Barium Esophagography: A Study for All Seasons Marc S. Levine, Stephen E. Rubesin, Igor Laufer  Clinical Gastroenterology and Hepatology  Volume 6, Issue 1, Pages 11-25 (January 2008) DOI: 10.1016/j.cgh.2007.10.029 Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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). Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

Figure 6 DES. Upright double-contrast esophagogram shows multiple severe, lumen-obliterating nonperistaltic contractions, producing a classic corkscrew appearance. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

Figure 9 Reflux esophagitis. Upright double-contrast esophagogram shows a small linear ulcer (arrow) in the distal esophagus near the gastroesophageal junction. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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 reflux-induced stricture. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

Figure 14 Candida esophagitis with plaques. Upright double-contrast esophagogram shows multiple small, linear plaques in the mid and distal esophagus. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

Figure 16 Herpes esophagitis. Upright double-contrast espophagogram shows multiple pinpoint ulcers in the midesophagus in an otherwise healthy patient with herpes esophagitis. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

Figure 20 Eosinophilic esophagitis. Prone single-contrast esophagogram shows a mild stricture in the midesophagus with distinctive ring-like 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;236:159–165 with permission of publisher.) Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

Figure 22 Superficial spreading carcinoma. Upright double-contrast esophagogram shows a confluent area of nodularity in the midesophagus caused by mucosal spread of tumor. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions

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. Clinical Gastroenterology and Hepatology 2008 6, 11-25DOI: (10.1016/j.cgh.2007.10.029) Copyright © 2008 AGA Institute Terms and Conditions