Esophagram Flashcards
(16 cards)
Pre-procedure for esophagram
Review if prior esophagram or modified
MUST BE FASTING 2-4 hours prior
Give fizzies in young, healthy esophagus. Consider reducing amount or AVOID FIZZIES in patients who look frail, BARIATRIC SURGERY, LARGE intrathoracic hernia, any recent GI surgery, if no passage of barium into the stomach
If MBS, dysphagia alone is not a billable diagnosis. It needs dysphagia + another symptom
Esophagram contrast
Barium for most. Visipaque for those with leak or aspiration. Gastrografin if looking for a leak but NO risk of aspiration
if pt is unable to tolerate thick barium after initial swallow, you can use the thin barium
also consider using 1/2 the fizzies depending on clinical situation
Esophagram fizzies
No fizzies for pts w/:
- achalasia
- significant stricture/obstruction
- post-surgery
- Bariatric surgery at any time
- old, frail
- big hernia
Esophagus anatomy
Esophagus = from UES formed by the cricopharyngeus muscle (around C5-C6) to the GEJ
Proximal ⅓ predominantly striated muscle + distal ⅔ (below level of aortic arch) predominantly smooth muscle
Normal impressions: aortic arch + left mainstem bronchus + LA
Esophagogastric region:
- Tubular -> [ A ring ] -> saccular (esophageal vestibule) -> [ Z line / B ring ] -> gastric epithelium
- B ring and Z line = radiographic markers for GEJ
- Z line = thin, ragged line/junction of esophageal squamous epithelium with gastric columnar epithelium
- B ring = Asymmetric mucosal ring/notch
Esophagram: Complementary imaging techniques
CT, EGD demonstrate esophageal wall and adjacent structures to determine the extent of dz
- CT poor evaluation of mucosa, unable to tell neoplastic vs inflammatory
- MR is alternative to CT
MR useful in confirming presence of varices and in evaluating mediastinal vascular anatomy
Strictures need further EGD eval to determine benign vs malignancy
Abnormal esophagram results
cricopharyngeal cartilage is nl unless >50% of diameter
dysmotility (examples)
- Mild dysmotility = retropulsive, non-propulsive
- Moderate dysmotility = + tertiary
- Severe = achalasia, esophageal spasms, aperistalsis
transition points: cervicothoracic junction, gastroesophageal (GE) junction
Intrinsic filling defect is a malignancy or severe inflammation until proven otherwise.
Narrowed GE junction is less than 13mm (barium tablet)
Esophageal for perforations, obstructions contrast and exam views
Standing only with GASTROGRAFIN
LAO, RAO, AP, Lateral views
Measurements of hernia and structures on esophagram in what view
LPO
Signs concerning for perforations
Plain films : subQ, cervical, or mediastinal emphysema within 1 hr of perforation
CXR may show widened mediastinum and pleural effusion or hydropneumothorax
CT demonstrates fluid collections, extraluminal contrast, AIR in the mediastinum
Esophagram: Dx associated with dysmotility
Esophageal Achalasia = absence of peristalsis + increase in resting pressure of LES + failure of LES to relax with swallowing
- Uniform dilatation + absence of peristalsis (tertiary waves in early stages) + tapered beak + increased incidence of epiphrenic diverticula and esophageal carcinoma
- Tx: balloon dilation or Heller myotomy
- Ddx: chagas dz, carcinoma of GEJ, peptic strictures
Diffuse esophageal spasm = syndrome
- Unknown etiology, most pt’s are middle-aged
- Multiple tertiary esophageal contractions + thickened esophageal wall + intermittent dysphagia
- Primary peristalsis usually present but contractions are infrequent
Esophagram: Dx associated with Hernias
Gap between crura of diaphragm should not exceed 15 mm
Sliding hiatal hernia : 95%
Paraesophageal hiatus hernia : GEJ remains in nl location below diaphgram
Mixed/compound
Esophagram: Dx associated with Outpouchings
Zenkers = posterior just proximal to UES, located in Killian dehiscence (think if pt ℅ halitosis, regurg)
Midesophageal diverticula: pulsion vs traction
Epiphrenic diverticula = just above LES, usually on right side
Sacculations = small outpouching (smooth contours) of esophagus usually as sequelae of severe esophagitis.
Intramural pseudodiverticula = 1-3 mm dilated excretory ducts of deep mucous (submucosal) glands of the esophagus; tend to occur in clusters (“intramural tracking” can occur) ; associated with strictures
Esophagram: Dx associated with Esophagitis
Esophagram will detect most mod-severe esophagitis, but fewer than ½ of mild cases
Radiographic signs:
- Thickened esophageal folds >3mm
- Limited esophageal distensibility (asymmetric flattening)
- Abnormal motility
- Mucosal plaques and nodules
- Erosions and ulcerations
- Localized stricture
- Intramural pseudodiverticulosis
**Ulcers
- Small (<1cm) : reflux esophagitis, herpes, acute radiation, drug-induced esophagitis, benign mucous
- Large (> 1cm) : cytomegalovirus, HIV, Barrett esophagus, carcinoma
Esophagram: Dx associated with Barrett esophagus
Candida : “shaggy” esophageal mucosa caused by multiple discrete plaquelike lesions; odynophagia is a prominent sx
HSV : Discrete vesicles -> discrete mucosal ulcers that may be linear, punctate, ringlike with radiolucent halo ; usually abscent nodules and plaques
Cytomegalovirus : 1+ large, flat mucosal ulcer
HIV : giant ulcers + severe odynophagia
Strictures seen on esophagram
Benign : typically smoothly tapering, concentric narrowing
Malignant : abrupt, asymmetric, eccentric narrowings with irregular, nodular mucosa, shouldering
**Need EGD eval b/c radiographic findings not reliable in differentiating benign from malignant strictures
Reflux esophagitis
- Schatzki’s ring at B ring level is pathologic
- Usually distal unless Barrett
Corrosive : longband symmetric ; occur years after initial injury
Radiation
Web = thin (1-2mm) delicate membranes that sweep partially across the lumen
Esophagram enlarged folds
Esophagitis
Varices = serpiginous filling defects best seen in mucosal relief views ; they collapse with esophageal peristalsis and distention
