The forgotten Upper gastrointestinal series. When and how I do it?

Transcription

1 The forgotten Upper gastrointestinal series. When and how I do it? Poster No.: C-0617 Congress: ECR 2015 Type: Educational Exhibit Authors: W. Mnari, K. Bouslama, M. Maatouk, A. Zrig, B. Hmida, R. Salem, M. Golli; Monastir/TN Keywords: Gastrointestinal tract, Fluoroscopy, Barium meal, Diverticula, Inflammation, Cancer DOI: /ecr2015/C-0617 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 33

2 Learning objectives To sort out the current indication of Upper gastrointestinal series. To be able to do a correct semiological analysis of organic and functional upper gastrointestinal disorders. To describe and illustrate the barium swallow features of common upper gastrointestinal diseases. Background Endoscopy and cross section imaging modalities have replaced the barium swallow for the assessment of upper gastrointestinal diseases. However, there remain some situations where barium swallow is indicated. Findings and procedure details Exam procedures Mixing of Barium:Thin or Thick, Determined by the radiologist. Barium must be stirred before use. Patient Preparation: NPO for 8-12 hours, No smoking, No gum chewing Room Preparation: Fluoro set up Spot film cassettes/cameras ready FluoroRoutine : General survey of chest & abdomen, Deglutition observed: Upright, PA/ AP, obliques, Recumbent, Optional: Trendelenburg, Valsalva, Water test. Nomal barium swallow Oesophageal peristaltis Normal (fig.1): Primary contraction: Propels bolus through the esophagus Secondary contraction: Follows primary contraction and propels any remaining bolus from thoracic esophagus Abnormal: Page 2 of 33

3 Tertiary contractions, presbyesophagus: Nonpropulsive contractions Diffuse esophageal spasm Nutcracker esophagus (fig.2) Decreased peristalsis resulting from achalasia, scleroderma, dermatomyositis, polymyositis, esophagitis, and secondary to many other diseases Common pathologic indications Achalasia (fig.3) Primary esophageal motor disorder of unknown etiology. It is due to an insufficient relaxation of the lower esophageal sphincter with loss of esophageal peristalsis. The long term result is the osophageal dilation. Minimal LES opening (" bird-beak "appearance) Megaossophagus is defined traditionally by manometric criteria. Barium swallow findings : uncoordinated, non-propulsive, tertiary contractions; oesophageal body dilatation which is typically maximal in the distal esophagus and pooling or stasis of barium in the oesophagus when the oesophagus has become atonic or non contractile. Chest radiograph may showing an air-fluid level in thoracic oesophagus. Corkscrew esophagus (fig.2) Knowen as diffuse oesophageal spasm. On barium swallow, DOS may appear as a corkscrew or rosary bead oesophagus but this is uncommon. Manometry is the goldstandard diagnostic test. Bezoar: (fig.4 and 5) Mass of undigested material trapped in the stomach. Usually made up of hair, certain vegetable fibers, or wood products. May form an obstruction in the stomach. Specific terms for bezoars include: Trichobezoar, made up of ingested hair; Phytobezoar made up of vegetable fiber or seeds. BS finding: Mass defined as a filling defect within the stomach. The bezoar retains a light coating of barium even after the stomach has emptied most of the barium. Zenker's diverticulum (fig.6) Pharangeal diverticulum may be posterior, lateral or poster lateral. Most commonly encountered type is the posterior pulsion diverticulum. It is an acquired pulsing Page 3 of 33

4 diverticulum through Killian's dehiscence. BS: contrast-filled sac posterior to the cervical oesophagus, which may extend into the mediastinum. Epiphrenic diverticula (fig.7) Arises in the distal of the esophagus, just above diaphragm; Comprising less than 10% of all oesophageal diverticula. Have been reported with numerous manometric abnormalities, namely DOS, nutcracker oesophagus, achalasia and cardiospasm. BS: Large (more than 5 cm) diverticula from the gastro-oesophageal junction. oesophagus stenosis Upper and middle oesophageal strictures most commonly result from Barrett osophagus, mediastinal radiation (fig.8), caustic ingestion (fig.9), congenital oeophageal stenosis Distal oesophageal strictures are caused by gastro-oesophageal reflux (fig.10 and 11). BS findings: Benign strictures typically show smoothly tapering, concentric narrowing. Malignant strictures are characteristically abrupt, asymmetric, eccentric narrowings with irregular, nodular mucosa. Tapered margins may occur with malignant lesions because of the ease of submucosal spread of tumour. Plummer Vincent syndrome Manifestation of severe, long term iron deficiency anaemia, Characterized by dysphagia, iron deficiency anemia and upper esophageal web. Barium study: Indentation on the proximal part of the cervical esophagus. Radiographic study showed the indentations of the proximal esophagus indicating webs (fig.12). Hiatal hernia Herniation of abdominal content through the esophageal hiatus of the diaphragm, seen in 60 % of population over age of 65. Classification recognizes 3 types of hiatal hernia: Sliding hiatal hernia: 95%: cardia and abdominal esophagus herniate into the chest (fig.13). Rolling hiatal hernia: Part of stomach herniate into the chest, cardia in place (fig.14). Mixed hiatal hernia: Both gastro-oesophageal junction and part of stomach herniates into the chest. Gastric tumors Page 4 of 33

5 95% of gastric cancers are adenocarcinomas. The remaining 5% are, sarcomas, GISTs, carcinoids, and squamous cell carcinomas. BS may be helpful in diagnosis of linitis plastica (fig.15), which is more obvious on radiographic study than on endoscopy. Other formes : polypoid mass (fig.16), focal stricture and ulcer. Ulcer bulbar stenosis The duodenal bulb is often deformed by edema and spasm (fig.17), stenosis occure later due to fibrosis (fig.18). Duodenal diverticulum (fig.19) Images for this section: Page 5 of 33

6 Fig. 1: Normal oedophgeal barium swallow. Page 6 of 33

7 Page 7 of 33

8 Page 8 of 33

9 Fig. 2: Image with thin layer of barium showed strong contractions in the esophageal wall. Page 9 of 33

10 Page 10 of 33

11 Fig. 3: Achalasia : dilated osophagus with stenosis of the lower sphincter. Fig. 4: Gastric bezoars. Page 11 of 33

12 Fig. 5: CT scan : Gastric bezears. Page 12 of 33

13 Page 13 of 33

14 Fig. 6: Zenker's diverticulum : Barium swallow study shows a large contrast-filled sac in the cervical oesophagus (arrow). Page 14 of 33

15 Page 15 of 33

16 Fig. 7: BS of a diabetic patient which demonstrates a large epiphrenic diverticulum (large arrow) with air-fluid level (arrow). Page 16 of 33

17 Page 17 of 33

18 Fig. 8: Oesophageal strictures (arrow) resulting from mediastinal irradiation). Page 18 of 33

19 Page 19 of 33

20 Fig. 9: Upper oesophageal stricture resulting from caustic injestion. Page 20 of 33

21 Page 21 of 33

22 Fig. 10: Gastro-oesophageal reflux Page 22 of 33

23 Page 23 of 33

24 Fig. 11: Peptic sticture (arrow) Page 24 of 33

25 Page 25 of 33

26 Fig. 12: Plummer Vincent syndroma Fig. 13: Sliding hiatal hernia (arrow). Page 26 of 33

27 Fig. 14: Rolling hiatal hernia. Page 27 of 33

28 Page 28 of 33

29 Fig. 15: gastric linitis plastica. Fig. 16: Proximal duodenum polypoid tumor. Page 29 of 33

30 Fig. 17: Bulbar ulcer (arrow) with deformity of the bulbo-duodenal truct (large arrow). Page 30 of 33

31 Fig. 18: Post bulbar stenosis. Page 31 of 33

32 Fig. 19: Duodenal diverticulum (arrow). Page 32 of 33

33 Conclusion Fluoroscopic imaging is not the main diagnostic tool for upper gastrointestinal diseases. It may therefore be omitted as an interesting diagnostic tool in some specifics disorders such as uncrossable stenosis, diverticula and functional abnormalities. Personal information References Logemann JA. Role of the modified barium swallow in management of patients with dysphagia. Otolaryngol Head Neck Surg Mar;116(3): Page 33 of 33