GI Imaging

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GI Imaging
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Densities

• X-ray allows visualization of different densities
• -Air
• -Fat
• -Water
• -Metal

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Visualization of the Esophagus

• Different density required for visualization
  i.e. contrast

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Contrast Agents

• Water Soluble
• Gastrografin
• Low-osmolality
• Inert
• Barium sulfate

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Single vs. Double Contrast

• Improved mucosal visualization

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Fluoroscope

• Real-time x-ray video
• Multiple sequential images
• Spot films

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Barium Studies

• (Video) Esophogram
• Barium Swallow
• UGI series
• Modified Barium Swallow

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GastroesophagealReflux
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GERD Barium

• Visualization of refluxing barium
• Patient position
• Valsalva
• Usefulness is arguable

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GERD Secondary Signs

• Hiatal Hernia (HH)
• Cricopharyngeus muscle spasm
• Reflux esophagitis
• Benign stricture
• Barretts esophagus
• Aspiration pneumonia

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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

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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

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Cricopharyngeous Muscle Spasm
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Reflux Esophagitis

• Begins distally
• Thickened folds
• May have associated linear ulcers

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Benign Stricture

• Distal or mid-esophagus
• Smooth walls
• May be partially distensible

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Barretts 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)

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Barretts Esophagus
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Aspiration Pneumonia

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

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Aspiration Pneumonia
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Aspiration
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Esophageal Cancer
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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

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Barium Swallow Patterns

• Annular constricting
• Most common
• Many variations
• Polypoid mass
• Infiltrative
• In submucosa, may simulate benign stricture
• Ulcerated mass

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Esophageal Cancer
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Esophago-bronchial fistula
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Tumor Staging

• CT most commonly used
• Endoscopic ultrasound in some centers

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Computed Axial Tomography
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Computed Axial Tomography
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CT Staging

• Wall thickness
• Infiltration of paraesophageal fat planes
• Regional invasion (trachea, pleura, pericardium,
  vertebrae etc)
• Lymphadenopathy
• Distant Metastases

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Normal CT
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Invasive Cancer
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Endoscopic Ultrasound

• Smaller lesions
• Assess wall involvement

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Esophageal Motility
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Normal Motility

• Best seen prone
• 3 phases
• Oral, pharyngeal, esophageal

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Esophageal Phase

• Primary wave
• Initiated by swallowing reflex
• Secondary Wave
• As response to esophageal distension

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Normal Swallow
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Abnormal Motility

• Non-specific finding
• Seen in reflux esophagitis, radiation injury,
  caustic ingestion, myxedema, diabetes mellitus

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Corkscrew esophagus

• Tertiary esophageal waves
• Non-propulsive
• Corkscrew or beaded appearance

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Scleroderma

• Fibrosis of smooth muscle
• Dilated esophagus with widely patent GEJ
• Resultant reflux
• Reflux esophagitis gt ulceration gt stricture
  (mild) gt Barretts gt neoplasm

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Scleroderma
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Achalasia

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

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Achalasia
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Neuromuscular Disorders

• Most common gt stroke
• Parkinsonism, Alzheimers, multiple sclerosis,
  CNS neoplasms, traumatic injury
• Modified barium swallow

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Zenkers Diverticulum
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Zenkers

• Herniation at posterior midline above UES
• Horizontal oblique fibers of inferior
  constrictor muscles gt Killians dehiscence
• Associated incomplete cricopharyngeus muscle
  relaxation
• Neck at superior aspect of sac
• Midline, but lateral extension with growth

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Zenkers Diverticulum
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Zenkers Diverticulum