2. GI Imaging

3. Densities X-ray allows visualization of different densities -Air -Fat -Water -Metal

4. Visualization of the Esophagus Different density required for visualization i.e.: contrast

5. Contrast Agents Water Soluble – Gastrografin – Low-osmolality Inert – Barium sulfate

6. Single vs. Double Contrast Improved mucosal visualization

7. Fluoroscope Real-time x-ray video Multiple sequential images Spot films

8. Barium Studies (Video) Esophogram Barium Swallow UGI series Modified Barium Swallow

9. Gastroesophageal Reflux

10. GERD & Barium Visualization of refluxing barium Patient position Valsalva Usefulness is arguable

11. GERD Secondary Signs Hiatal Hernia (HH) Cricopharyngeus muscle spasm Reflux esophagitis Benign stricture Barrett’s esophagus Aspiration pneumonia

12. Hiatal Hernia Extension of stomach into chest through esophageal hiatus 2 types: – Sliding 95% – Para-esophageal 5%  Not associated with GERD May be more prominent when supine

14. Cricopharyngeous Muscle Posterior wall of pharyngoesophageal junction Normally relaxes with swallowing to allow passage of food Incomplete relaxation can be seen as protective mechanism in GER patients Smooth impression at C5-6 level

15. Cricopharyngeous Muscle Spasm

16. Reflux Esophagitis Begins distally Thickened folds May have associated linear ulcers

17. Benign Stricture Distal or mid-esophagus Smooth walls May be partially distensible

18. Barrett’s Esophagus In approx. 10% of untreated reflux patients Metaplasia of normal squamous epithelium to a gastric columnar epithelium Nodular or granular mucosa Look for focal ulceration, stricture, and cancer (15% or 30x increase)

19. Barrett’s Esophagus

20. Aspiration Pneumonia Appearance will vary with amount of aspirate, patient position, reaction to aspiration Often bilateral, associated atalectasis Posterior and basal areas more common

21. Aspiration Pneumonia

22. Aspiration

23. Esophageal Cancer

24. Detection Barium studies are not as sensitive as endoscopy, but more readily available Suspect cases referred on to endoscopy CT, MRI not suitable for screening

25. Barium Swallow Patterns 1. Annular constricting Most common Many variations 2. Polypoid mass 3. Infiltrative In submucosa, may simulate benign stricture 4. Ulcerated mass

26. Esophageal Cancer

27. Esophago- bronchial fistula

28. Tumor Staging CT most commonly used Endoscopic ultrasound in some centers

29. Computed Axial Tomography

31. CT Staging Wall thickness Infiltration of paraesophageal fat planes Regional invasion (trachea, pleura, pericardium, vertebrae etc…) Lymphadenopathy Distant Metastases

32. Normal CT

33. Invasive Cancer

34. Endoscopic Ultrasound Smaller lesions Assess wall involvement

35. Esophageal Motility

36. Normal Motility Best seen prone 3 phases: – Oral, pharyngeal, esophageal

37. Esophageal Phase Primary wave: – Initiated by swallowing reflex Secondary Wave: – As response to esophageal distension

38. Normal Swallow

39. Abnormal Motility Non-specific finding Seen in reflux esophagitis, radiation injury, caustic ingestion, myxedema, diabetes mellitus…

40. Corkscrew esophagus Tertiary esophageal waves – Non-propulsive – Corkscrew or beaded appearance

41. Scleroderma Fibrosis of smooth muscle Dilated esophagus with widely patent GEJ Resultant reflux Reflux esophagitis => ulceration => stricture (mild) => Barrett’s => neoplasm

42. Scleroderma

43. Achalasia Diffusely decreased or absent peristalsis Lower esophageal sphincter fails to relax Smooth, tapered distal esophageal narrowing Some passage of food in upright position

44. Achalasia

45. Neuromuscular Disorders Most common => stroke Parkinsonism, Alzheimer’s, multiple sclerosis, CNS neoplasms, traumatic injury Modified barium swallow

46. Zenker’s Diverticulum

47. Zenker’s Herniation at posterior midline above UES Horizontal & oblique fibers of inferior constrictor muscles => Killian’s dehiscence Associated incomplete cricopharyngeus muscle relaxation Neck at superior aspect of sac Midline, but lateral extension with growth

48. Zenker’s Diverticulum