Patients with suspected pharyngeal or esophageal disease CLINICAL IMAGING. Barium Esophagography: A Study for All Seasons

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1 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:11 25 CLINICAL IMAGING Barium Esophagography: A Study for All Seasons MARC S. LEVINE, STEPHEN E. RUBESIN, and IGOR LAUFER Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania See editorial on page 6. Although a variety of diagnostic procedures are often performed on patients with pharyngeal or esophageal symptoms, barium esophagography is a noninvasive, inexpensive, and readily available test that can simultaneously evaluate swallowing function, esophageal motility, gastroesophageal reflux, and a host of structural abnormalities in the pharynx and esophagus. This article reviews the role of barium esophagography for assessing swallowing function, morphologic abnormalities of the pharynx (diverticula, webs, and carcinoma), esophageal motility disorders (achalasia and diffuse esophageal spasm), and morphologic abnormalities of the esophagus (reflux esophagitis, Barrett s esophagus, infectious esophagitis, drug-induced esophagitis, eosinophilic esophagitis, Schatzki s ring, and esophageal carcinoma). Patients with suspected pharyngeal or esophageal disease might undergo a variety of diagnostic tests including an ear, nose, and throat examination to evaluate pharyngeal abnormalities, endoscopy to evaluate esophageal abnormalities, manometry to evaluate esophageal motility, and 24-hour ph esophageal monitoring to evaluate acid reflux. In contrast, barium esophagography is a single examination that can simultaneously evaluate swallowing function, esophageal motility, gastroesophageal reflux (GER), and morphologic abnormalities in the pharynx and esophagus. The barium study is therefore a global test that can assess both functional and structural diseases of the pharynx and esophagus. It also is a simple, noninvasive, readily available, and inexpensive procedure that can facilitate selection of other diagnostic tests. This article reviews the role of barium esophagography in current medical practice. Technique The pharyngeal phase of the barium examination includes dynamic recordings (DVD/video) to evaluate oral and pharyngeal function and double-contrast spot images in frontal and lateral projections to evaluate morphologic abnormalities in the pharynx. 1 The esophagus is then evaluated by having the patient ingest high-density barium in an upright position for double-contrast views of the esophagus. 2 The patient is next placed in a prone position and swallows discrete boluses of low-density barium to evaluate esophageal motility. Esophageal dysmotility is present when abnormal peristalsis is detected on 2 or more of 5 separate swallows. 3 The patient then gulps low-density barium to optimally distend the esophagus and rule out rings or strictures that could be missed on doublecontrast radiographs. 2 Finally, various maneuvers are performed to assess for GER. Abnormalities of Swallowing Function Swallowing dysfunction is a common problem in elderly patients with neurologic conditions such as strokes and Parkinson s disease. 4 6 Dynamic recordings enable detection of various signs of swallowing dysfunction such as abnormal tongue movement, pharyngeal muscle dysfunction, laryngeal penetration, and tracheobronchial aspiration. 7 In one study, the risk of developing aspiration pneumonia was directly related to the degree of swallowing dysfunction on pharyngoesophagography; the risk in patients with silent aspiration was nearly 15 times greater that that in patients with normal swallowing. 8 A barium swallow is sometimes performed with the assistance of a speech therapist, an examination also known as a modified barium swallow. 7,9 This study focuses on the oral cavity and pharynx to assess abnormalities of the oral (eg, difficulty propelling bolus) and pharyngeal (eg, tracheal aspiration) phases of swallowing. The patient is given bariums of varying viscosity and items of varying consistency (eg, barium pudding) to assess swallowing of solids or semisolids. Compensatory maneuvers for preventing aspiration or improving motor function can also be assessed. 7,9 Morphologic Abnormalities of the Pharynx Diverticula Zenker s diverticulum is an acquired mucosal herniation through a congenital weakness between the oblique and horizontal fibers of the cricopharyngeus muscle, known as Killian s dehiscence. 10,11 Affected individuals often present with dysphagia or halitosis. Although the pathogenesis is uncertain, it has been postulated that reflux disease causes cricopharyngeal dysfunction, predisposing to the development of a diverticulum. 12,13 Zenker s diverticulum typically appears radio- Abbreviations used in this paper: AIDS, acquired immunodeficiency syndrome; CMV, cytomegalovirus; DES, gastroesophageal reflux; GER, diffuse esophageal spasm; GERD, gastroesophageal reflux disease; HIV, human immunodeficiency virus; LES, lower esophageal sphincter by the AGA Institute /08/$34.00 doi: /j.cgh

2 12 LEVINE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 1 Figure 2. Pharyngeal carcinoma. Lateral view from double-contrast pharyngogram shows an ulcerated lesion (arrows) at the base of the tongue. Biopsy specimens revealed squamous cell carcinoma. graphically as a barium-filled midline sac on frontal views (Figure 1A), with the opening of the sac above a prominent cricopharyngeus and the remainder of the sac coursing inferiorly behind the cervical esophagus on lateral views (Figure 1B). Residual barium in the diverticulum can be regurgitated into the hypopharynx, causing overflow aspiration in some patients. It is important for gastroenterologists to be aware of a Zenker s diverticulum diagnosed on barium studies because of an increased risk of perforation at endoscopy. Webs Cervical esophageal webs are common findings on pharyngoesophagography. 14,15 Although the pathogenesis is uncer- 4 Figure 1. Zenker s diverticulum. (A) Frontal view from double-contrast pharyngogram shows a barium-filled midline sac (arrow). (B) Lateral view shows that the opening of the sac is above a prominent cricopharyngeus (black arrows), with the sac (white arrow) coursing posteriorly and inferiorly behind the cervical esophagus.

3 January 2008 BARIUM ESOPHAGOGRAPHY 13 with mucosal atrophy and fibrosis. Barium studies can reveal a smooth, featureless pharynx with an enlarged, bulbous epiglottis and flattened valleculae (Figure 3). 20,21 This radiation damage can result in severe pharyngeal dysfunction and poor epiglottic tilt with tracheal aspiration (Figure 3). Esophageal Motility Disorders Achalasia Achalasia is defined as primary when it is idiopathic and as secondary when it is caused by other conditions, most commonly malignant tumors. Primary achalasia is characterized by absent esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter (LES), manifested on barium studies by a flaccid, dilated esophagus with tapered, beak-like narrowing at the gastroesophageal junction (Figure 4). 22,23 In advanced disease, the esophagus can become massively dilated and tortuous, producing a sigmoid esophagus. In various studies, it has been shown that 20% 30% of patients with achalasia on barium studies have no evidence of Figure 3. Chronic radiation change involving pharynx. Lateral view from double-contrast pharyngogram shows a smooth, featureless, contracted pharynx. Note how the valleculae are flattened (black arrow). Pharyngeal dysfunction with poor epiglottic tilt resulted in penetration of barium into the larynx (large white arrows) with aspiration of barium into the proximal trachea (small white arrows). tain, many patients are found to have underlying gastroesophageal reflux disease (GERD). 16 Cervical webs typically appear on barium studies as thin folds arising from the anterior wall of the cervical esophagus. These webs occasionally can extend circumferentially, with a deeper shelf on the anterior wall. Most patients are asymptomatic, but some develop dysphagia if the web occludes more than 50% of the lumen. Cervical esophageal webs can not be recognized at endoscopy if the web is ruptured by the advancing endoscope. Pharyngeal Carcinoma In the United States, squamous cell carcinoma of the pharynx and larynx is 5 times more common than squamous cell carcinoma of the esophagus. In patients with pharyngeal cancer, frontal and lateral double-contrast views of the pharynx can reveal that the contour of the involved structure (eg, palatine tonsil, tongue base, epiglottis, vallecula, or piriform sinus) has been disrupted by a mass protruding into the lumen or by an ulcer extending outside the lumen (Figure 2). 13,17 19 Other patients can have plaque-like or circumferentially infiltrating lesions. Patients with pharyngeal or laryngeal carcinoma frequently are treated with radiation therapy. Chronic radiation injury to the pharynx is characterized by vascular/lymphatic damage Figure 4. Primary achalasia. Prone single-contrast esophagogram shows a dilated esophagus with retained debris and beak-like narrowing (arrow) at the gastroesophageal junction caused by incomplete opening of the LES. This degree of esophageal distention usually indicates relatively longstanding disease.

4 14 LEVINE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 1 with chest pain or dysphagia. DES is classically manifested on barium studies by intermittently absent peristalsis with lumenobliterating nonperistaltic contractions that compartmentalize the esophagus, producing a distinctive corkscrew appearance (Figure 6). 22,23,30 In one study, however, lumen-obliterating non- Figure 5. Secondary achalasia. Prone single-contrast esophagogram shows tapered narrowing of the distal esophagus (black arrow), but the narrowed segment is longer than that in the patient with primary achalasia in Figure 4. Also note the plaque-like lesion (white arrow) in the adjacent gastric fundus caused by fundal carcinoma invading the distal esophagus. LES dysfunction on manometry Nevertheless, the dysphagia often resolves after endoscopic or surgical treatment for achalasia. If barium studies reveal typical achalasia, such patients can therefore be treated without need for manometry, avoiding the cost, inconvenience, and discomfort of this procedure. 26 However, manometry can still be required for patients with suspected achalasia who have equivocal or negative barium studies. Secondary achalasia usually results from carcinoma of the gastric cardia or fundus destroying the ganglion cells at the gastroesophageal junction. 27 Although secondary achalasia can resemble primary achalasia, the length of the narrowed segment often is greater than that in primary achalasia and might be nodular or ulcerated because of underlying tumor (Figure 5). 27 The clinical history also is helpful, because primary achalasia tends to occur in younger people with longstanding dysphagia, whereas secondary achalasia tends to occur in older people (older than age 60 years) with recent onset of dysphagia (less than 6 months) and weight loss. 28 As a result, these conditions can usually be differentiated on the basis of the clinical and radiographic findings without need for endoscopy. Diffuse Esophageal Spasm Diffuse esophageal spasm (DES) is an esophageal motility disorder characterized by intermittently abnormal peristalsis with multiple, simultaneous nonperistaltic contractions. 29 Patients with DES can be asymptomatic or can present Figure 6. DES. Upright double-contrast esophagogram shows multiple severe, lumen-obliterating nonperistaltic contractions, producing a classic corkscrew appearance.

5 January 2008 BARIUM ESOPHAGOGRAPHY 15 Morphologic Abnormalities of the Esophagus Gastroesophageal Reflux Disease In the past, barium studies have been advocated for patients with reflux symptoms primarily to document the presence of a hiatal hernia or GER, to detect complications such as deep ulcers or strictures, and to rule out other organic or motor abnormalities in the esophagus. By permitting a more detailed assessment of the esophageal mucosa, however, double-contrast radiographic techniques have made it possible to detect superficial ulceration and other changes of mild or moderate esophagitis before the development of deep ulcers or strictures. Double-contrast esophagography is also a useful screening examination for Barrett s esophagus to determine the relative need for endoscopy and biopsy in these patients. With doublecontrast techniques, barium studies therefore have a major role in the evaluation of patients with known or suspected GERD. Figure 7. DES with LES dysfunction. Prone single-contrast esophagogram shows moderately severe nonperistaltic contractions (large white arrows) with tapered narrowing of the distal esophagus (small white arrow) caused by incomplete opening of the LES. Also note the small hiatal hernia (black arrows) in this patient. peristaltic contractions were detected on barium studies in less than 15% of patients with DES. 31 Instead, most patients had nonperistaltic contractions of varying magnitude that did not obliterate the lumen. This study also found that two thirds of patients with DES had impaired opening of the LES, manifested by the beak-like distal esophageal narrowing typically associated with achalasia. 31 It therefore should be recognized that DES is often characterized on barium studies by LES dysfunction with nonperistaltic contractions of varying severity rather than a classic corkscrew appearance (Figure 7). Figure 8. Reflux esophagitis. Upright double-contrast esophagogram shows extensive granularity of the mucosa in the lower third of the thoracic esophagus caused by mucosal edema and inflammation.

6 16 LEVINE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 1 (Figure 11). Occasionally, scarring from reflux esophagitis can also lead to longitudinal shortening of the esophagus and the development of fixed transverse folds, producing a characteristic stepladder appearance (Figure 11). 39 Some gastroenterologists believe that endoscopy and biopsy are required to rule out malignant tumor in all patients with radiographically diagnosed peptic strictures because of diffi- Figure 9. Reflux esophagitis. Upright double-contrast esophagogram shows a small linear ulcer (arrow) in the distal esophagus near the gastroesophageal junction. Reflux esophagitis. Double-contrast esophagography has a sensitivity approaching 90% for the diagnosis of reflux esophagitis because of the ability to detect mucosal disease that cannot be visualized on single-contrast studies. 32,33 Early reflux esophagitis can be manifested by a finely nodular or granular appearance with poorly defined radiolucencies as a result of mucosal inflammation and edema (Figure 8). 34,35 In more advanced disease, small ulcers and erosions can be seen in the distal esophagus. 36 Other patients can have a solitary ulcer at or near the gastroesophageal junction (Figure 9), often on the posterior esophageal wall. 37 It has been postulated that the location of these ulcers is related to prolonged exposure to refluxed acid that pools posteriorly when patients sleep in the supine position. 37 Scarring and strictures. Scarring from reflux esophagitis can lead to the development of reflux-induced (peptic) strictures in the distal esophagus, almost always above a hiatal hernia. 36,38 These strictures usually appear as smooth, tapered areas of narrowing (Figure 10), but asymmetric scarring can lead to eccentric narrowing with focal sacculation of the wall Figure 10. Peptic stricture. Upright double-contrast esophagogram shows a smooth, tapered stricture (arrows) in the distal esophagus above a hiatal hernia. This appearance is characteristic of a refluxinduced stricture.

7 January 2008 BARIUM ESOPHAGOGRAPHY 17 Figure 11. Scarring from reflux esophagitis. Upright double-contrast esophagogram shows mild narrowing of the distal esophagus with sacculations (white arrows) and fixed transverse folds (black arrows), producing a stepladder appearance. culty differentiating benign peptic strictures from infiltrating esophageal carcinomas on esophagography In a large retrospective study, however, no patients with unequivocally benign-appearing peptic strictures in the distal esophagus on double-contrast esophagograms were found to have malignant tumor on endoscopy, 43 so endoscopy is not necessary to rule out esophageal cancer in these patients. If the strictures are irregular or nodular or have more abrupt proximal or distal margins, however, endoscopy and biopsy should be performed to rule out malignant tumor, particularly an adenocarcinoma arising in Barrett s esophagus. Barrett s esophagus. The classic radiologic signs of Barrett s esophagus consist of a high stricture or ulcer at a discrete distance from the gastroesophageal junction (Figure 12). 44 In the presence of a hernia or reflux, these findings should be highly suggestive of Barrett s esophagus. A distinctive reticular pattern of the mucosa has also been recognized as a specific Figure 12. Barrett s esophagus with a midesophageal stricture. Upright double-contrast esophagogram shows a moderately long stricture in the midesophagus. This patient also had a hiatal hernia and gastroesophageal reflux at fluoroscopy.

8 18 LEVINE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 1 condition. 47 Conversely, less than 1% of patients classified as low risk for Barrett s esophagus because of the absence of esophagitis or strictures were found to have this condition. 47 Other investigators have also found morphologic evidence of reflux esophagitis and/or peptic strictures on double-contrast esophagograms in 97% of all patients with long-segment Barrett s esophagus. 46 Thus, esophagitis or peptic scarring severe enough to cause Barrett s esophagus can almost always be detected on technically adequate double-contrast examinations. On the basis of such data, it seems reasonable to conclude that patients who are found to be at high risk for Barrett s esophagus on double-contrast esophagograms because of a midesophageal stricture or ulcer or a reticular mucosal pattern should undergo endoscopy and biopsy for a definitive diagnosis. A larger group of patients are found to be at moderate risk for Barrett s esophagus because of reflux esophagitis or peptic Figure 13. Barrett s esophagus with a reticular pattern. Upright double-contrast esophagogram shows a distinctive reticular pattern (arrows) in the distal esophagus caused by biopsy-proven Barrett s esophagus. sign of Barrett s esophagus (Figure 13), particularly if adjacent to a midesophageal stricture. 45 However, the classic radiologic signs of Barrett s esophagus (ie, a high esophageal stricture, ulcer, or reticular pattern) are found in only 5% 10% of all patients with this condition. 44,45 Other more common findings in Barrett s esophagus, such as reflux esophagitis and peptic strictures, are often present in patients with uncomplicated reflux disease. 46 Thus, those findings that are more specific for Barrett s esophagus are not sensitive, and those findings that are more sensitive are not specific. In 1988, Gilchrist et al 47 introduced a novel approach for the diagnosis of Barrett s esophagus on double-contrast esophagography by stratifying patients on the basis of the following radiologic criteria: patients were classified as high risk for Barrett s esophagus if double-contrast images revealed a high stricture or ulcer or a reticular mucosal pattern, patients were classified as moderate risk if the images revealed a distal stricture or reflux esophagitis, and patients were classified as low risk if the images revealed a normal-appearing esophagus. The vast majority of patients classified as high risk, and approximately 15% classified as moderate risk for Barrett s esophagus on double-contrast esophagograms were found to have this Figure 14. Candida esophagitis with plaques. Upright double-contrast esophagogram shows multiple small, linear plaques in the mid and distal esophagus.

9 January 2008 BARIUM ESOPHAGOGRAPHY 19 Infectious Esophagitis Candida esophagitis. Candida esophagitis is usually an opportunistic infection in immunocompromised patients, but it is also caused by local esophageal stasis as a result of severe esophageal motility disorders such as achalasia and scleroderma. 48 Double-contrast esophagography has a sensitivity of 90% in detecting esophageal candidiasis in relation to endoscopy. 49,50 Candida esophagitis is typically manifested on double-contrast studies by discrete, linear, plaque-like lesions separated by normal intervening mucosa (Figure 14). 49 During the past 2 decades, a much more fulminant form of candidiasis has been encountered in patients with acquired immune deficiency syndrome (AIDS), who can present with a grossly irregular or Figure 15. Advanced Candida esophagitis. Upright double-contrast esophagogram shows a grossly irregular or so-called shaggy esophagus caused by innumerable coalescent plaques and pseudomembranes. This patient had AIDS. strictures in the distal esophagus, so clinical judgment should be used regarding the decision for endoscopy in this group on the basis of the severity of symptoms, age, and overall health of the patients (ie, whether they are reasonable candidates for endoscopic surveillance). However, most patients are found to be at low risk for Barrett s esophagus because of the absence of esophagitis or strictures, and the risk of Barrett s esophagus is so low in this group that endoscopy does not appear to be warranted. Thus, the major value of double-contrast esophagography is its ability to separate patients into these various risk groups for Barrett s esophagus to determine the relative need for endoscopy and biopsy. 47 Figure 16. Herpes esophagitis. Upright double-contrast espophagogram shows multiple pinpoint ulcers in the midesophagus in an otherwise healthy patient with herpes esophagitis.

10 20 LEVINE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 1 Figure 17. CMV esophagitis. Upright double-contrast esophagogram shows a large, flat ulcer (arrows) on the left anterolateral wall of the midesophagus caused by proven CMV infection. This patient had AIDS. shaggy esophagus caused by innumerable coalescent plaques and pseudomembranes, with trapping of barium between the lesions (Figure 15). 51 Some of the plaques can eventually slough, producing 1 or more deep ulcers superimposed on a background of diffuse plaque formation. When barium studies reveal typical findings of Candida esophagitis, these patients can be treated without need for endoscopy. Herpes esophagitis. Herpes esophagitis is typically manifested on double-contrast esophagography by small, discrete ulcers on a normal background mucosa. 52,53 Because ulcers in Candida esophagitis are associated with diffuse plaque formation, the presence of small ulcers without plaques should suggest herpes esophagitis in immunocompromised patients with odynophagia. Nevertheless, this condition occasionally can develop as an acute self-limited disease in otherwise healthy patients with innumerable punctate ulcers in the esophagus (Figure 16). 54 The ulcers are even smaller than those in immunocompromised patients with herpes esophagitis, presumably because these people have an intact immune system that prevents the ulcers from enlarging. Af- Figure 18. HIV esophagitis. Upright double-contrast esophagogram shows a giant, flat ulcer (black arrows) in the midesophagus with a cluster of small satellite ulcers superiorly (white arrows). Endoscopic brushings, biopsies specimens, and cultures were negative for CMV, and the patient responded to treatment with oral steroids.

11 January 2008 BARIUM ESOPHAGOGRAPHY 21 fected individuals typically have a flu-like prodrome for 7 10 days before the sudden onset of severe odynophagia. 54 As a result, the diagnosis of herpes esophagitis in healthy patients can often be suggested on the basis of the clinical and radiographic findings without need for endoscopy. Cytomegalovirus esophagitis. Cytomegalovirus (CMV) esophagitis only occurs in patients with AIDS. CMV esophagitis can be manifested on double-contrast studies by giant, flat ulcers that are 1 or more centimeters in length (Figure 17). 55 Because herpetic ulcers rarely become this large, 1 or more giant ulcers should suggest CMV esophagitis in patients with AIDS. However, the differential diagnosis also includes giant human immunodeficiency virus (HIV) ulcers in the esophagus. Because CMV esophagitis is treated with toxic antiviral agents such as ganciclovir, endoscopy is required to confirm the presence of CMV before treating these patients. Human immunodeficiency virus esophagitis. HIV infection of the esophagus can lead to the development of giant ulcers indistinguishable from those caused by CMV. Doublecontrast studies typically reveal giant ovoid or diamond-shaped Figure 19. Drug-induced esophagitis. Upright double-contrast esophagogram shows a moderately large, flat ulcer (white arrow) in the midesophagus with adjacent small ulcers (black arrows) caused by ibuprofen ingestion. Figure 20. Eosinophilic esophagitis. Prone single-contrast esophagogram shows a mild stricture in the midesophagus with distinctive ringlike indentations (arrows) in the region of the stricture. This patient had longstanding dysphagia and an atopic history. (Reproduced from Zimmerman SL, Levine MS, Rubesin SE, et al. Idiopathic eosinophilic esophagitis in adults: the ringed esophagus. Radiology 2005;236: with permission of publisher.)

12 22 LEVINE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 1 superficial ulcers indistinguishable from those in herpes esophagitis, 61,62 whereas other medications can cause more severe injury with small or large ulcers (Figure 19) and strictures Eosinophilic Esophagitis Eosinophilic esophagitis usually occurs in young men with longstanding dysphagia and occasional superimposed food impactions. These patients often have an atopic history and/or peripheral eosinophilia. Barium studies can reveal an esophageal stricture containing multiple distinctive ring-like indentations, also known as a ringed esophagus (Figure 20). 67 The diagnosis can be confirmed by the presence of a dense infiltrate of eosinophils on biopsy specimens from the esophagus. Affected individuals can respond to treatment with steroids, particularly inhaled preparations. Schatzki s Ring The term Schatzki s ring is reserved for patients with rings who present with dysphagia. The rings typically appear on barium studies as 2 3 mm in height, symmetric, circumferential constrictions (usually less than 13 mm in diameter) Figure 21. Schatzki s ring. Prone single-contrast esophagogram shows a smooth, symmetric, ring-like constriction (arrow) at the gastroesophageal junction above a small hiatal hernia. This appearance is characteristic of a Schatzki s ring. ulcers surrounded by a radiolucent rim of edema (Figure 18). 56,57 HIV esophagitis is a diagnosis of exclusion, so endoscopic biopsy specimens, brushings, or cultures are required to rule out CMV as the cause of the ulcers. Unlike CMV ulcers, HIV esophageal ulcers can heal dramatically on treatment with steroids. 56,57 Endoscopy is therefore required in HIV-positive patients with giant esophageal ulcers to differentiate HIV and CMV, so appropriate therapy can be instituted. Drug-Induced Esophagitis Tetracycline and doxycycline are the 2 agents most commonly responsible for drug-induced esophagitis in the United States, but other offending medications include potassium chloride, quinidine, alendronate, and aspirin or other nonsteroidal anti-inflammatory drugs Affected individuals typically ingest the medications with little or no water before going to bed. The pills become lodged in the midesophagus, where it is compressed by the adjacent aortic arch or left main bronchus. Prolonged contact of the esophageal mucosa with the pills presumably causes an irritant contact esophagitis. The radiographic findings in drug-induced esophagitis depend on the nature of the offending medication. Tetracycline and doxycycline injury can be manifested by small, Figure 22. Superficial spreading carcinoma. Upright double-contrast esophagogram shows a confluent area of nodularity in the midesophagus caused by mucosal spread of tumor.

13 January 2008 BARIUM ESOPHAGOGRAPHY 23 technique for diagnosing Schatzki s rings, occasionally detecting rings that are missed at endoscopy. 69 Esophageal Carcinoma About 50% of esophageal cancers are squamous cell carcinomas, and the remaining 50% are adenocarcinomas arising in Barrett s esophagus. Double-contrast esophagography has a sensitivity of greater than 95% in detecting esophageal cancer, 70 a figure comparable to the reported endoscopic sensitivity of 95% 100%. 71 Early esophageal cancers can be manifested on double-contrast studies by small protruded or plaque-like lesions or by focal irregularity of the wall. 67 In contrast, superficial spreading carcinomas are manifested by poorly defined nodules or plaques, producing a confluent area of disease (Figure 22). 72 Endoscopy and biopsy should be performed for a definitive diagnosis when early or superficial cancers are suspected on barium studies, because early esophageal cancer is associated with 5-year survival rates of greater than 95%. 71 Advanced esophageal carcinomas usually appear on barium studies as infiltrating, polypoid, or ulcerative lesions (Figure 23). 71,73 Squamous cell carcinomas and adenocarcinomas cannot be reliably differentiated on esophagography. However, squamous cell carcinomas tend to involve the upper or midesophagus, whereas adenocarcinomas tend to involve the distal esophagus and have a marked tendency to invade the gastric cardia and fundus, comprising as many as 50% of all malignant tumors at the gastroesophageal junction. 71,74,75 Figure 23. Polypoid, ulcerated carcinoma. Upright double-contrast esophagogram shows a long meniscoid ulcer (white arrows) surrounded by a thick, irregular rind of tumor (black arrows) in the midesophagus. at the gastroesophageal junction above a hiatal hernia (Figure 21). 68 The rings can be missed if the distal esophagus is not adequately distended, so prone views must be obtained during continuous drinking of low-density barium to visualize these structures. Barium esophagography is a sensitive References 1. Rubesin SE. Pharynx: normal anatomy and examination techniques. In: Gore RM, Levine MS, Laufer I, eds. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: WB Saunders, 2000: Levine MS, Rubesin SE, Herlinger H, et al. Double-contrast upper gastrointestinal examination: technique and interpretation. Radiology 1988;168: Ott DJ, Chen YM, Hewson EG, et al. Esophageal motility: assessment with synchronous video tape fluoroscopy and manometry. Radiology 1989;173: Buchholz DW. Neurologic causes of dysphagia. Dysphagia 1987; 1: Robbins J, Levine RL. Swallowing after unilateral stroke of the cerebral cortex: preliminary evidence. Dysphagia 1988;3: Leopold NA, Kagel MC. Pharyngo-esophageal dysphagia in Parkinson s disease. Dysphagia 1997;12: Jones B. Functional abnormalities of the pharynx. In: Gore RM, Levine MS, eds. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: WB Saunders, 2000: Picus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. AJR 2003;180: Rubesin SE, Stiles TD. Principles of performing a modified barium swallow examination. In: Balfe DM, Levine MS, eds. Categorical course in diagnostic radiology: gastrointestinal. Oak Brook, IL: RSNA Publications, 1997: Frieling T, Berges W, Lubke HJ, et al. Upper esophageal sphincter function in patients with Zenker s diverticulum. Dysphagia 1988; 3: Knuff TE, Benjamin SB, Castell DO. Pharyngoesophageal (Zenker s) diverticulum: a reappraisal. Gastroenterology 1982;82:

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15 January 2008 BARIUM ESOPHAGOGRAPHY 25 nonsteroidal antiinflammatory medication. South Med J 1986;79: de Groen PC, Lubbe DF, Hirsch LJ, et al. Esophagitis associated with the use of alendronate. N Engl J Med 1996;335: Creteur V, Laufer I, Kressel HY, et al. Drug-induced esophagitis detected by double contrast radiography. Radiology 1983;147: Bova JG, Dutton NE, Goldstein HM, et al. Medication-induced esophagitis: diagnosis by double-contrast esophagography. AJR 1987;148: Teplick JG, Teplick SK, Ominsky SH, et al. Esophagitis caused by oral medication. Radiology 1980;134: Levine MS, Rothstein RD, Laufer I. Giant esophageal ulcer due to Clinoril. AJR 1991;156: Levine MS, Borislow SM, Rubesin SE, et al. Esophageal stricture caused by a Motrin tablet (ibuprofen). Abdom Imaging 1994;19: Ryan JM, Kelsey P, Ryan BM, et al. Alendronate-induced esophagitis: case report of a recently recognized form of severe esophagitis with esophageal stricture radiographic features. AJR 1998;206: Zimmerman SL, Levine MS, Rubesin SE, et al. Idiopathic eosinophilic esophagitis in adults: the ringed esophagus. Radiology 2005;236: Schatzki RE. The lower esophageal ring: long term follow-up of symptomatic and asymptomatic rings. AJR 1963;90: Ott DJ, Chen YM, Wu WC, et al. Radiographic and endoscopic sensitivity in detecting lower esophageal mucosal ring. AJR 1986;147: Levine MS, Chu P, Furth EE, et al. Carcinoma of the esophagus and esophagogastric junction: sensitivity of radiographic diagnosis. AJR 1997;168: Levine MS, Halvorsen RA. Carcinoma of the esophagus. In: Gore RM, Levine MS, eds. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: WB Saunders, 2000: Levine MS, Dillon EC, Saul SH, et al. Early esophageal cancer. AJR 1986;146: Gloyna RE, Zornoza J, Goldstein HM. Primary ulcerative carcinoma of the esophagus. AJR 1977;129: Levine MS, Caroline D, Thompson JJ, et al. Adenocarcinoma of the esophagus: relationship to Barrett mucosa. Radiology 1984; 150: Keen SJ, Dodd GD, Smith JL. Adenocarcinoma arising in Barrett s esophagus: pathologic and radiologic features. Mt Sinai J Med 1984;51: Address requests for reprints to: Marc S. Levine, MD, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA marc.levine@uphs.upenn.edu; fax: Drs Levine and Rubesin are consultants for E-Z-EM Company.