Clinical/Standard Approach to Barium Esophagus • Applied Radiology (2023)

Despite advances in gastrointestinal (GI) radiology, barium esophagography remains an indispensable technique for the detection of various morphological abnormalities of the esophagus, including nodules or plaques, ulcers, strictures, and esophageal rings. These abnormalities may be associated with radiologic findings that strongly suggest an underlying cause of the disease. However, it is not uncommon for a correct diagnosis to be made only by combining imaging findings with clinical history and presentation. Therefore, this article proposes a standard approach to esophagography based on imaging and clinical findings.

technology

A double-contrast esophagogram is performed as a duplex exam, including single-contrast and double-contrast views of the esophagus.¹After ingestion of the effervescent, the patient continuously ingested high-density barium in an upright, left posterior oblique position for double-contrast imaging of the esophagus. The double-contrast view of the gastric cardia is also obtained in the reclined position, right side down. The patient was then placed in a prone, right anterior oblique position, and asked to swallow low-dense fluid carefully to assess esophageal motility. Finally, the patient is in the prone position and swallows low-density barium continuously to optimally dilate the esophagus. The double-contrast phase of the study optimized the detection of mucosal disease, while the single-contrast phase optimized the detection of strictures due to esophageal strictures or rings.

nodules or plaques

reflux esophagitis

Reflux esophagitis is the most common inflammatory condition of the esophagus, most often presenting in double-contrast studies with a fine nodular or granular appearance due to mucosal edema and inflammation. Granularity is characterized by a continuous area of ​​disease with ill-defined radiolucency in the distal esophagus extending proximally from the gastroesophageal junction (Figure 1).^1-3This finding is relatively sensitive and specific for reflux esophagitis, especially in patients with reflux symptoms such as heartburn, acid regurgitation, cough, and less commonly, dysphagia or globular sensation.³

candidal esophagitis

Candida albicansEsophagitis is the most common cause of infectious esophagitis, usually occurring as an opportunistic infection in immunocompromised patients due to diabetes, malignancy, chemotherapy, AIDS, or other causes.^4,5seldom,CandidaEsophagitis is caused by stasis caused by esophageal motility disorders such as scleroderma and achalasia, which allow fungal organisms to overgrow and colonize the esophagus.⁶Affected individuals typically experience acute dysphagia (dysphagia), or more commonly, odynophagia (dysphagia). In some cases, the pain can be so severe that the affected person cannot swallow saliva. However, only about 50% of patients have concomitant candidiasis, so the absence of oropharyngeal disease does not exclude the diagnosis in any way.⁵

CandidaEsophagitis typically presents as multiple discrete plaque-like defects with intervening normal mucosa in double-contrast studies (Fig. 2A).^4,5Plaques tend to involve the upper and/or middle esophagus and are linear or irregular in shape.^4,5AIDS patients may develop a more violent form of candidiasis, with barium trapped between the many plaques and pseudomembranes, producing what is known asdisheveledEsophagus (Fig. 2B).⁵This finding can actually diagnoseCandidaEsophagitis is uncommon in modern medical practice as treatments are more effective in HIV-positive patients.

Saccharose

Glycogenic acanthosis is a common degenerative disease characterized by the accumulation of cytoplasmic glycogen in the squamous epithelium of the esophagus. This condition manifests as small nodules and round plaques in double-contrast studies, more commonly in the middle esophagus (Figure 3).⁷Glycogenic acanthosis may resembleCandidaEsophagitis, but plaques in candidiasis tend to have a linear or irregular appearance, whereas nodules in glycogenic acanthosis are more rounded. also,CandidaEsophagitis occurs in immunocompromised patients with odynophagia, whereas glycogenacanthosis occurs in immunocompromised elderly patients without esophageal symptoms. Therefore, it is almost always possible to distinguish these conditions on the basis of clinical findings.

superficial spreading carcinoma

Superficial spreading carcinoma (SCC) is a rare type of esophageal cancer in which the tumor is confined to the mucosa or submucosa, with or without nodal metastasis.⁸SSC typically appears in double-contrast studies as clusters of ill-defined nodules or plaques merging into one another to produce confluent areas of disease.^1,8,9SSC can usually be distinguished fromCandidaEsophagitis and glycogenic acanthosis in which plaques and nodules have discontinuous borders and are separated by normal intermediate mucosa. They developed more serious diseases.

small ulcer

reflux esophagitis

Reflux esophagitis is the most common inflammation involving the esophagus. Although the mucosa is finely nodular or granular in many patients with reflux esophagitis (see previous section), more advanced disease may present with multiple small, superficial ulcerations and erosions in the distal esophagus. Ulcers are usually punctate or linear and may be accompanied by radial folds or surrounding haloes of mucosal edema (Figure 4).¹Ulcers almost always develop at or near the gastroesophageal junction and extend proximally for a variable distance as a continuous area of ​​disease.¹Therefore, an ulcer that does not involve the distal esophagus should suggest another cause of disease. Less commonly, reflux esophagitis may present as a single overt ulcer at or near the gastroesophageal junction. these callsmarginal ulcerThey are usually located on the posterior wall of the distal esophagus and may result from prolonged exposure to reflux acid that accumulates in the posterior esophagus due to gravity while the patient sleeps in the supine position.¹⁰

herpetic esophagitis

Herpes simplex virus type 1 is the second most common cause of infectious esophagitis in immunocompromised patients.⁵This condition usually presents in double-contrast studies as multiple small ulcers in the upper or middle esophagus, often surrounded by radiolucent edematous mounds (Figure 5).^11,12Most patients have odynophagia, but herpetic lesions are uncommon in the oropharynx, making it difficult to differentiate from herpes and herpes.CandidaEsophagitis based on clinical findings.

Herpetic esophagitis occasionally develops as an acute, self-limited disease in otherwise healthy patients. Affected individuals develop an influenza-like syndrome including fever, headache, myalgia, and upper respiratory symptoms 7 to 10 days before the onset of severe odynophagia.¹³Double-comparison studies often show multiple microscopic ulcers, even smaller than those in immunocompromised patients with herpetic esophagitis, possibly because they have an intact immune system that prevents ulcer enlargement.¹³

drug induced esophagitis

Patients taking oral medications, particularly antibiotics such as estrocycline and doxycycline, and nonsteroidal anti-inflammatory drugs (NSAIDs), may develop focal contact esophagitis. These individuals often have acute odynophagia and a history of ingesting harmful medications with little or no water at bedtime. As a result, the capsule or tablet may become lodged in the middle of the esophagus, where it is compressed by the aortic arch or left main bronchi. Double contrast studies usually show multiple small ulcerations in the mid-esophagus (Figure 6).^1,14This condition is difficult to distinguish from herpetic esophagitis on barium studies, but the clinical history can usually suggest the correct diagnosis.

Crohn's disease

Crohn's disease involving the esophagus occasionally presents as small superficial ulcers that are indistinguishable from aphthous ulcers in the small intestine or colon in patients with this disease.^15,16Because esophageal Crohn's disease is almost always associated with ileocolonic disease, this diagnosis should only be considered in patients with known Crohn's disease elsewhere in the GI tract.

large ulcer

CMV esophagitis

CMV esophagitis can manifest as one or more large flat ulcers that are indistinguishable from human immunodeficiency virus (HIV) ulcers in the esophagus (see next section).¹Affected individuals typically experience dysphagia and are diagnosed with AIDS. Due to the potential toxicity of antiviral drugs such as ganciclovir, an endoscopic biopsy or culture is required to confirm the presence of CMV before initiating treatment. Although better treatment of HIV patients has reduced the number of AIDS patients, CMV esophagitis occasionally occurs in patients receiving steroids or bone marrow transplants.^17-19

Anteater HIV

HIV-infected individuals may develop one or more large esophageal ulcers directly caused by the HIV virus itself, and electron microscopy of biopsy specimens reveals viral particles with morphological characteristics characteristic of HIV.²⁰These ulcers are usually located in the lower or middle part of the esophagus and appear on barium studies as large craters (greater than 1 cm), oval or diamond-shaped, surrounded by a thin, radiolucent edematous rim (Figure 7).^21,22These ulcers are indistinguishable from giant CMV ulcers in the esophagus, but most HIV ulcers heal quickly with steroid treatment.^21,22In contrast, CMV ulcers require treatment with antiviral drugs. Therefore, endoscopy and biopsy are required to differentiate these infections before initiating treatment.

drug induced esophagitis

Esophagitis caused by potassium chloride, quinidine, NSAIDs, and alendronate can sometimes lead to giant esophageal ulcers, unlike tetracycline or doxycycline-induced esophagitis, which presents as small, superficial ulcers development of.^23-25The clinical history usually suggests the correct diagnosis.

Barrett's esophagus

Barrett's esophagus is an acquired disorder in which progressive columnar metaplasia develops in the distal esophagus secondary to long-standing reflux disease. Barrett's esophagus occasionally presents as a single large ulcer within the columnar epithelium, occurring slightly distal to the gastroesophageal junction. Although uncommon, this finding should be highly suggestive of Barrett's esophagus in patients with hiatal hernia and gastroesophageal reflux.^1,14,26

Esophageal cancer

Necrotic carcinoma of the esophagus may appear as a large ulcerated mass. In this case, barium examination may reveal a large meniscus-shaped oro-oval ulcer surrounded by an irregular thick tumor mass (Fig. 8). Produces a different radiographic appearance (see Figure 7).

ulcer simulator

Intramural pseudodiverticulosis

Intramural pseudodiverticula are dilated excretory ducts of mucous glands deep in the esophagus. Barium examination usually reveals multiple small flask-shaped pouches arranged in a longitudinal row parallel to the long axis of the esophagus (Fig. 9A).²⁷Viewed from the front, a pseudodiverticulum can easily be mistaken for a small ulcer. Viewed from the side, however, these structures often appear to "float" outside the esophagus, whereas true ulcers communicate directly with the lumen. Some pseudodiverticula are diffuse and associated with high-grade strictures (see Figure 9A), but pseudodiverticula are more commonly seen in the distal esophagus in patients with peptic strictures (Figure 9B).^27,28Although the pathogenesis is uncertain, it is hypothesized that pseudodiverticulum is the result of glandular dilatation caused by chronic inflammation. Occasionally they can also occur in alcoholism, diabetes orCandidaEsophagitis.²⁹

Heterotopic gastric mucosa

>Heterotopic gastric mucosa is a common congenital anomaly not associated with Barrett's esophagus. It is usually found incidentally on the right side wall or less frequently on the left side of the upper esophagus or near the thoracic entrance, and appears in bariatric studies as a wide, flat depression with shallow indentations and lower margins in its upper portion . bottom. Figure 10).³⁰Although this finding may be confused with a flat ulcer, its characteristic appearance and location should suggest the correct diagnosis. The vast majority of patients with esophageal heterotopia and gastric mucosa are symptomatic.

Upper and middle esophageal strictures

Barrett's esophagus

Although most strictures in Barrett's esophagus are distal to the esophagus, some patients may develop a ring or funnel-shaped stricture in the middle of the esophagus (Figure 11).²⁶Since uncomplicated gastrointestinal strictures are almost always located a few centimeters from the gastroesophageal junction, interesophageal strictures should be highly suggestive of Barrett's esophagus in patients with hiatal hernia and reflux.²⁶

Mediastinal irradiation

Patients receiving high-dose external beam radiation to the mediastinum may develop radiation stenosis within 4 to 8 months of stopping treatment. These strictures typically appear as long, smooth, tapered narrowings of the upper or middle esophagus, within pre-existing radiative entrances (Fig. 12).³¹

Esophageal cancer

Malignancies in the upper or middle esophagus are usually squamous cell carcinomas. Benign strictures typically have smooth contours and sharp edges (Figures 11 and 12), whereas malignant strictures exhibit a more irregular contour and steep shelf-like edges and are often associated with nodules and mucosal ulcers (Figure 13).^1,31History is also important because patients with benign strictures have longer-lasting dysphagia and little or no weight loss, whereas patients with malignant strictures have recent onset progressive dysphagia and significant weight loss. Thus, invasive carcinoma can often be distinguished from benign strictures based on clinical and radiographic findings.

distal esophageal stricture

Digestive tract stricture

Most benign strictures of the distal esophagus are scarring caused by reflux esophagitis.^28,31These induced reflux or so-calledDigestiveStenosis most commonly appears as a discrete segment (1–4 cm in length) with a smooth, tapered narrowing, almost always over a hiatal hernia (Fig. 9B). However, it is not uncommon for peptic strictures to be short (less than 1 cm long) annular constrictions at or near the gastroesophageal junction. This narrowing may be confused with Schatzkirings (Fig. 14),^28,31In contrast, nasogastric intubation, Zollinger-Ellison syndrome, and alkaline reflux esophagitis can result in rapidly progressive reflux-like strictures that involve far longer distal esophageal segments than most peptic strictures.²⁸Peptic strictures with clearly benign imaging findings are almost always considered benign, but nodular, irregular, or asymmetric strictures should be evaluated by endoscopy and biopsy to rule out malignancy.

Adenocarcinoma

Esophageal adenocarcinoma arises in areas of preexisting columnar metaplasia in Barrett's esophagus and thus tends to be distal to the esophagus. Advanced adenocarcinomas are usually invasive lesions that narrow the lumen and, unlike squamous cell carcinomas, have a marked propensity to invade the cardia and fundus.¹These lesions typically appear on barium studies as irregular areas of luminal narrowing with shelf-like margins (Fig. 15). Occasionally, however, early-stage adenocarcinoma can be identified by nodules or irregularities in pre-existing strictures of the digestive tract.¹Endoscopy and biopsy are required to rule out malignancy in these patients.

diffuse esophageal stricture

eosinophilic esophagitis

Eosinophilic esophagitis is an inflammatory disorder that typically occurs in children or young adults (particularly males) with longstanding dysphagia and recurrent food impactions. Affected individuals typically have a history of atopic disease, asthma, and/or peripheral eosinophilia.³²In some patients, the entire thoracic esophagus has long-segment stenosis or diffuse loss of dilatation (without discrete stenosis), resulting in the so-calledSmall Bore Esophagus(Fig. 16A).³³Other patients have multiple distinct annular indentations (sometimes associated with focal or diffuse esophageal strictures), producing so-calledRing esophagus(Fig. 16B).³⁴In young men with a long history of dysphagia and atopy, a small-bore or annular esophagus should be highly suggestive of eosinophilic esophagitis.

Corrosive ingestion

Ingestion of strong acids or bases can cause severe esophagitis, leading to strictures within 1 to 3 months. Lye stenosis manifests as segmental narrowing of the upper or middle esophagus, or in advanced cases, diffuse and marked narrowing of almost the entire thoracic esophagus (Fig. 17).^28,31The small-bore esophagus of eosinophilic esophagitis can produce a similar appearance (see Figure 16A), but is usually not as narrow and irregular as severe lye strictures. In problematic cases, the correct diagnosis can almost always be made based on the clinical history.

Esophageal ring

cat esophagus

The feline esophagus appears in barium studies as thin, narrow horizontal streaks extending around the circumference of the esophagus (Figure 18).³⁵Although a feline esophagus may be discovered incidentally, it is almost always associated with gastroesophageal reflux and is usually seen during an actual reflux episode.³⁵The characteristic appearance and transient nature of the feline esophagus allow it to be distinguished from other types of esophageal rings.

Fixed horizontal folds

Double-contrast barium studies may occasionally show fixed transverse folds in the distal esophagus with barium entrapment between the folds, producing the characteristicladderAppearance (Figure 19).³⁶The folds are usually 2 to 5 mm wide and do not extend all the way into the esophagus.³⁶They almost always occur in areas of peptic strictures, probably due to longitudinal scarring and shortening of the esophagus due to chronic reflux esophagitis (see Figure 19).³⁶Unlike the feline esophagus and nonperistaltic esophageal contractions, which are transient in nature, these transverse folds are seen as a persistent finding on esophagography.³⁶

eosinophilic esophagitis ring esophagus

As noted previously, patients with eosinophilic esophagitis may develop a distinctive annular indentation (sometimes associated with focal or diffuse esophageal strictures), forming a ring esophagus (see Figure 16).³⁴Although the pathogenesis of rings is unknown, this presentation should be highly suggestive of eosinophilic esophagitis, especially in young men with a history of chronic dysphagia, repeated food impactions, and a history of allergies or asthma.

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