GI Imaging

Densities
X-ray allows visualization of different densities
-Air
-Fat
-Water
-Metal
 Visualization of the Esophagus

Different density required for visualization

i.e.: contrast
 Contrast Agents
Water Soluble
Gastrografin
Low-osmolality

Inert
Barium sulfate
 Single vs. Double Contrast
Improved mucosal visualization
 Fluoroscope
Real-time
x-ray video
Multiple sequential
images
Spot films
 Barium Studies
(Video) Esophogram
Barium Swallow
UGI series
Modified Barium
Swallow
Gastroesophageal
Reflux
 GERD & Barium
Visualization of
refluxing barium
Patient position
Valsalva

Usefulness is
arguable
 GERD Secondary Signs
Hiatal Hernia (HH)
Cricopharyngeus muscle spasm
Reflux esophagitis
Benign stricture
Barretts esophagus
Aspiration pneumonia
 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

 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
Cricopharyngeous Muscle
Spasm
 Reflux Esophagitis
Begins distally
Thickened folds
May have associated
linear ulcers
 Benign Stricture
Distal or mid-esophagus
Smooth walls
May be partially distensible
 Barretts 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)
Barretts Esophagus
 Aspiration Pneumonia
Appearance will vary with amount of
aspirate, patient position, reaction to
aspiration
Often bilateral, associated atalectasis
Posterior and basal areas more common
Aspiration Pneumonia
Aspiration
Esophageal Cancer
 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
 Barium Swallow Patterns
1. Annular constricting
Most common
Many variations
2. Polypoid mass
3. Infiltrative
In submucosa, may simulate benign stricture
4. Ulcerated mass
Esophageal
Cancer
Esophago-
bronchial
fistula
 Tumor Staging
CT most commonly used
Endoscopic ultrasound in some centers
Computed Axial Tomography
Computed Axial Tomography
 CT Staging
Wall thickness
Infiltration of paraesophageal fat planes
Regional invasion (trachea, pleura,
pericardium, vertebrae etc)
Lymphadenopathy
Distant Metastases
Normal CT
Invasive Cancer
 Endoscopic Ultrasound
Smaller lesions
Assess wall involvement
Esophageal Motility
 Normal Motility
Best seen prone
3 phases:
Oral, pharyngeal, esophageal
 Esophageal Phase
Primary wave:
Initiated by swallowing reflex
Secondary Wave:
As response to esophageal distension
Normal Swallow
 Abnormal Motility
Non-specific finding
Seen in reflux esophagitis, radiation injury,
caustic ingestion, myxedema, diabetes
mellitus
 Corkscrew esophagus
Tertiary esophageal waves
Non-propulsive
Corkscrew or beaded
appearance
 Scleroderma
Fibrosis of smooth muscle
Dilated esophagus with widely patent GEJ
Resultant reflux
Reflux esophagitis => ulceration =>
stricture (mild) => Barretts => neoplasm
Scleroderma
 Achalasia
Diffusely decreased or absent peristalsis
Lower esophageal sphincter fails to relax
Smooth, tapered distal esophageal
narrowing
Some passage of food in upright position
Achalasia
 Neuromuscular Disorders
Most common => stroke
Parkinsonism, Alzheimers, multiple
sclerosis, CNS neoplasms, traumatic injury
Modified barium swallow
Zenkers Diverticulum
 Zenkers
Herniation at posterior midline above UES
Horizontal & oblique fibers of inferior
constrictor muscles => Killians dehiscence
Associated incomplete cricopharyngeus
muscle relaxation
Neck at superior aspect of sac
Midline, but lateral extension with growth
Zenkers Diverticulum
Zenkers Diverticulum