Barium esophagogram as the first step to modern tecniques

Transcription

1 Barium esophagogram as the first step to modern tecniques Poster No.: C-0603 Congress: ECR 2014 Type: Educational Exhibit Authors: R. Morcillo, V. Rodriguez Laval, L. M. Cruz Hernandez, M. Hernandez Guilabert, L. Garcia Sanz; Toledo/ES Keywords: Dynamic swallowing studies, Diagnostic procedure, Barium meal, Plain radiographic studies, CT, Fluoroscopy, Anatomy, Gastrointestinal tract, Contrast agents, Motility, Pathology, Swallowing disorders DOI: /ecr2014/C-0603 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 55

2 Learning objectives The aim of this exhibit is to: illustrate the normal anatomy and most common anomalies and diseases of the esophagus obtained with barium esophagogram; demonstrate that barium studies are still the gold standard for the diagnosis of many esophageal pathologies. Background The role of barium studies has been progressively declining in modern radiology practice, in contrast to the use of endoscopy and advanced cross-sectional imaging modalities. Barium esophagogram is still a valuable diagnostic test for evaluating structural and functional abnormalities of the esophagus. It is essential for assessing motility disorders such as achalasia and diffuse esophageal spasm and for evaluating submucosal and extrinsic mass lesions. It is a safe, inexpensive, and cost-effective diagnostic test and it is also a hepful tool for clarifying uncertain findings on endoscopy and CT. However, barium studies are very operator dependent. The performance and interpretation of these tests require highly experienced radiologists. Anatomy and terminology: Esophagus: is a fibromuscular tube of cm in length which runs behind the trachea (and left main bronchus) and heart (left atrium), in front of the spine and to the right of the descending thoracic aorta. Just before entering the stomach, the esophagus passes through the diaphragm. This organ is located in the posterior mediastinum and it is formed by non-keratinized stratified squamous epithelium and outer longitudinal and inner circular muscle fibers (striated muscle in upper third and smooth muscle in distal two thirds). Upper esophageal sphincter (UES): represents the pharyngoesophageal junction and it's formed primarily by cricopharyngeal muscle. Lower esophageal sphincter (LES): synonymous with phrenic ampulla and esophageal vestibule. It's between the esophageal "A" and "B"rings. Page 2 of 55

3 "A" or muscular ring: indentation of esophageal lumen that represents the tubulo-vestibular junction. "B" or mucosal ring: indentation that marks the esophagogastric junction Z-line: corresponding to the mucosal junction between squamous and columnar epithelium. Barium studies show the esophagogastric junction with the structures mentioned above (Fig. 1 on page 3 and Fig. 2 on page 4). Phrenic ampulla is best demonstrated with retention of breath in inspiration or a Valsalva maneuver by increase intraabdominal pressure. Do not mistake this for a hiatal hernia; presence of "B" ring > 2 cm above the diaphragmatic hiatus is diagnostic for hiatal hernia (Fig. 2 on page 4). Barium esophagogram shows the normal mucosal folds like longitudinal, thin, parallela and uniform (Fig. 3 on page 5). These folds should be differentiated from the "feline" esophagus: thin transverse striations due to transient and insignificant muscularis mucosae contractions in patients with gastroesophageal reflux, peptic esophagitis or hiatal hernia (Fig. 4 on page 7). Images for this section: Page 3 of 55

4 Fig. 1: Barium esophagogram shows tubular esophagus (orange arrow), esophageal vestibular (yellow arrow), "A" ring (red arrows) and "B" ring (blue arrows). Page 4 of 55

5 Fig. 2: Esophagogram reveals tubular esophagus (orange arrow), esophageal vestibular (yellow arrow), "A" ring (red arrow) and "B" ring (blue arrow). Esophagogastric junction >2cm above esophageal hiatus is diagnostic for hiatal hernial (white asterisk). Page 5 of 55

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7 Fig. 3: Barium esophagogram reveals longitudinal, thin, parallela and uniform folds (yellow arrows). Fig. 4: Barium studies (A, B) show the "feline" esophagus with thin transverse striations due to muscularis mucosae contractions. Page 7 of 55

8 Findings and procedure details In this article, we review imaging findings of esophageal anomalies and pathologies with barium studies. Impressions 1- Physiological: are three normal extrinsic impressions: aortic arch, left main bronchus and heart (Fig. 5 on page 13). 2- Vascular: Aberrant right subclavian artery (ARSA): This is the most common thoracic arterial anomaly (0,5-1% of all individuals). The artery is the last branch of a four branch vessel aortic arch and extends up and to the right producing a dorsal diagonal impression on the esophagus (Fig. 6 on page 15). Rarely causes symptoms, but compression by ARSA on the posterior esophagus may occasionally cause "dysphagia lusoria". Right aortic arch: leftward displacement of barium column on esophagogram (Fig. 7 on page 15). Double aortic arch: the arches impressing the esophagus at different levels: right arch typically higher and larger than left arch (Fig. 8 on page 15). Right aortic arch with aberrant left subclavian artery: right aortic arch that originates leftward displacement of barium column on esophagogram and aberrant left subclavian artery that produces a dorsal indentation on lateral view (Fig. 9 on page 16). Aberrant left subclavian artery arises low the aortic arch and extends to left dorsal to esophagus and trachea. It's most often an incidental finding, but dilated subclavian artery (diverticulum of Kommerell) may cause esophageal compression. Uphill esophageal varices: Serpentine, tortuous and longitudinal filling defects confined in the distal half of the thoracic portion of the esophagus and they are characterized by change in appearance during the inspiration or Valsalva maneuver (Fig. 10 on page 17). Uphill varices are usually caused by portal hypertension with reversed flow (hepatofugal) through dilated esophageal collateral vessels to the superior vena cava. Page 8 of 55

9 3- Extrinsic: the most frequent causes are by cardiomegaly with left atrial enlargement (Fig. 11 on page 18) and by multinodular goiter with intrathoracic extension (Fig. 12 on page 19). Indentations 1- Esophageal web: is a thin mucosal band projecting into lumen most frequently in anterior wall of proximal cervical esophagus (Fig. 13 on page 20). Webs are more common in females and rarely causes symptoms, but they develop dysphagia if > 50% luminal narrowing. Webs may be congenital or acquired most frequently due to sequela of inflammation or scarring. They can be associated with Plummer-Vinson (PatersonKelly) syndrome (which increases risk of carcinoma), iron deficiency anemia, chronic gastroesophageal reflux, eosinophilic esophagitis, pemphigoid benign or epidermolysis bullosa. Treatment is often with balloon dilations. 2- Cricopharyngeal achalasia: is afailure of cricopharyngeal muscle (UES) relaxation due to hypertrophy or spasm at the pharyngo-esophageal junction. In barium studies, cricopharyngeal achalasia represents an intermittent indentation on the posterior lumen at the pharyngo-esophageal junction (at the C5-C6 level) with swallowing (Fig. 14 on page 21). This disorder can be associated with gastroesophageal reflux or motility disorders. 3- Large anterior cervical osteophytes: persistent indentation on pharyngoesophageal junction simulating cricopharyngeal achalasia (Fig. 15 on page 23). Cricopharyngeal achalasia and cervical osteophytes can coexit and we must know differentiate them (Fig. 16 on page 25). 4- Schatzki ring: appears as a smooth, symmetric, thin, nondistensible and transverse ringlike constriction at the gastroesophageal junction or "B" ring above a hiatal hernia (Fig. 17 on page 27). This annular narrowing can be associated with gastroesophageal reflux and peptic esophagitis and it may cause episodic dysphagia if ring <13mm in diameter. Schatzki ring is best evaluated in prone right anterior oblique (RAO) during deep inspiration with valsalva maneuver while barium column passes through GE junction. 5- Muscular or contractile or "A" ring: appears as an active muscular contraction at the tubulo-vestibular junction that varies in size and position due to esophageal contraction Page 9 of 55

10 (Fig. 18 on page 29). This narrowing could be mistaken for Schatzki ring (Fig. 19 on page 31). Diverticula 1- Pulsion diverticulum: More common. Due to increased intraluminal pressure. Saccular outpouching with narrow neck. Proximal, mid or distal esophagus. Mucosal and submucosal herniation through muscularis propria with lack of muscle: pseudodiverticulum. Often associated with motility disorders. Tend to fill after swallowing. More common types: Zenker diverticulum: is a pulsion diverticulum in midline posterior wall of pharyngoesophageal junction just above cricopharyngeus muscle at C5-C6 level (Killian's dehiscence). The esophagram shows a barium-filled sac posterior to cervical esophagus that may protrude laterally to left and compress esophagus (Fig. 20 on page 32). Almost all patients have associated hiatal hernia and many of them have gastroesophageal reflux and peptic esophagitis or motility disorders. The clinical presentation can be dysphagia, regurgitation, aspiration, halitosis or a mass or air-fluid level on chest radiographs. It is important to know that the diverticulum can result in carcinoma (seen in 0.3% of cases). Epiphrenic diverticulum: is a pulsion diverticulum with protrusion saclike in distal esophagus just above diaphragm. Barium study shows large barium-filled sac in epiphrenic area more common in right side (Fig. 21 on page 32). This diverticulum often is associated with achalasia or hiatal hernia. Midesophageal diverticula: frequently multiple of varied sizes with smooth and rounded contours. Diverticula are seen as transient outpouchings that develop only during peristalsis, usually associated with diffuse esophageal spasm (Fig. 22 on page 33). 2- Traction diverticulum: Less common. Page 10 of 55

11 Due to fibrosis and scarring in periesophageal tissues (Fig. 23 on page 35). Usually have no neck. Tented or triangular configuration. Mid esophagus. Herniation of all layers (mucosa, submucosa & muscularis propria): true diverticulum. Tend to empty after swallowing. Often associated with pulmonary tuberculosis, histoplasmosis and sarcoidosis. Motility disorders 1- Presbyesophagus: is an esophageal motility dysfunction associated with aging. There are non-peristaltic contractions (tertiary contractions): non-propulsive, transient, simultaneous and intermittent contractions (Fig. 24 on page 35). 2- Achalasia: is a primary esophageal motility disorder characterized by absence of primary peristalsis in the esophagus and incomplete or absent relaxation of LES with swallowing. Malignant tumor involving the gastroesophageal junction (especially carcinoma of the gastric cardia) may result in secondary achalasia. Barium studies show a dilated esophagus with a smooth and tapered beaklike narrowing of the distal esophagus just above the gastroesophageal junction (Fig. 25 on page 36). In advanced disease, the esophagus can be massively dilated and tortuous ("sigmoid" esophagus) (Fig. 26 on page 37). 3- Diffuse esophageal spasm: is a non-cardiac cause of chest pain characterized by simultaneous, intermittent and non-peristaltic contractions of the mid and distal esophagus producing a "corkscrew" or "rosary bead" pattern (Fig. 27 on page 38). Strictures 1- Peptic: scarring from reflux esophagitis is the most common cause of stricture in the distal esophagus. Such strictures appear as a concentric smooth narrowing (1 to 4 cm in length) of distal esophagus with proximal dilatation, almost always located above a hiatal hernia (Fig. 28 on page 39). Ulcers often are seen as focal sacculations or as a ballooning of the esophageal wall. Page 11 of 55

12 2- Neoplasm: in advanced esophageal neoplasms, infiltrating lesion is the most common: asymmetric, irregular, ulcerated and fixed contours with abrupt proximal borders of a narrowed esophageal segment (Fig. 29 on page 41). Adenocarcinoma is a malignant epithelial neoplasm that usually arises from malignant degeneration of underlying Barrett epithelium in the distal esophagus. Squamous cell carcinoma is a malignant tumor of epithelial cells that most commonly develops in patients with a longstanding history of alcohol and/or tobacco typically more common in the mid esophagus (Fig. 30 on page 43). Advanced adenocarcinoma in Barrett esophagus is radiologically indistinguishable from advanced squamous cell carcinoma. 3- Corrosive ingestion: accidental or intentional ingestion ingestion of strong acids or strong bases may leads to stricture formation 1-3 months after the initial injury. Affected patients may develop long or short segmental strictures: smooth, concentric and symmetric (Fig. 31 on page 45) or irregular, eccentric and asymmetric. In severe cases, the entire esophagus has a diffuse long filiform appearance (Fig. 32 on page 47) due to extensive scarring and fibrosis. Patients with chronic strictures also have an increased risk of developing esophageal carcinoma. 4- Radiation esophagitis: usually with a radiation mediastinal dose of 5000 cgy or more, almost always 4-8 months after completion of radiation therapy. Most radiation strictures occur in the upper or mid esophagus because of the location of the radiation portal. Radiation strictures typically appear as a smooth, concentric, and tapered narrowing (Fig. 33 on page 49). 5- Idiopatic eosinophilic esophagitis (IEE): is a chronic inflammatory disease characterized by eosinophilic infiltration of the esophagus, typically in young men with long-standing dysphagia and recurrent food impactions and often associated with history of allergies and peripheral eosinophilia. The diagnosis of IEE may be suggested at barium studies by the presence of segmental esophageal narrowings, sometimes with ringlike indentations that produced a "ringed" esophagus (Fig. 34 on page 49). These ringlike indentations may have a variable location in the esophagus and they are seen as multiple, fixed, closely spaced, concentric rings that traversed the stricture (Fig. 35 on page 51). The appearance of the small-caliber esophagus on barium studies may also suggest the diagnosis of IEE (Fig. 36 on page 51). Intramural benign tumors Page 12 of 55

13 Leiomyoma: is the most common benign esophageal neoplasm. Most patients are asymptomatic, but dysphagia and pain may develop depending on the size of the lesion and how much it encroaches on the lumen. Leiomyomas usually manifest on barium study as a smooth submucosal mass with round or ovoid filling defects and an epicenter of the lesion inside the esophagus, with upper and lower borders of lesion forming right or slightly obtuse angles with the adjacent esophageal wall when viewed in profile (Fig. 37 on page 53). As a result, these lesions may be indistinguishable from other intramural benign tumors such as lipomas, fibromas, neurofibromas and hemangiomas. Images for this section: Page 13 of 55

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15 Fig. 5: Barium esophagogram shows normal extrinsic impressions from aortic arch (black arrow), left main bronchus (yellow arrow) and heart (blue arrow). Fig. 6: Barium esophagograms (A, B) reveal an aberrant right subclavian artery producing a dorsal impression on the esophagus and coursing superiorly from left to right (blue arrows). Axial CECT (C) demonstrates the aberrant right subclavian artery (yellow arrow) coursing posterior to the trachea and esophagus. Fig. 7: Barium study (A) shows right aortic arch (yellow arrow) with leftward displacement of barium column. PA radiographic (B) reveals right paratracheal density (blue arrow) representing the right aortic arch. Axial CECT (C) shows right aortic arch (orange arrow) with left paravertebral mesothelial cyst (green arrow). Page 15 of 55

16 Fig. 8: Barium esophagogram (A) shows double aortic arch (red arrows) impressing the esophagus at different levels. 3D image (B) reveals double aortic arch (blue arrows). Page 16 of 55

17 Fig. 9: Barium study (A) shows right aortic arch (red arrow) with aberrant left subclavian artery (yellow arrow). Esophagogram with lateral view (B) confirms dorsal impression by aberrant left subclavian artery (yellow arrow). Axial CECT (C) shows right aortic arch (red arrow), aberrant left subclavian artery (yellow arrow) and a diverticulum of Kommerell (blue arrow). Page 17 of 55

18 Fig. 10: Barium studies without (A) and with (B) Valsalva maneuver show uphill esophageal varices as serpiginous, tortuous and longitudinal filling defects (white arrows) in lower esophagus in patient with portal hypertension. These filling defects change in appearance during the Valsalva maneuver (B). Page 18 of 55

19 Fig. 11: Barium esophagogram reveals cadiomegaly with left atrial enlargement with backtward displacement of barium column (red arrows). Page 19 of 55

20 Fig. 12: Barium study (A) shows rightward displacement of barium column (yellow arrows). Axial CECT (B) demonstrates multinodular goiter with intrathoracic extension predominantly left (red arrow). Page 20 of 55

21 Fig. 13: Frontal (A) and lateral (B) views of esophagogram show a web (black arrows) in anterior wall of proximal cervical esophagus. Page 21 of 55

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23 Fig. 14: Lateral view of esophagogram shows rounded hypertrophied cricopharyngeus muscle impinging on the posterior lumen at the pharyngo-esophageal junction (red arrow). Page 23 of 55

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25 Fig. 15: Lateral view of esophagogram reveals large anterior cervical osteophytes impinging on the posterior lumen at the pharyngo-esophageal junction simulating cricopharyngeal achalasia (yellow arrows). Page 25 of 55

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27 Fig. 16: Lateral view of esophagogram reveals rounded hypertrophied cricopharyngeus muscle (red arrow) and anterior cervical osteophytes (yellow arrow) impinging on the posterior lumen at the pharyngo-esophageal junction. Page 27 of 55

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29 Fig. 17: Prone RAO spot image from esophagogram reveals a Schatzki ring (white arrows) at the gastroesophageal junction above a hiatal hernia (HH). Tubular esophagus (T) and esophageal vestibular (V) are seen. Page 29 of 55

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31 Fig. 18: Prone RAO spot image from esophagogram shows an "A" ring (black arrows) at the tubulo-vestibular junction. Tubular esophagus (T) and esophageal vestibular (V) are seen. Page 31 of 55

32 Fig. 19: Prone RAO spot image from esophagogram shows an "A" ring (black arrows) at the tubulo-vestibular junction and a Schatzki ring (white arrows) at the gastroesophageal junction above a hiatal hernia (HH). Tubular esophagus (T) and esophageal vestibular (V) are seen. Fig. 20: Frontal view of barium esophagram (A) shows Zenker diverticulum (black arrow) with retained barium after the bolus has passed. Lateral view esophagram (B) shows large diverticulum (yellow arrow) displacing and compressing the posterior wall of the proximal esophagus. Axial CECT (C) reveals Zenker diverticulum (orange arrow) with leftward displacement of the proximal esophagus. Page 32 of 55

33 Fig. 21: Barium study (A) shows a distal esophageal epiphrenic diverticulum (red arrow). Axial CECT (B) demonstrates a large epiphrenic diverticulum (yellow arrow) containing retained food. Page 33 of 55

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35 Fig. 22: Barium esophagogram reveals diffuse esophageal spasm with diverticula midesophageal (red arrows). Fig. 23: Barium esophagogram reveals a traction diverticulum due to fibrosis and scarring in periesophageal tissues in patient with chronic obstructive pulmonary disease (COPD) (yellow arrow). Page 35 of 55

36 Fig. 24: Barium studies (A, B) show non-propulsive, transient, simultaneous and intermittent contractions (black arrows) in an elderly patient ("presbyesophagus "). Page 36 of 55

37 Fig. 25: Barium studies (A, B) show a dilated esophagus (black arrow) with a tapered beaklike narrowing of the distal esophagus junction (yellow arrows) in patient with achalasia. Axial CECT (C) demonstrates marked dilatation of esophagus with air-fluid level in patient with achalasia. Page 37 of 55

38 Fig. 26: Chest x-ray AP view (A) shows advanced achalasia with mediastinal widening and air-fluid level in cervical esophagus. Outer borders represent dilated esophagus projecting beyond shadows of aorta and heart (red arrows). Barium esophagogram (B) reveals a dilated and tortuous esophagus with "sigmoid" appearance. Page 38 of 55

39 Fig. 27: Barium studies (A, B) show "corkscrew" esophagus due to diffuse esophageal spasm (red arrows). Page 39 of 55

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41 Fig. 28: Barium esophagogram shows concentric smooth peptic stricture in distal esophagus (red asterisk) above a hiatal hernia (yellow asterisk). Focal saculations are seen due to ulcerations (blue arrows). Page 41 of 55

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43 Fig. 29: Barium esophagogram shows an irregular narrowing (black arrows) with abrupt proximal borders (red arrow) and areas of ulceration (yellow arrow) in distal esophagus due to advanced infiltrating neoplasm (adenocarcinoma). Page 43 of 55

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45 Fig. 30: Barium esophagogram shows an irregular stricture (black arrow) in mid esophagus due to advanced infiltrating neoplasm (squamous cell carcinoma). Page 45 of 55

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47 Fig. 31: Esophagogram years after caustic ingestion shows short, smooth, concentric and symmetric stricture (yellow arrow) in mid esophagus. Page 47 of 55

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49 Fig. 32: Esophagogram months after caustic ingestion shows a diffuse long filiform stricture (red arrows) in the thoracic esophagus. Fig. 33: Frontal (A) and lateral (B) views of esophagogram show a smooth, concentric, and tapered stricture (red arrows) in upper thoracic esophagus. This patient had larynx cancer and prior mediastinal irradiation. Page 49 of 55

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51 Fig. 34: Barium esophagogram shows a ringed esophagus (orange arrows) due to IEE. Fig. 35: Frontal (A) and lateral (B) views of esophagogram show two concentric closely spaced rings (red arrows) in the region of the stricture caused by IEE. Page 51 of 55

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53 Fig. 36: Barium esophagogram shows a small-caliber esophagus (red arrows) secondary to IEE. Fig. 37: Lateral view of barium esophagram (A) shows a smooth submucosal mass (blue arrows) and an epicenter of the lesion inside the esophagus (yellow asterisk), with upper and lower borders of lesion forming right angles with the adjacent esophageal wall (red arrows). Axial CECT (B) demonstrates a mass in esophageal wall without signs of invasion or metastases. This patient had a leiomyoma. Page 53 of 55

54 Conclusion Barium study is a key imaging method for the initial management of esophageal pathologies. Knowledge of esophagogram imaging findings enables the radiologist to make a more accurate and rapid diagnosis. It is crucial to preserve barium radiology for the quality of patient care. Personal information Rafael Morcillo Carratalá 2nd year Radiology Resident at Hospital Virgen de la Salud, Toledo, Spain; rafaelmorcillocarratala@hotmail.es V. Rodriguez Laval, Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain; vrlaval@gmail.com L. M. Cruz Hernandez, Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain; lina_cruzhernandez@hotmail.com M. Hernandez Guilabert, Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain; maria.hg@hotmail.com L. Garcia Sanz, Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain; llggss06@gmail.com References 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: Page 54 of 55

55 3. 4. 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 Stefan L. Zimmerman, BS Marc S. Levine, MD Stephen E. Rubesin, MD Marcia C. Mitre, MD Emma E. Furth, MD Igor Laufer et al. Idiopathic Eosinophilic Esophagitis in Adults: The Ringed Esophagus. Radiology. 2005; 236: Page 55 of 55