Barium esophagogram as the first step to modern tecniques
Poster No.: C-0603
Congress: ECR 2014
Type: Educational Exhibit
Authors: R. Morcillo, V. Rodriguez Laval, L. M. Cruz Hernandez, M.
Hernandez Guilabert, L. Garcia Sanz; Toledo/ES
Keywords: Dynamic swallowing studies, Diagnostic procedure, Barium
meal, Plain radiographic studies, CT, Fluoroscopy, Anatomy,
Gastrointestinal tract, Contrast agents, Motility, Pathology,
Swallowing disorders
DOI: 10.1594/ecr2014/C-0603
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Learning objectives
The aim of this exhibit is to: illustrate the normal anatomy and most common anomalies
and diseases of the esophagus obtained with barium esophagogram; demonstrate
that barium studies are still the gold standard for the diagnosis of many esophageal
pathologies.
Background
The role of barium studies has been progressively declining in modern radiology practice,
in contrast to the use of endoscopy and advanced cross-sectional imaging modalities.
Barium esophagogram is still a valuable diagnostic test for evaluating structural and
functional abnormalities of the esophagus. It is essential for assessing motility disorders
such as achalasia and diffuse esophageal spasm and for evaluating submucosal and
extrinsic mass lesions. It is a safe, inexpensive, and cost-effective diagnostic test and it
is also a hepful tool for clarifying uncertain findings on endoscopy and CT.
However, barium studies are very operator dependent. The performance and
interpretation of these tests require highly experienced radiologists.
Anatomy and terminology:
• Esophagus: is a fibromuscular tube of 20-24 cm in length which runs behind
the trachea (and left main bronchus) and heart (left atrium), in front of the
spine and to the right of the descending thoracic aorta. Just before entering
the stomach, the esophagus passes through the diaphragm. This organ
is located in the posterior mediastinum and it is formed by non-keratinized
stratified squamous epithelium and outer longitudinal and inner circular
muscle fibers (striated muscle in upper third and smooth muscle in distal two
thirds).
• Upper esophageal sphincter (UES): represents the pharyngoesophageal
junction and it's formed primarily by cricopharyngeal muscle.
• Lower esophageal sphincter (LES): synonymous with phrenic ampulla and
esophageal vestibule. It's between the esophageal "A" and "B"rings.
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• "A" or muscular ring: indentation of esophageal lumen that represents the
tubulo-vestibular junction.
• "B" or mucosal ring: indentation that marks the esophagogastric junction
• Z-line: corresponding to the mucosal junction between squamous and
columnar epithelium.
Barium studies show the esophagogastric junction with the structures mentioned above
(Fig. 1 on page 3 and Fig. 2 on page 4). Phrenic ampulla is best demonstrated
with retention of breath in inspiration or a Valsalva maneuver by increase intraabdominal
pressure. Do not mistake this for a hiatal hernia; presence of "B" ring > 2 cm above the
diaphragmatic hiatus is diagnostic for hiatal hernia (Fig. 2 on page 4).
Barium esophagogram shows the normal mucosal folds like longitudinal, thin, parallela
and uniform (Fig. 3 on page 5). These folds should be differentiated from the
"feline" esophagus: thin transverse striations due to transient and insignificant muscularis
mucosae contractions in patients with gastroesophageal reflux, peptic esophagitis or
hiatal hernia (Fig. 4 on page 7).
Images for this section:
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Fig. 1: Barium esophagogram shows tubular esophagus (orange arrow), esophageal
vestibular (yellow arrow), "A" ring (red arrows) and "B" ring (blue arrows).
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Fig. 2: Esophagogram reveals tubular esophagus (orange arrow), esophageal vestibular
(yellow arrow), "A" ring (red arrow) and "B" ring (blue arrow). Esophagogastric junction
>2cm above esophageal hiatus is diagnostic for hiatal hernial (white asterisk).
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Fig. 3: Barium esophagogram reveals longitudinal, thin, parallela and uniform folds
(yellow arrows).
Fig. 4: Barium studies (A, B) show the "feline" esophagus with thin transverse striations
due to muscularis mucosae contractions.
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Findings and procedure details
In this article, we review imaging findings of esophageal anomalies and pathologies with
barium studies.
Impressions
1- Physiological: are three normal extrinsic impressions: aortic arch,
left main bronchus and heart (Fig. 5 on page 13).
2- Vascular:
• Aberrant right subclavian artery (ARSA): This is the most common thoracic
arterial anomaly (0,5-1% of all individuals). The artery is the last branch of a
four branch vessel aortic arch and extends up and to the right producing a
dorsal diagonal impression on the esophagus (Fig. 6 on page 15). Rarely
causes symptoms, but compression by ARSA on the posterior esophagus
may occasionally cause "dysphagia lusoria".
• Right aortic arch: leftward displacement of barium column on esophagogram
(Fig. 7 on page 15).
• Double aortic arch: the arches impressing the esophagus at different levels:
right arch typically higher and larger than left arch (Fig. 8 on page 15).
• Right aortic arch with aberrant left subclavian artery: right aortic arch that
originates leftward displacement of barium column on esophagogram and
aberrant left subclavian artery that produces a dorsal indentation on lateral
view (Fig. 9 on page 16). Aberrant left subclavian artery arises low the
aortic arch and extends to left dorsal to esophagus and trachea. It's most
often an incidental finding, but dilated subclavian artery (diverticulum of
Kommerell) may cause esophageal compression.
• Uphill esophageal varices: Serpentine, tortuous and longitudinal filling
defects confined in the distal half of the thoracic portion of the esophagus
and they are characterized by change in appearance during the inspiration
or Valsalva maneuver (Fig. 10 on page 17). Uphill varices are usually
caused by portal hypertension with reversed flow (hepatofugal) through
dilated esophageal collateral vessels to the superior vena cava.
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3- Extrinsic: the most frequent causes are by cardiomegaly with left atrial enlargement
(Fig. 11 on page 18) and by multinodular goiter with intrathoracic extension (Fig. 12
on page 19).
Indentations
1- Esophageal web: is a thin mucosal band projecting into lumen most frequently in
anterior wall of proximal cervical esophagus (Fig. 13 on page 20). Webs are more
common in females and rarely causes symptoms, but they develop dysphagia if > 50%
luminal narrowing. Webs may be congenital or acquired most frequently due to sequela
of inflammation or scarring. They can be associated with Plummer-Vinson (Paterson-
Kelly) syndrome (which increases risk of carcinoma), iron deficiency anemia, chronic
gastroesophageal reflux, eosinophilic esophagitis, pemphigoid benign or epidermolysis
bullosa. Treatment is often with balloon dilations.
2- Cricopharyngeal achalasia: is afailure of cricopharyngeal muscle (UES) relaxation
due to hypertrophy or spasm at the pharyngo-esophageal junction. In barium studies,
cricopharyngeal achalasia represents an intermittent indentation on the posterior lumen
at the pharyngo-esophageal junction (at the C5-C6 level) with swallowing (Fig. 14 on
page 21). This disorder can be associated with gastroesophageal reflux or motility
disorders.
3- Large anterior cervical osteophytes: persistent indentation on pharyngoesophageal
junction simulating cricopharyngeal achalasia (Fig. 15 on page 23). Cricopharyngeal
achalasia and cervical osteophytes can coexit and we must know differentiate them (Fig.
16 on page 25).
4- Schatzki ring: appears as a smooth, symmetric, thin, nondistensible and transverse
ringlike constriction at the gastroesophageal junction or "B" ring above a hiatal hernia
(Fig. 17 on page 27). This annular narrowing can be associated with gastroesophageal
reflux and peptic esophagitis and it may cause episodic dysphagia if ring <13mm in
diameter. Schatzki ring is best evaluated in prone right anterior oblique (RAO) during
deep inspiration with valsalva maneuver while barium column passes through GE
junction.
5- Muscular or contractile or "A" ring: appears as an active muscular contraction at the
tubulo-vestibular junction that varies in size and position due to esophageal contraction
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(Fig. 18 on page 29). This narrowing could be mistaken for Schatzki ring (Fig. 19 on
page 31).
Diverticula
1- Pulsion diverticulum:
• More common.
• Due to increased intraluminal pressure.
• Saccular outpouching with narrow neck.
• Proximal, mid or distal esophagus.
• Mucosal and submucosal herniation through muscularis propria with lack of
muscle: pseudodiverticulum.
• Often associated with motility disorders.
• Tend to fill after swallowing.
• More common types:
• Zenker diverticulum: is a pulsion diverticulum in midline posterior
wall of pharyngoesophageal junction just above cricopharyngeus
muscle at C5-C6 level (Killian's dehiscence). The esophagram shows
a barium-filled sac posterior to cervical esophagus that may protrude
laterally to left and compress esophagus (Fig. 20 on page 32).
Almost all patients have associated hiatal hernia and many of them
have gastroesophageal reflux and peptic esophagitis or motility
disorders. The clinical presentation can be dysphagia, regurgitation,
aspiration, halitosis or a mass or air-fluid level on chest radiographs.
It is important to know that the diverticulum can result in carcinoma
(seen in 0.3% of cases).
• Epiphrenic diverticulum: is a pulsion diverticulum with protrusion sac-
like in distal esophagus just above diaphragm. Barium study shows
large barium-filled sac in epiphrenic area more common in right side
(Fig. 21 on page 32). This diverticulum often is associated with
achalasia or hiatal hernia.
• Midesophageal diverticula: frequently multiple of varied sizes with
smooth and rounded contours. Diverticula are seen as transient
outpouchings that develop only during peristalsis, usually associated
with diffuse esophageal spasm (Fig. 22 on page 33).
2- Traction diverticulum:
• Less common.
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• Due to fibrosis and scarring in periesophageal tissues (Fig. 23 on page
35).
• Usually have no neck.
• Tented or triangular configuration.
• Mid esophagus.
• Herniation of all layers (mucosa, submucosa & muscularis propria): true
diverticulum.
• Tend to empty after swallowing.
• Often associated with pulmonary tuberculosis, histoplasmosis and
sarcoidosis.
Motility disorders
1- Presbyesophagus: is an esophageal motility dysfunction associated with aging.
There are non-peristaltic contractions (tertiary contractions): non-propulsive, transient,
simultaneous and intermittent contractions (Fig. 24 on page 35).
2- Achalasia: is a primary esophageal motility disorder characterized by absence of
primary peristalsis in the esophagus and incomplete or absent relaxation of LES
with swallowing. Malignant tumor involving the gastroesophageal junction (especially
carcinoma of the gastric cardia) may result in secondary achalasia.
Barium studies show a dilated esophagus with a smooth and tapered beaklike narrowing
of the distal esophagus just above the gastroesophageal junction (Fig. 25 on page 36).
In advanced disease, the esophagus can be massively dilated and tortuous ("sigmoid"
esophagus) (Fig. 26 on page 37).
3- Diffuse esophageal spasm: is a non-cardiac cause of chest pain characterized
by simultaneous, intermittent and non-peristaltic contractions of the mid and distal
esophagus producing a "corkscrew" or "rosary bead" pattern (Fig. 27 on page 38).
Strictures
1- Peptic: scarring from reflux esophagitis is the most common cause of stricture in the
distal esophagus. Such strictures appear as a concentric smooth narrowing (1 to 4 cm
in length) of distal esophagus with proximal dilatation, almost always located above a
hiatal hernia (Fig. 28 on page 39). Ulcers often are seen as focal sacculations or as
a ballooning of the esophageal wall.
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2- Neoplasm: in advanced esophageal neoplasms, infiltrating lesion is the most common:
asymmetric, irregular, ulcerated and fixed contours with abrupt proximal borders of a
narrowed esophageal segment (Fig. 29 on page 41). Adenocarcinoma is a malignant
epithelial neoplasm that usually arises from malignant degeneration of underlying
Barrett epithelium in the distal esophagus. Squamous cell carcinoma is a malignant
tumor of epithelial cells that most commonly develops in patients with a longstanding
history of alcohol and/or tobacco typically more common in the mid esophagus (Fig.
30 on page 43). Advanced adenocarcinoma in Barrett esophagus is radiologically
indistinguishable from advanced squamous cell carcinoma.
3- Corrosive ingestion: accidental or intentional ingestion ingestion of strong acids
or strong bases may leads to stricture formation 1-3 months after the initial injury.
Affected patients may develop long or short segmental strictures: smooth, concentric
and symmetric (Fig. 31 on page 45) or irregular, eccentric and asymmetric. In severe
cases, the entire esophagus has a diffuse long filiform appearance (Fig. 32 on page
47) due to extensive scarring and fibrosis. Patients with chronic strictures also have
an increased risk of developing esophageal carcinoma.
4- Radiation esophagitis: usually with a radiation mediastinal dose of 5000 cGy or more,
almost always 4-8 months after completion of radiation therapy. Most radiation strictures
occur in the upper or mid esophagus because of the location of the radiation portal.
Radiation strictures typically appear as a smooth, concentric, and tapered narrowing (Fig.
33 on page 49).
5- Idiopatic eosinophilic esophagitis (IEE): is a chronic inflammatory disease
characterized by eosinophilic infiltration of the esophagus, typically in young men with
long-standing dysphagia and recurrent food impactions and often associated with history
of allergies and peripheral eosinophilia. The diagnosis of IEE may be suggested at barium
studies by the presence of segmental esophageal narrowings, sometimes with ringlike
indentations that produced a "ringed" esophagus (Fig. 34 on page 49). These ringlike
indentations may have a variable location in the esophagus and they are seen as multiple,
fixed, closely spaced, concentric rings that traversed the stricture (Fig. 35 on page 51).
The appearance of the small-caliber esophagus on barium studies may also suggest the
diagnosis of IEE (Fig. 36 on page 51).
Intramural benign tumors
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• Leiomyoma: is the most common benign esophageal neoplasm. Most
patients are asymptomatic, but dysphagia and pain may develop depending
on the size of the lesion and how much it encroaches on the lumen.
Leiomyomas usually manifest on barium study as a smooth submucosal
mass with round or ovoid filling defects and an epicenter of the lesion
inside the esophagus, with upper and lower borders of lesion forming
right or slightly obtuse angles with the adjacent esophageal wall when
viewed in profile (Fig. 37 on page 53). As a result, these lesions may
be indistinguishable from other intramural benign tumors such as lipomas,
fibromas, neurofibromas and hemangiomas.
Images for this section:
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Fig. 5: Barium esophagogram shows normal extrinsic impressions from aortic arch (black
arrow), left main bronchus (yellow arrow) and heart (blue arrow).
Fig. 6: Barium esophagograms (A, B) reveal an aberrant right subclavian artery
producing a dorsal impression on the esophagus and coursing superiorly from left to right
(blue arrows). Axial CECT (C) demonstrates the aberrant right subclavian artery (yellow
arrow) coursing posterior to the trachea and esophagus.
Fig. 7: Barium study (A) shows right aortic arch (yellow arrow) with leftward displacement
of barium column. PA radiographic (B) reveals right paratracheal density (blue arrow)
representing the right aortic arch. Axial CECT (C) shows right aortic arch (orange arrow)
with left paravertebral mesothelial cyst (green arrow).
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Fig. 8: Barium esophagogram (A) shows double aortic arch (red arrows) impressing the
esophagus at different levels. 3D image (B) reveals double aortic arch (blue arrows).
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Fig. 9: Barium study (A) shows right aortic arch (red arrow) with aberrant left subclavian
artery (yellow arrow). Esophagogram with lateral view (B) confirms dorsal impression by
aberrant left subclavian artery (yellow arrow). Axial CECT (C) shows right aortic arch (red
arrow), aberrant left subclavian artery (yellow arrow) and a diverticulum of Kommerell
(blue arrow).
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Fig. 10: Barium studies without (A) and with (B) Valsalva maneuver show uphill
esophageal varices as serpiginous, tortuous and longitudinal filling defects (white arrows)
in lower esophagus in patient with portal hypertension. These filling defects change in
appearance during the Valsalva maneuver (B).
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Fig. 11: Barium esophagogram reveals cadiomegaly with left atrial enlargement with
backtward displacement of barium column (red arrows).
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Fig. 12: Barium study (A) shows rightward displacement of barium column (yellow
arrows). Axial CECT (B) demonstrates multinodular goiter with intrathoracic extension
predominantly left (red arrow).
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Fig. 13: Frontal (A) and lateral (B) views of esophagogram show a web (black arrows)
in anterior wall of proximal cervical esophagus.
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Fig. 14: Lateral view of esophagogram shows rounded hypertrophied cricopharyngeus
muscle impinging on the posterior lumen at the pharyngo-esophageal junction (red
arrow).
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Fig. 15: Lateral view of esophagogram reveals large anterior cervical osteophytes
impinging on the posterior lumen at the pharyngo-esophageal junction simulating
cricopharyngeal achalasia (yellow arrows).
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Fig. 16: Lateral view of esophagogram reveals rounded hypertrophied cricopharyngeus
muscle (red arrow) and anterior cervical osteophytes (yellow arrow) impinging on the
posterior lumen at the pharyngo-esophageal junction.
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Fig. 17: Prone RAO spot image from esophagogram reveals a Schatzki ring (white
arrows) at the gastroesophageal junction above a hiatal hernia (HH). Tubular esophagus
(T) and esophageal vestibular (V) are seen.
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Fig. 18: Prone RAO spot image from esophagogram shows an "A" ring (black arrows)
at the tubulo-vestibular junction. Tubular esophagus (T) and esophageal vestibular (V)
are seen.
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Fig. 19: Prone RAO spot image from esophagogram shows an "A" ring (black arrows) at
the tubulo-vestibular junction and a Schatzki ring (white arrows) at the gastroesophageal
junction above a hiatal hernia (HH). Tubular esophagus (T) and esophageal vestibular
(V) are seen.
Fig. 20: Frontal view of barium esophagram (A) shows Zenker diverticulum (black arrow)
with retained barium after the bolus has passed. Lateral view esophagram (B) shows
large diverticulum (yellow arrow) displacing and compressing the posterior wall of the
proximal esophagus. Axial CECT (C) reveals Zenker diverticulum (orange arrow) with
leftward displacement of the proximal esophagus.
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Fig. 21: Barium study (A) shows a distal esophageal epiphrenic diverticulum (red arrow).
Axial CECT (B) demonstrates a large epiphrenic diverticulum (yellow arrow) containing
retained food.
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Fig. 22: Barium esophagogram reveals diffuse esophageal spasm with diverticula
midesophageal (red arrows).
Fig. 23: Barium esophagogram reveals a traction diverticulum due to fibrosis and scarring
in periesophageal tissues in patient with chronic obstructive pulmonary disease (COPD)
(yellow arrow).
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Fig. 24: Barium studies (A, B) show non-propulsive, transient, simultaneous and
intermittent contractions (black arrows) in an elderly patient ("presbyesophagus ").
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Fig. 25: Barium studies (A, B) show a dilated esophagus (black arrow) with a tapered
beaklike narrowing of the distal esophagus junction (yellow arrows) in patient with
achalasia. Axial CECT (C) demonstrates marked dilatation of esophagus with air-fluid
level in patient with achalasia.
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Fig. 26: Chest x-ray AP view (A) shows advanced achalasia with mediastinal widening
and air-fluid level in cervical esophagus. Outer borders represent dilated esophagus
projecting beyond shadows of aorta and heart (red arrows). Barium esophagogram (B)
reveals a dilated and tortuous esophagus with "sigmoid" appearance.
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Fig. 27: Barium studies (A, B) show "corkscrew" esophagus due to diffuse esophageal
spasm (red arrows).
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Fig. 28: Barium esophagogram shows concentric smooth peptic stricture in distal
esophagus (red asterisk) above a hiatal hernia (yellow asterisk). Focal saculations are
seen due to ulcerations (blue arrows).
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Fig. 29: Barium esophagogram shows an irregular narrowing (black arrows) with abrupt
proximal borders (red arrow) and areas of ulceration (yellow arrow) in distal esophagus
due to advanced infiltrating neoplasm (adenocarcinoma).
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Fig. 30: Barium esophagogram shows an irregular stricture (black arrow) in mid
esophagus due to advanced infiltrating neoplasm (squamous cell carcinoma).
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Fig. 31: Esophagogram years after caustic ingestion shows short, smooth, concentric
and symmetric stricture (yellow arrow) in mid esophagus.
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Fig. 32: Esophagogram months after caustic ingestion shows a diffuse long filiform
stricture (red arrows) in the thoracic esophagus.
Fig. 33: Frontal (A) and lateral (B) views of esophagogram show a smooth, concentric,
and tapered stricture (red arrows) in upper thoracic esophagus. This patient had larynx
cancer and prior mediastinal irradiation.
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Fig. 34: Barium esophagogram shows a ringed esophagus (orange arrows) due to IEE.
Fig. 35: Frontal (A) and lateral (B) views of esophagogram show two concentric closely
spaced rings (red arrows) in the region of the stricture caused by IEE.
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Fig. 36: Barium esophagogram shows a small-caliber esophagus (red arrows) secondary
to IEE.
Fig. 37: Lateral view of barium esophagram (A) shows a smooth submucosal mass
(blue arrows) and an epicenter of the lesion inside the esophagus (yellow asterisk), with
upper and lower borders of lesion forming right angles with the adjacent esophageal wall
(red arrows). Axial CECT (B) demonstrates a mass in esophageal wall without signs of
invasion or metastases. This patient had a leiomyoma.
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Conclusion
Barium study is a key imaging method for the initial management of esophageal
pathologies. Knowledge of esophagogram imaging findings enables the radiologist to
make a more accurate and rapid diagnosis. It is crucial to preserve barium radiology for
the quality of patient care.
Personal information
Rafael Morcillo Carratalá
2nd year Radiology Resident at Hospital Virgen de la Salud, Toledo, Spain; email:
[email protected]
V. Rodriguez Laval, Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain;
email:
[email protected]L. M. Cruz Hernandez, Department of Radiology, Hospital Virgen de la Salud, Toledo,
Spain; email:
[email protected]M. Hernandez Guilabert, Department of Radiology, Hospital Virgen de la Salud, Toledo,
Spain; email:
[email protected]L. Garcia Sanz, Department of Radiology, Hospital Virgen de la Salud, Toledo, Spain;
email:
[email protected]References
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Weinstein,MD,Igor Laufer,MD. Radiologic Diagnosis of Benign Esophageal
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