain.
• Screening and surveillance of Barrett’s
Esophagus
• Treatment and surveillance of Esophageal
varices

43. Indications
• Evaluation and management
of Dysphagia including dilatation of
esophageal strictures
• Evaluation and management of Odynophagia
• Evaluation and management of esophageal
cancer, including placement of esophageal
stents
• Evaluation of the esophagus after abnormal
imaging studies

44. Contraindications
• Absolute:
- Hemodynamic instability
- Possibility of perforation
• Relative:
- Anticoagulation in the appropriate setting (ie,
esophageal dilation)
- Head and neck surgery
- Pharyngeal diverticulum

45. Technique
• Full history & examination.
• Focus on oral cavity and pharynx, thyroid gland,
cervical and supraclavicular lymph nodes.
• Position : Left lateral decubitus position.
• Moderate sedation: narcotic + bzd.
• Scope inserted into the oropharynx with
visualization of epiglottis and vocal cords.
• Scope advanced through pyriform sinuses and
esophageal lumen.
• Air insufflation

46. Complications
• Bleeding.
• Infection.
• Perforation.
• Aspiration.
• Over sedation.
• Hypoventilation.
• Cervical sepsis.
• Dental injury.

47. Images

48. Normal Proximal Esophagus

49. Endoscopic landmarks

50. Barrett’s Esophagus

51. Short Segment Barrett’s

52. Long Segment Barrett’s

53. Esophagitis

54. Esophagitis

55. CA Esophagus

56. CA Esophagus

57. Eosinophilic Esophagitis

58. Nissen’s Fundoplication

59. Nissen’s Fundoplication

60. Magnification Esophagoscopy
(Acetic Acid)

61. Magnification Esophagoscopy
(Narrow Band Spectroscopy)

62. Magnification Esophagoscopy
( Indigo Carmine)

63. Manometry

64. Definition
• Test devised to monitor:
- LES pressures
- Esophageal peristalsis

65. Device
• Flexible catheter with pressure sensors placed
at 5cm intervals
• It may :
- Contain water
- Be perfused
- Solid state

66. Indications
• Primary motility disorders of the esophagus
• In GERD for planning surgery

67. Measurements &Technique
• Assessment of LES:
- Mean resting pressure
1. Station pull through: 12-30mmHg
2. Rapid pull through: Higher pressures
due to artefacts
- Also provides information regarding:
1. Total length
2. Intra-abdominal length
3. Location of the sphincter wrt the nares

68. Measurement & Techniques
• Esophageal body:
- To assess the effectivity of peristalsis
- Specific parameters:
1. Peristaltic activity: percentage of initiated
swallows that transmitted successfully. Normal
>80%
2. Amplitude: Avg of pressures generated at
the distal end of the esophagus while
transmitting the peristaltic waves. Normal
>30mmHg

69. Measurements &Technique
• Technique:
- 4 channels placed at 3, 8, 13, 18 cms from
LES
- Atleast 10 series of 5ml aliquots of water
swallowed

70. High Resolution Impedence
Manometry
• Combination of pressure tomography with
impedance testing
• Advantages:
- Greater accuracy
- Effective continuous recording of motor activity
along the entire length of the esophagus
- No pseudorelaxation
• Colour contour plot with:
- time: X Axis
- esophageal length: Y Axis

73. pH Monitoring

74. Definition
• Technique to identify as well as quantify acid
reflux over a period of 24 hrs
• Technique:
-

75. Technique
• Catheter containing one or more solid-state
electrodes in the esophagus
• Electrodes are spaced 5 to 10 cm apart
• Sense fluctuations in the pH between 2 and 7
• Electrodes are connected to a data recorder
that the patient wears for the period of
observation
• There is a digital clock displayed on the
recorder

76. Indications
• Regurgitation
• Chest pain
• Cough
• Heartburn
• GERD

77. Information obtained
1. Total number of episodes
2. Longest episode of reflux
3. Episodes> 5mins
4. Extent of reflux in upright and supine
positions

78. Interpretation
1. De Meester’s Score > 14.7
2. Total % of time pH < 4:
- Proximal: 1%
- Distal: 4%
3. Correlation of symptom diary with reflux
episodes

79. De Meester’s Score

80. Impedance pH monitoring
• Basis:
- Detection of reflux events based on a change
in resistance to flow of an electrical currents
b/w electrodes
- Impedance decreases with air and increases
with a liquid bolus

81. Impedance pH monitoring
• Advantages:
- Differentiates b/w acidic and alkaline reflux
- Estimation of the proximal extent of reflux
- Distinction b/w true reflux and the ingestion
of an acidic liquid
• Disadvantage:
- Over estimation of the number of reflux
episodes
- Availability

82. Impedance pH monitoring
• Indication:
- Pts with symptoms despite PPI therapy and
normal distal acid exposure on standard pH
monitoring

83. Bilitec 2000

84. Basis
• Patent of Medtronic
• Using bilirubin as a marker for bile it records
the frequency and duration of bile exposure in
either the stomach or the esophagus over 24
hrs
• Works on the principle of Spectrophotometry

85. Indications
1. Pts with typical reflux symptoms, who do not
successfully respond to therapy and are not
affected by esophagitis at endoscopy
2. Atypical symptoms and normal endoscopy
3. Patients on follow-up after medical and
surgical therapy

87. Endoscopic Esophageal
Ultrasound

88. Technology
• Based on the “Pulse Echo Technique”
• Aka B Mode/ Gray scale ultrasonography
• Fast frame display: 12 images / second
• Transducer frequencies b/w 5-20 MHz
• 360 degree sector scan perpendicular to the
transducer tip
• Soft tissue penetration b/w 3-12 cms

89. Technique
• Production of acoustic interface b/w
transducer and tissue:
- Water filled balloon
- Transient filling of esophagus with water
• Radial mechanical blind probe for the
assessment of esophageal strictures

90. Indications
• Carcinoma esophagus
- Initial staging
- EUS guided FNAC of LN’s
- Post RT staging
• Benign tumours
• Esophageal cyst
• Achalasia cardia
• Varices

91. EUS Anatomy

92. Images

93. Ca Esophagus (T staging)

94. Ca Esophagus (N Staging)

95. Ca Esophagus( Hepatic mets)

96. Leiomyoma

97. Foregut Cyst