Canadian Association of Radiologists Journal xx (2017) 1e8

www.carjonline.org

Pediatric Radiology / Radiologie pediatrique

Lower Esophageal Disorders in Childhood Evaluated by Transabdominal

Ultrasound and Fluoroscopy: A Pictorial Essay
Chrysoula Koumanidou, MD, PhDa,*, Marina Vakaki, MD, PhDa, Argyro Mazioti, MD, PhDb,
Efthymia Alexopoulou, MD, PhDb
a
Radiology Department, P & A Kyriakou Children’s Hospital, Athens, Greece
b
2nd Radiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece

Key Words: Esophagus; Fluoroscopy; Pediatric; Ultrasound

Pediatric lower esophageal disorders and diseases are rare
in the pediatric population. The most common include hiatus
hernia, achalasia, duplication cyst, esophageal varices, and
esophagitis. In all these disorders transabdominal sonography
and fluoroscopy are able to provide substantial diagnostic data,
including both morphologic and functional information of the
lower esophagus. The educational objective of this pictorial
essay is to review the technique of esophageal ultrasound and
fluoroscopy, as well as the imaging findings of the commonest
pediatric lower esophageal disorders.
Esophageal Fluoroscopy Technique
Esophageal fluoroscopy is performed after adequate
fasting of the child, with the use of contrast material, most
commonly barium sulfate. The contrast media is delivered by
a baby bottle in infants and small children, or taken from a
cup in older children. The examination begins with the child
in the lateral projection, obtaining images from the naso-
pharynx to the esophagogastric junction as well as the
stomach fundus. Subsequently the child lies supine, to
examine the esophagus in the anteroposterior projection. The
anatomic course, the calibre, the mucosal surface of the
esophagus, and the position of the gastroesophageal junction
should be evaluated. In addition, esophageal peristalsis
should be assessed and possible reflux should be documented
* Address for correspondence: Chrysoula Koumanidou, MD, PhD, Fthio-
tidos 13, Marousi, Athens, 15122, Greece.
E-mail address: argyromazioti@hotmail.com (C. Koumanidou).
(Figures 1 and 2). Further imaging of the remainder of the
stomach and the duodenum is usually performed, which will
not be assessed in this essay. The ALARA (As Low As
Reasonably Achievable) principle should always be applied,
to keep radiation dose low [1].
Esophageal Sonography Technique
The evaluation of the distal esophagus should be per-
formed in quiet and calm infants after giving a weight-related
food amount (milk or chamomile) for filling the stomach
sufficiently. Children should be examined in the supine and
anterior oblique positions, and in some cases in the erect
position. The examination should be performed with a
curvilinear transducer of 5-8 MHz or a linear high frequency
transducer, using the left hepatic lobe as acoustic window
[2,3]. In longitudinal section, the esophagus is revealed as a
tubular structure consisted of 2 hypoechoic peripheral bands,
which represent the muscular layers and a central hyper-
echoic line, which represents the mucosa and collapsed
lumen. In cross-sectional images esophagus appears as a
target with a hypoechoic peripheral ring, which represents its
muscular layer and a hyperechoic centre, the mucosa and
collapsed lumen. Some ultrasound measurements should be
made when necessary, for precise evaluation of esophageal
disorders. Abdominal esophageal length should be measured
at the end of a normal exhalation, from the point at which the
esophagus penetrates the diaphragm, to the base of the
triangular pad of gastric folds at the anterior surface of
the fundus of the stomach. The mean length normally ranges

0846-5371/$ - see front matter Ó 2017 Canadian Association of Radiologists. All rights reserved.
https://doi.org/10.1016/j.carj.2017.10.001
2 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8
Figure 1. Gastroesophageal reflux. Esophageal fluoroscopy in a 2-month-old
boy with recurrent vomiting demonstrates gastroesophageal reflux up to the
intrathoracic esophagus. The gastroesophageal angle is normal (arrow).
from 22.2 mm in newborns to 27.2 mm in 1-year-old infants
and exceeds up to 34 mm in children older than 6 years of
age [2,3] (Figures 3A and 3B). In the same view the
gastroesophageal angle (angle of His) can be measured, be-
tween the abdominal esophagus and the posterior gastric
wall: an angle of 70 -100 is considered normal, whereas
100-130 is obtuse and 130 -180 is completely obtuse
(Figure 4). The total esophageal diameter should be 10 mm
normally, and the esophageal wall thickness (defined as the
total hypoechoic layer and measured on the anterior wall at
the midpoint of the abdominal esophagus) measures from
2.1-5.7 mm, depending on the age of the child [3] (Figure 5).
Imaging Findings
Hiatal Hernia
Hiatal hernia is a herniation of the gastroesophageal
junction and part of the stomach through the esophageal
hiatus of the diaphragm into the mediastinum. There are
3 types of hiatal hernia: sliding hernia, paraesophageal
hernia, and congenital short esophagus [4].
In sliding hernia, a widened hiatus permits upward
movement of the gastroesophageal junction and the cardia of
stomach into the chest. It represents more than 95% of all
hiatal hernias and is often associated with gross gastro-
esophageal reflux [2,4,5].
Figure 2. Gastroesophageal reflux. Esophageal fluoroscopy in a 3-month-old
boy with recurrent vomiting demonstrates gross gastroesophageal reflux up
to the upper esophagus. The esophagus is dilated, with wide opening of its
intra-abdominal part and the gastroesophageal angle is obtuse (thin arrow).
Note the dysplastic ribs on the left hemithorax (thick arrow).
Fluoroscopy can easily demonstrate the sliding hernia,
depicting the gastroesophageal junction located above the
diaphragmatic hiatus (Figure 6).
Sonography, having the advantage of no radiation exposure,
is also a reliable diagnostic tool. It can demonstrate: 1) the
presence of severe GER, 2) a short abdominal esophagus, 3) an
increased gastroesophageal angle of more than 130 , and 4) an
enlarged ‘‘beak’’ at the gastroesophageal junction with a wide
opening of gastroesophageal junction [4,5] (Figure 7). During
real time examination sliding of the stomach fundus towards
the diaphragm is observed [2].
In paraesophageal hernia, part of the stomach herniates
through the esophageal hiatus, whereas the gastroesophageal
junction remains in its normal location [4]. This type of hernia
does not relate to gastroesophageal reflux disease (GERD), and
may present with respiratory tract symptoms and vomiting.
Fluoroscopy can reveal the normal position of gastroesopha-
geal junction and the presence of stomach above the hiatus
(Figure 8). This may also be demonstrated by transabdominal
sonography, after adequate filling of the stomach (Figure 9).
Further imaging is usually not required, although is some
cases esophageal endoscopy is also performed.
Achalasia
The term achalasia is used to describe an abnormal
lower esophageal sphincter relaxation in response to
deglutition [6,7]. Distal esophageal achalasia is a rare
primary motility disorder in the pediatric population, with
an annual incidence of 1 in 100,000 [6,7]. The most
 Esophageal ultrasound and fluoroscopy / Canadian Association of Radiologists Journal xx (2017) 1e8 3

Figure 3. Normal abdominal esophagus. Sonographic longitudinal scan in a 3-month-old girl using the left hepatic lobe as acoustic window. (A) The panel is
not annotated. (B) The normal triangular pad of gastric folds at the anterior surface of the fundus of the stomach is shown (sketch triangle). The esophageal
length is measured from the point at which the esophagus penetrates the diaphragm, to the base of the triangular pad (double arrow).

common clinical symptoms include progressive dysphagia

for solid and liquid food, regurgitation, retrosternal pain,
and weight loss. Esophageal achalasia can be suspected
from a chest x-ray, when an air-filled distended esophagus
is demonstrated.
Imaging findings of achalasia in fluoroscopy include a
dilated proximal esophagus with a ‘‘bird’s beak’’elike
tapering of its lower part or a ‘‘champagne glass’’ appear-
ance, and dilatation of the esophagus above the gastro-
esophageal junction [6,7] (Figure 10). Delayed passage of
the barium and intermittent small spurts through the nar-
rowing lower esophageal sphincter are noted [6,7]. Lack of
esophageal peristalsis is also noted fluoroscopically. It should
be stressed that in the early phase of the disease none of these
signs may be present.
Transabdominal ultrasonography may also be used for the
evaluation of esophageal achalasia. It can reveal the ‘‘bird’s
beak’’ appearance of the lower esophagus, the dilatation of
the distal esophagus with a smooth and symmetric thickening
of the esophageal wall, and the absence of a mass located
near or at the gastric cardia [8,9] (Figure 11). Dilatation of
the distal part of esophagus is best revealed in the erect
position after deglutition of water.
Final diagnosis of achalasia is based on esophageal
manometry.

Duplication Cyst
Figure 4. Normal abdominal esophagus. Sonographic longitudinal scan in
Esophageal duplication cyst is a rare developmental the same 3-month-old girl. The gastroesophageal angle (angle of His) is
anomaly, with an estimated incidence of 1 in 8200 [10]. measured (curved line).
4 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8

Figure 7. Hiatal sliding hernia. Sonographic longitudinal scan in a 20-month-

old girl with recurrent vomiting. The stomach is filled with milk and the
gastric fundus is located above the diaphragm.
Figure 5. Normal abdominal esophagus. Sonographic longitudinal scan in a
2-month-old girl. The stomach is filled with milk (asterisk). The abdominal
esophagus is a tubular structure that consists of 2 hypoechoic peripheral but also provide the final diagnosis by revealing the char-
bands that represent the muscular layers (double arrow) and a central acteristic ‘‘gut signature’’ of gastrointestinal duplication
hyperechoic line that represents the mucosa and collapsed lumen (arrow). cysts. The lesion appears as a cystic mass adjacent to the
abdominal part of esophagus, with an internal appearance
Although usually asymptomatic, they may present with that varies from anechoic to hyperechoic, depending on its
gastrointestinal symptoms due to compression of the
esophagus.
Fluoroscopy may reveal a mass lesion at the lower end of
esophagus. The study can also delineate possible communi-
cation of the cyst with the esophageal lumen (Figure 12).
Transabdominal ultrasound can be very helpful in the
evaluation of these cases, as it can not only depict the lesion,

Figure 8. Hiatal paraesophageal hernia. Esophageal fluoroscopy in a 2.5-

Figure 6. Hiatal sliding hernia. Esophageal fluoroscopy in an 8-month-old year-old boy with recurrent vomiting and weight loss. A portion of the
boy with vomiting. There is herniation of the gastric fundus above the stomach herniates, through the esophageal hiatus, inside the thoracic cavity,
diaphragm, into the thorax (arrow). The gastroesophageal junction is located anterior to the esophagus (short arrow). The gastroesophageal junction re-
above the diaphragm. mains in its normal location (long arrow).
 Esophageal ultrasound and fluoroscopy / Canadian Association of Radiologists Journal xx (2017) 1e8
Figure 9. Hiatal paraesophageal hernia. Sonographic longitudinal scan. The
stomach is filled with milk and herniates into the thorax. The gastroesoph-
ageal junction remains in its normal location, but it cannot be demonstrated,
as the stomach (short arrow) is anterior to the esophagus (long arrow). Its
upper gastrointestinal contrast radiography corresponds to that shown in
Figure 8.
content (infected or hemorrhagic). The characteristic
appearance of the cyst wall (‘‘gut signature’’) enables the
diagnosis by ultrasound: the inner part is hyperechoic (mu-
cosa) and the outer part is hypoechoic (muscular layer)
(Figure 13) [10].
Figure 10. Achalasia. Esophageal fluoroscopy in a 7-year-old boy with
regurgitation and dysphagia for liquid and solid demonstrates the typical
narrowing of the abdominal esophagus with a ‘‘bird-beak’’ appearance
(arrow).
5
Figure 11. Achalasia. Sonographic longitudinal scan in a 10-year-old girl
with dysphagia, vomiting, and abdominal pain. A dilated distal esophagus
with fluid retention is demonstrated (short arrow). There is narrowed ‘‘bird-
beak’’ appearance of esophageal end (long arrow) and thickened esophageal
wall (curved arrow).
Final diagnosis can be based on those examinations,
although in many cases pediatric surgeons require further
imaging with magnetic resonance imaging or computed to-
mography to better appreciate the relevant anatomy.
Figure 12. Esophageal duplication cyst. Esophageal fluoroscopy in a 12-
year-old girl with dysphagia and intermittent abdominal pain. There is
extrinsic smooth compression of the right esophageal wall (arrow).
6 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8

Figure 13. Esophageal duplication cyst. Sonographic longitudinal scan. A

cystic mass is depicted in contact with the anterior wall of the abdominal
esophagus (arrow). The cyst demonstrates internal fluid-fluid level of
different echogenicity. This is the same child as in Figure 12.

Figure 15. Esophageal varices. Esophageal fluoroscopy in a 14-year-old girl

Esophageal Varices with cystic fibrosis demonstrates multiple serpentine filling defects of the
lower esophagus (arrows).
Esophageal varices represent a rare, life-threatening
In this scenario, abdominal ultrasound, together with
complication, mostly secondary to portal hypertension. The
other clinical parameters, may aid the diagnosis. First, vari-
presence of esophageal varices is related to an enlarged left
ces can be clearly depicted as tortuous veins in contact with
gastric vein. Whereas current guidelines for adults recom-
mend performing esophagogastroduodenoscopy in all pa-
tients with portal hypertension to identify patients with
varices who may benefit from prophylactic therapy, a similar
approach is not supported in children. This is due to the
invasiveness of the method and the need of sedation or
general anesthesia in children [11]. Therefore, a noninvasive
test is needed, able to triage children with higher risk of
esophageal varices.

Figure 14. Esophageal and gastric fundus varices. Sonographic longitudinal

scan in a 13-year-old girl with cirrhosis. There are several serpentine
hypoechoic tubular structures (arrow) in the area of the lesser omentum,
which correspond to the gastric varices. Fewer hypoechoic tubular structures
that represent esophageal varices (small arrow) are also demonstrated in the
anatomic position of the gastroesophageal junction. The latest area is not
shown well in this image, as the cursor is slightly rotated.
Figure 16. Bacterial esophagitis. Barium meal in a 6-year-old boy demon-
strates thickened esophageal mucosal folds with stenosis of abdominal
esophagus (arrow) and mucosal erosions at the upper part of esophagus
(thick arrow).
 Esophageal ultrasound and fluoroscopy / Canadian Association of Radiologists Journal xx (2017) 1e8 7

Figure 19. Reflux esophagitis. Transabdominal ultrasound in a 7.5-month-

old boy with stagnation of weight, refusal to eat, and vomiting after
receiving food for the last trimester. The examination was performed to
exclude extraluminal causes of stenosis. An asymmetrically thickened wall
at the level of abdominal esophagus was revealed. Calibres demonstrate
measurement of wall thickness.

of LO thickness to aortic diameter at the same level is

increased in cases of esophageal varices. Considering 1.3 as
the lower limit, the predictive value of the method is 91%
[12]. However, it should be emphasized that not all children
with portal hypertension have a thick LO and that steroid
Figure 17. Eosinophilic esophagitis. Esophageal fluoroscopy in a 16-year-old
girl with dysphagia. The examination is normal.
therapy, obesity, and lymphadenopathy may also affect LO

the abdominal esophagus on longitudinal images (Figure 14).

Other ultrasound markers have also been reported. An
increased thickness of the lesser omentum (LO) has been
correlated with the presence of esophageal varices [12]. LO
thickness should be measured between the left hepatic lobe
and the aorta at the level of celiac axis. In this view, the ratio

Figure 18. Eosinophilic esophagitis. Transabdominal ultrasound in the same Figure 20. Reflux esophagitis. Barium meal in the same boy as in Figure 19.
girl as in Figure 17 demonstrates mild esophageal thickening. Wall thickness An eccentric stenosis at the level of abdominal esophagus is revealed (thick
(measured between calibres) is 0.41 cm. arrow). Further workup of the child revealed reflux esophagitis.
8 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8
thickness. Another proposed reliable marker for the diag-
nosis of esophageal varices in children is the ratio of the
portal vein to body surface [12]. It has been postulated that
the correlation of a ratio of LO thickness to aortic diameter at
the same level between 1.3-1.8 and a ratio of the portal vein
to body surface >12 mm or the presence of portal obstruc-
tion increases the diagnostic predictivity to 100% [12].
Esophageal fluoroscopy is able to detect varices as mul-
tiple serpiginous filling defects, which interrupt the normal
parallel course of the esophageal mucosal folds (Figure 15).
Esophagitis
Types of pediatric esophagitis include infectious, chemi-
cal (resulting from GERD or from the ingestion of corrosive
substances), radiation-induced, or eosinophilic esophagitis.
Diagnosis relies on endoscopy in the majority of cases.
Although barium meal and sonography are usually per-
formed to exclude other causes of the child’s symptoms, they
may sometimes depict abnormal findings.
Infectious esophagitis usually occurs in immunocompro-
mised patients, with Candida representing the most common
pathogen, but bacterial or viral infection may occur. Barium
meal may reveal dysmotility stenotic lesions, thickened
mucosal folds, or ulcers (Figure 16).
Eosinophilic esophagitis is a chronic inflammatory dis-
ease characterized by eosinophilia in the esophageal
epithelium and resistance to proton pump inhibitor treatment.
Barium meal may be normal in the majority of cases
(Figure 17). Abnormal studies may show gastroesophageal
reflux, dysmotility, mucosal irregularity, esophageal rings,
strictures, or filling defects [13]. Transabdominal ultrasound
is not recommended for diagnosis, however, it may show
thickening of esophageal wall (Figure 18). Recent studies
with endoscopic ultrasonography have shown expansion of
the esophageal wall and individual tissue layers [14].
GERD represents one of the commonest disorders of the
gastrointestinal tract in children. According to recent
guidelines, although neither fluoroscopy nor ultrasonography
is recommended as a routine diagnostic tool for GERD, both
methods are useful to rule out other abnormalities that may
cause similar symptoms. In addition, ultrasonography can
provide useful information, morphological and functional,
not available through other techniques, such as the distal
esophageal length, diameter, and wall thickness; gastro-
esophageal angle of His; position of the lower esophageal
sphincter relative to the diaphragm; opening of the gastric
pad; and the passage of gastric content into distal esophagus
[15] (Figures 19 and 20).
Conclusions
Pediatric lower esophageal disorders and diseases are rare
in the pediatric population. Their clinical symptoms are vari-
able and diagnosis is often delayed. For the investigation of the
upper gastrointestinal tract, esophageal fluoroscopy is one of
the first imaging studies required. In addition, ultrasonogra-
phy, having the advantages of being a low-cost and rapid im-
aging method, with no patient discomfort, no radiation
exposure, and no need for patient hospitalization, is also able to
contribute substantially to the diagnostic procedure, as it can
also provide both morphologic and functional information.
This is why radiologists should be familiar with these imaging
techniques as well as the imaging findings of these disorders, to
guide the diagnostic process in a correct and quick manner. In
that way the need for performing more invasive studies (eg,
radionuclide scanning, endoscopy, esophageal manometry, pH
monitoring, endoscopic esophageal sonography) is carefully
evaluated and is some cases may even be omitted or postponed.
References
[1] Imsande HM, Baghdanian A, Setty B, Castro-Aragon I. Pediatric
fluoroscopy - instructions, clinical pearls, and radiation-reduction
techniques. Poster No. C-1399, European Congress of Radiology
2015; March 4e8, 2015; Vienna, Austria.
[2] Koumanidou C, Vakaki M, Pitsoulakis G, et al. Sonographic measure-
ment of the abdominal esophagus length in infancy: a diagnostic tool for
gastroesophageal reflux. AJR Am J Roentgenol 2004;183:801e7.
[3] Savino A, Cecamore C, Matronola MF, et al. US in the diagnosis of
gastroesophageal reflux in children. Pediatr Radiol 2012;42:515e24.
[4] Chavhan GB, Babyn PS, Cohen RA, et al. Multimodality imaging of
the pediatric diaphragm: anatomy and pathologic conditions. Radio-
graphics 2010;30:1797e817.
[5] Cakmakci E, Celebi I, Tahtabasi M, et al. Accuracy of ultrasonography
in the diagnosis of sliding hiatal hernias. Acad Radiol 2013;20:453e6.
[6] Hallal C, Kieling CO, Nunes DL, et al. Diagnosis, misdiagnosis, and
associated diseases of achalasia in children and adolescents: a twelve-
year single center experience. Pediatr Surg Int 2012;28:1211e7.
[7] Zhang Y, Xu CD, Zaouche A, Cai W. Diagnosis and management of
esophageal achalasia in children: analysis of 13 cases. World J Pediatr
2009;5:56e9.
[8] Iacob D, Fufezan O, Farcau D, et al. Clinical and ultrasound approach
to achalasia in a child. Case report. Med Ultrasonogr 2010;12:66e70.
[9] Chuah SK, Hu TH, Wu KL, et al. Sonographic findings in esophageal
achalasia. Chang Gung Med J 2009;32:204e11.
[10] Madhusudhan KS, Seith A, Srinivas M, Gupta AK. Esophageal
duplication cyst causing unilateral hyperinflation of the lung in a
neonate. Acta Radiol 2007;48:588e90.
[11] Gana JC, Turner D, Mieli-Vergani G, et al. A clinical prediction rule
and platelet count predict esophageal varices in children. Gastroen-
terology 2011;141:2009e16.
[12] Giakomo C, Tomasi G, Gatti C, et al. Ultrasonographic prediction of
the presence and severity of Esophageal varices in children. J Pediatr
Gastroenterol Nutr 1989;9:431e5.
[13] Diniz LO, Putnum PE, Towbin AJ. Fluoroscopic findings in pediatric
eosinophilic esophagitis. Pediatr Radiol 2012;42:721e7.
[14] Fox VL, Nurko S, Teitelbaum JE, Badizadegan K, Furuta GT. High-
resolution EUS in children with eosinophilic ‘‘allergic’’ esophagitis.
Gastrointest Endosc 2003;57:30e6.
[15] Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric
gastroesophageal reflux clinical practice guidelines: joint recom-
mendations of the North American Society for Pediatric Gastro-
enterology, Hepatology, and Nutrition (NASPGHAN) and the
European Society for Pediatric Gastroenterology, Hepatology, and
Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009;49:498e
547.