Esophagus: Spectrum of pathologies on Barium Swallow

Transcription

1 Esophagus: Spectrum of pathologies on Barium Swallow Poster No.: C-1426 Congress: ECR 2013 Type: Authors: Keywords: DOI: Educational Exhibit E. Dhamija 1, D. Chandan 1, D. Srivastava 2 ; 1 New Delhi/IN, 2 New Delhi, DELHI/IN Pathology, Dynamic swallowing studies, Fluoroscopy, Conventional radiography, Gastrointestinal tract /ecr2013/C-1426 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives Barium Radiology has been largely replaced by newer techniques like endosccopy, manometry,etc. The purpose of this exhibit is to review the role of Barium study/swallow in diagnosing esophageal diseases. To enumerate and illustrate various pathological findings on barium swallow Background Although endoscopy is a valuable test for evaluation of esophageal pathologies, Barium swallow excels over it in evaluation of motility disorders, sub mucosal lesions and extrinsic pathology. Barium study also remains a helpful tool for patients with equivocal or uncertain findings on endoscopy and CT. Normal anatomy: Esophagus Muscular tube cm in length Lined by stratified squamous epithelium Outer longitudinal and inner circular muscle fibers Striated muscle in upper third Smooth muscle in distal 2/3 rd Upper esophageal sphincter At pharyngo esophageal junction Formed primarily by cricopharyngeus Lower esophageal sphincter Defined by manometric evidence of high resting tone or pressure Page 2 of 16

3 Images for this section: Fig. 1: Normal esophageal anatomy Page 3 of 16

4 Fig. 2 Page 4 of 16

5 Imaging findings OR Procedure details Barium swallow is performed using low density Barium when passage of the bolus is monitored under guidance of Flouroscopy. Single and Double contrast imaging are advisable for the study as Double contrast optimizes visualization of mucosa and single contrast optimizes esophageal distension Duplication cyst Location-usually thoracic esophagus Barium swallow shows a large extrinsic impression CECT fluid-attenuating cystic structure Carcinoma esophagus: Terminology-Squamous cell carcinoma and Adenocarcinoma: in Barrett mucosa Imaging Findings- Barium Swallow Best diagnostic clue: Fixed irregular narrowing of lumen Infiltrating, polypoid, ulcerative, varicoid lesions Plaque-like lesions; flat, sessile polyps Asymmetric contour with abrupt proximal borders (shouldering) and narrowed distal segment (rat-tail appearance) Differential Diagnoses-Inflammatory stricture Intramural primary esophageal tumor Esophageal web: Circumferential radiolucent ring Commonly in proximal cervical oesophagus Jet phenomena D/D:Oesophageal stricture /Schatzki ring / Cricopharangeal achalasia Post corrosive stricture: Diffuse long segmental narrowing-thread like /Filiform appearance Non distensible rigid esophagus Extensive ulceration Double Barreled appearance CT-Diffuse esophageal wall thickening> 5 mm Page 5 of 16

6 Target sign, pneumomediastinum, pleural effusion D/D:Reflux oesophagitis,infectious oesophagitis, oesophageal ca Achalasia: Primary oesophageal motility disorder characterized by hypertensive LOS which fails to relax on swallowing. Markedly dilated oesophagus Absent primary peristalsis Bird Beak deformity D/D:Scleroderma,Oesophageal ca, Gastric ca CT - To exclude secondary mass Sliding hernia: Lower oesophageal ring observed 2 cm or more above diaphragmatic hiatus Diverticulum: Barium filled tented or triangular outpouching Tends to empty in collapsed oesophagus D/D:Oesophageal perforation,oesophageal ulcer Epiphrenic diverticulum- These pulsion diverticula are classified by their location near the diaphragm. They can narrow the esophagus or lead to aspiration, if large in size. CMV Esophagitis: Occurs primarily in patients with AIDS. manifest as multiple small ulcers or one or more giant #at ulcers on doublecontrast studies Tertiary Contractions: non-propulsive, transient, and intermittent contractions Inconstant in location Usually in older patients. Images for this section: Page 6 of 16

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8 Fig. 6: Significantly dilated esophagus with abrupt tapering at the level of GE junction Page 8 of 16

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10 Fig. 4: Irregular luminal narrowing with mucosal irregularity involving lower esophagus. Note dilated proximal esophagus and shouldering of the segment proximal to stricture Fig. 3: Barium swallow show extrinsic mass effect on thoracic esophagus. Contrast enhanced CT scan shows presence of well defined cystic mass posterior to esophagus Fig. 5: Radioluncent ring in cervical esophagus Page 10 of 16

11 Fig. 7: Bird beak deformity at the level of lower esophageal sphincter and GE junction Page 11 of 16

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13 Fig. 8: Diverticulum seen as contrast filled outpouching from lower esophagus Page 13 of 16

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15 Fig. 9: Large ephiphrenic diverticulum Fig. 10: Multiple small ulcerations in a HIV positive patient presenting with dysphagia Page 15 of 16

16 Conclusion Barium study in esophageal pathologies still holds its place in evaluation of mucosal disease, submucosal pathologies and motility disorders. It also serves as helping tool in uncertain findings. References 1. Marc S. Levine, MD, Stephen E. Rubesin, MD; Diseases of the Esophagus:Diagnosis with Esophagography; Radiology 2005; 237: Pia Luedtke,BA, Marc S. Levine,MD, Stephen E. Rubesin,MD, Donald S. Weinstein,MD,Igor Laufer,MD; Radiologic Diagnosis of Benign Esophageal Strictures: A Pattern Approach; RadioGraphics 2003; 23: Marc S. Levine,MD, Stephen E. Rubesin,MD, Igor Laufer,MD; Barium Studies in Modern Radiology: Do They Have a Role? Radiology 2009; 250:18-22 Personal Information Page 16 of 16