All right, you know, so as Terrell said, my name is Mike Olson. I'm going to be speaking to you today about the esophagram. I have nothing to disclose. And so the objectives of my talk are to help you understand the steps involved in a standard dual contrast esophagram and to identify a few common conditions in which esophagography can be complementary to endoscopy. And so esophagrams really are excellent tools for the evaluation of esophageal morphology caliber and motility. And so the goals of my presentation are to visually illustrate the steps involved in a routine esophagram and to highlight a few commonly encountered pathologic conditions. In addition to touching on eosinophilic esophagitis, I'll just mention a few brief words about akalasia and some postoperative and postprocedural complications. You know, and so despite what I was told in medical school, as a radiologist, I do still occasionally have to talk to patients. And so we like to begin each encounter by just taking a brief history. First, we would like to elicit kind of what types of symptoms patients are having, get a feel for any relevant prior surgeries or procedures, and then we ask them to ingest a small amount of effervescent agents, almost like alka-seltzer or Poprox, with water. And this results in gaseous distention of the esophagus and the stomach. You know, and so when I was first getting started as a radiology resident, I really had no idea what a typical esophagram entailed. I think a lot of our patients are kind of surprised at how physical the test can be. And so I thought it might be helpful for you as ordering providers to kind of know what your patients are doing when they're progressing through an esophagram. And so I had one of our techs and residents kind of put me through the paces. And so as I talk here about the esophagram, you'll kind of see in the video what patients are doing. And then I'll show you kind of the images that we're trying to acquire and what those images are used for. All right. So again, you know, we begin each encounter by giving patients a little bit of effervescent agents, trying to introduce that gas into the esophagus and stomach. We then ask them to turn into an upright LPO position about 45 degrees away from us. The objective here is to move the esophagus off the spine. We then ask them to drink an entire glass of thick barium as quickly as possible. And the idea is to try to get mucosal relief views of the distended esophagus. Other typical issues that we can run into would be incomplete esophageal distension or a dense barium column. And so this would be an example of the type of picture that we're trying to acquire. So we can see that the esophagus is nice and well distended. We can see that the barium coats the esophageal mucosa, but we can still see through the lumen of the esophagus. So this would be another example of normal here where we have a nice, well-distended esophagus that mucosa is coated with barium, but we can kind of see through. We can see a few areas here where there are retained effervescent crystals. These would be the views that we're using to evaluate for mucosal pathology like ulcers, masses, and so forth. This would be an example of an incompletely distended esophagus. So some patients just can't quite drink that barium quickly. They're taking small sips, and we can see that that mucosa is collapsed and coapted. We can see overlapping folds here, really precludes us from evaluating that underlying esophageal mucosa. This would be an example of incomplete gaseous distension of the esophagus. We can see that there's that dense barium column. We just don't quite have that air contrast, kind of that double contrast component, the air and the barium. And so we can see the barium column. We can't see through that esophageal lumen, can't see anything about the underlying mucosa. And so after we've evaluated that mucosa with kind of those upright standing images, we'll tilt the table down, and we ask patients to do some rolling. So we're trying to coat the stomach with that barium. And so we have them turn 270 degrees. We want them to roll into a right lateral position, kind of bring those arms up above their head. And the objective here is to get a good look at the gastric fundus or the cardiac rosette. So we're trying to see preservation of nice normal rugal folds, kind of radiating to a central point right at that gastroesophageal junction. So another example of normal here, we have the distal esophagus coming down, we've got the gastric fundus, and we can see preservation of those nice normal rugal folds radiating to that cardiac rosette. Obliteration of that rosette can signal underlying pathology. This is actually a patient who's undergone a Nissen fundoplication. It actually looks like there's a mass effect or sort of an imprint sitting on the gastric fundus here. So we're seeing mass effect from the fundoplication wrap. This would be an example of effacement of those rugal folds. So the so-called bald stomach, we can see that there's no longer kind of that preservation of the nice mucosa. We'd be thinking about things like atrophic gastritis, potentially an underlying mass. Unfortunately, this patient had an endoscopically confirmed GE junction adenocarcinoma. And so after we've asked patients or after we've taken those images of the gastric fundus, we'll turn patients into a recumbent RAO position. We want that abdomen kind of flush against the examination table. We'll give them a cup of barium with a straw and ask them to do some drinking in this position. And so initially, we'll ask them to take one large drink from the straw and to swallow one time. And the objective here is to evaluate esophageal peristalsis. And so we'll watch two or three peristaltic runs. And then we ask them to drink the remainder of the cup as quickly as possible. We want them really chugging from the straw, trying to drink as fast as they can. And the idea is to maximally distend out the esophagus. So we want to get a good look at esophageal caliber, kind of maximum and minimum diameter. And again, because they're flush against the table, we have elevated intraabdominal pressure. And so that's our best look at distal esophageal pathology, things like hiatal hernias, things like rings and strictures. And so this would be an example of normal peristalsis. If we can get the video to play here, let's see. There we go. Perfect. So this is an example of normal peristalsis. We can see that this patient takes one big drink, swallows one time. And we have an intact primary stripping wave that kind of carries the bolus all the way through from the esophagus to the stomach. If we can advance here. So this would be a patient who has underlying esophageal dysmotility. So we can see there's still retained barium in that esophagus from when the patient was drinking upright. If we ask the patient to take one big drink, swallow one time, we can see that bolus come down and it kind of stops in this mid-esophagus. There's proximal escape of that primary stripping wave, and we can kind of see intermittent non-propulsive tertiary contractions within that mid and distal esophagus, an example of dysmotility on an esophagram here. This would be an example of kind of what we're looking for when patients are drinking rapidly in that recumbent RAO positions. We're trying to maximally distend out that esophagus all the way from the thoracic inlet to the level of the GE junction, trying to get a sense of kind of maximum and minimum diameter. And this would be an example of a patient with a small sliding hiatal hernia. So we see the diaphragm here, the patient's in that recumbent RAO position drinking quickly, and we can see the rugal folds creeping up above the diaphragm. So we have a small sliding hiatal hernia here in the gastroesophageal junctions a few centimeters above the diaphragm. This would be a larger hernia. So again, we can see diaphragm here. There's mass effect on that gastric body where it's kind of squeezing through that diaphragmatic hiatus. We have esophagus coming down here and GE junction posteriorly, and we have a large portion of the gastric fundus and proximal body that's herniated up into the chest. And so this would be a moderate to large mixed sliding and paraesophageal hiatal hernia. Another example of a small sliding hiatal hernia here with those rugal folds coming up above the diaphragm. This patient has an obstructive short segment stricture, Schottky's ring, right at the apex of that hernia sac at the level of the GE junction. And so after we've had patients kind of drink that whole barium cup as quickly as possible, we have them turn back over onto their backs, and we ask them to do a little bit more rolling. So we have them turn from that supine AP position up onto their right shoulder into that right lateral position. And the objective here is to try to elicit gastroesophageal reflux. So we can see, again, this patient is in the supine AP position. We ask them to do some rolling, to turn over onto that right shoulder. We can see as that patient rolls, contrast from the fundus refluxes into the esophagus all the way up to about the level of the thoracic inlet here. We have another example here. So this is a patient with a small sliding hiatal hernia. We can see that there is some retained contrast within that hernia sac. And even before this patient starts to roll, we can see that there's reflux from the fundus into the hernia, and from that hernia into the esophagus, all the way up to about the level of the clavicular heads here. And so after we've evaluated for gastroesophageal reflux, we'll stand patients back up. So once they're in this standing AP position, we ask them to swallow a 13-millimeter barium tablet whole with a glass of water. And the objective is to look for functional narrowing of the esophagus. So if patients have pill dysphagia, if they have issues with bread, meats, solids, we're looking for areas where that tablet kind of may hang up, areas of functional narrowing that may elicit their symptoms. We can see that there's a retained tablet here, right at the level of the GE junction. So it would be another patient with a relatively normal, proximal, and mid-esophagus. We can see that there's a tapered stricture here, distally, near the level of the GE junction. If we window that image hard, we can see that that 13-millimeter barium tablet is retained here at the proximal margin of that stricture. All right, so kind of a whirlwind tour through an esophagram. Again, I think patients can be a little surprised at how physically involved it is. It can be a challenge for our elderly patients or patients on oxygen and so forth. So I think just helpful to kind of see what patients are doing, what we're asking them to do as we try to acquire those images in a standard esophagram. And so I'll show just a few images here. We'll look at a number of kind of pathologic conditions quickly, EOE included. And so with achalasia, some of the imaging features we're looking for would be absence of the primary peristalsis, esophageal dilatation with some tapering distally in a bird's beak configuration, an incomplete opening of that lower esophageal sphincter. And so on esophagrams, we can get a pretty good look at primary esophageal peristalsis. We can also get a sense of how well the esophagus empties. And so we can try to quantitate the height and width of a standing column of barium within the esophagus. And so we can do this over time, kind of see how patients' symptoms are progressing or in response to therapy, either a POM or a surgical myotomy and fundoplication. And so we'll ask all of our patients with known or suspected achalasia to drink 200 mLs of thick barium as quickly as they can. And we take images, the kind of one, two, and five-minute time points. And so we're trying to quantitate the standing height and width of that column at those various time points or in response to intervention. This would be an example of a patient with achalasia who has absent primary peristalsis. So they're in that recumbent RAO position. We ask them to take a big drink of barium from the cup. We can see that that bolus comes down to about the level of the mid-esophagus and stops. There's no primary peristalsis within that mid- and distal esophagus. We can see that tapered narrowing at the level of the GE junction here. And these patients almost universally retain the 13-millimeter barium tablet at that area of tapered narrowing. Okay, so if we look at eosinophilic esophagitis specifically, so some of the things that we can see on an esophogram in patients with EOE would be esophageal strictures, you know, smooth contour, tapered margins, in contrast to shouldered strictures or ulcerative strictures that we could see with esophageal malignancy. We can look for diffuse esophageal narrowing or a small-caliber esophagus. And then where our mucosal relief views really excel would be in the depiction of these esophageal mucosal rings. So we can get a pretty good look on some of these standing upright images at that ringed appearance of the esophagus. We have another case here where we can see kind of that corrugated appearance, you know, within the mid-esophagus here at the level of the aortic arch, and we can see some subtle ridges extending all the way inferiorly to the level of the GE junction. This would be more of a 5-plus case of EOE where we can see these diffuse prominent rings extending along the entire course of the esophagus. I know these numbers are hard to read, but this would be an example of a patient with diffuse esophageal narrowing. So when we start to get under about 2 centimeters on esophagography, that's when we start to wonder about underlying pathology. So we have this patient in that recumbent REO position. They're drinking as fast as they can, trying to really maximally distend out that esophagus, and we can try to provide maximum and minimum esophageal diameter. And so we can see in this patient, the maximum esophageal diameter here in the level of the mid-esophagus is about 17 millimeters. As we get down toward the GE junction and the distal esophagus, the esophagus is really only distending out to about 10, 11 millimeters. And so this, as with akalasia, this is something that we can evaluate over time or in response to therapy. So we have some patients who come in every 6, 12, 18 months. We can provide maximum and minimum diameters, get a sense of how things have changed. Or we can image patients following steroid therapy, esophageal dilatation, and just see how that luminal diameter improves in response to therapy. And so just a few words now on postoperative, postprocedural complications. So esophagography can be performed in the immediate postprocedural or postoperative period. We'll generally do it with a little bit of water-soluble contrast, looking for a large-volume esophageal leak. If we don't see anything that looks like a leak, we typically repeat the exam with some thick barium. We use that denser, more viscous liquid to see if we can really bring out any subtle leaks or fistulae. And so this was a patient who actually came to us from pulmonology, had developed a chronic cough following repeated esophageal dilatations on the outside. These aren't the best upright mucosal relief images. We can see that there's a pretty dense column of barium in that mid and distal esophagus here. As we chase this bolus down, we can see that it almost looks like there's a little tail of contrast arising from that right lateral wall of the esophagus. I like to tell all of our residents that the keys to fluoroscopy are gravity and time. So if you see something that looks kind of abnormal on that right side of the esophagus, we can put that patient right side down, have that individual drink barium, and just see how things evolve over time. And so in this patient, that's what we did. We put them into that recumbent RAO position, had that person continue to drink quickly, and we could see that there is, in fact, a patent channel on the right lateral wall of the esophagus here. We're starting to opacify airways in the right lower lobe of the lung. We ended up with a pretty nice barium bronchogram here. So we've got a pacification of almost the entire bronchial tree in that right lower lobe, as well as the trachea, main stem bronchi, and this patient had a subsequent chest CT. If I can get this to play, this is the esophagus here. We can see that there is an abnormal patent communication extending into the right lower lobe of the lung there. We have a bronchoesophageal fistula, both on fluoroscopy and on CT. This was another patient came to us following a gastrectomy done overseas, had chronically elevated white count, low-grade fever, and so we started off with an esophogram. We had this patient take a drink. We're kind of looking, trying to get the lay of the land. So we can see the esophagus here. There are loops of small bowel in the left upper quadrant, so we're kind of looking at the esophagojejunal anastomosis here. As we progress through, we're kind of looking now at the distal esophagus. There are loops of small bowel in that left upper quadrant, kind of like that previous case. We can see that there's a little area, a little tail of contrast, sort of fills and empties throughout the course of the examination. So if we focus in on that area, you can see that the distal esophagus is here. You can see loops of small bowel and jejunum in that left upper quadrant, and we're starting to fill this irregular cavity along the posterior aspect of that esophagojejunal anastomosis, looking at it in profile here where we can see that there's that abnormal cavity extending posteriorly from the esophagojejunal anastomosis. This patient also had a chest CT. We can see that there is that abnormal cavity extending posteriorly into the left pleural space. So this was a patient with a contained perforation or leak extending from the esophagojejunal anastomosis into that left pleural cavity. Finally, just a couple quick words on kind of Roux-en-Y gastric bypass. Esophagography is actually really good for the evaluation of the gastric pouch and the gastrojejunal anastomosis, and it's superior to CT for the assessment of gastro-gastric fistula or areas of anastomotic narrowing. This was a patient who had weight gain following a Roux-en-Y gastric bypass, yet underwent a CT of the abdomen and pelvis. It's pretty normal. We can see the pouch and the excluded stomach in that upper abdomen, and there's really nothing on that CT that appears pathologic, nothing obvious for a gastro-gastric fistula on the CT. It came to us for an upper GI, and again, we can see contrast in the esophagus here. We're trying to get the lay of the land and kind of find that surgical site, and we're starting to get into gastric pouch here, but it looks like there's pretty prompt opacification of the greater curvature of that excluded stomach. So we have an exposure here where we're seeing gastric pouch. This looks like greater curvature of the stomach with mucosal folds here, and as the examination progresses, we can see that we opacify that gastric pouch. We have a pretty normal-looking Roux limb here, but we do have opacification of the excluded stomach as well as the proximal duodenum, so a large gastro-gastric fistula that's pretty evident on fluoro, but a cult on CT. This was a patient who came in with chest pain following a Roux-en-Y gastric bypass, came to the ED, had a CTPE that was negative, no evidence of PE. We're just kind of getting into his gastric pouch on those cuts of the upper abdomen here, but nothing on the chest CT that could explain his pain, so he underwent an upper GI to look at that surgical anatomy. You can see that he has a dilated pouch. There's a lot of fluid kind of retained within that pouch, and what looks like a pretty tight gastrojejunal anastomosis right here prior to his Roux limb. As the exam progresses, we can see that that pouch is not emptying particularly well. It's dilated. That anastomosis is really only distending out to about one to two millimeters. Similar view here on our AP images, a pretty tight gastrojejunal anastomotic stricture, and this patient underwent a successful endoscopic dilatation of that gastrojejunal anastomotic stricture. It came to us for a follow-up upper GI where we can see that that anastomosis looks a little more open, and the pouch was emptying better in real time. This was just a patient who came to us for an upper GI, had had a partial gastrectomy, was having nonspecific abdominal pain. We see the staple lines from that subtotal gastrectomy or partial gastrectomy, and what looks like kind of a disc-shaped flat object here, almost looks like a coin or a button battery persisted throughout the course of the exam. We can see a halo of edema here, and this was a patient who was swallowing foreign objects, coins, batteries, and so on and so forth. As a radiologist, I do still have to talk to patients, but in situations like this, I'm glad to be able to refer them back to people like Sorel and our excellent colleagues in GI. That is all I have. I appreciate your attention, and I'd be happy to answer any questions. Thank you, Dr. Olson. It's very, very helpful and informative talk. I would probably start with the panelists. Are there any questions? Yes, great, great talk, Dr. Olson. You know, when we send patients to get an esophogram, we'll often have discussions about tertiary contracts or tertiary waves. Can you kind of comment on what all that means? I think the average person that's not a radiologist that's practicing sometimes doesn't quite know how to interpret what all that means and whether it's pathologic and whether it would lead us towards a differential diagnosis. Right, yeah. You know, I think esophageal dysmotility may kind of be the bane of the existence of some of our colleagues in GI here. I think on an esophogram, you know, if you could recall from those initial videos we showed, what we're kind of looking for is that nice normal primary peristaltic wave. We want to see an uninterrupted stripping wave that carries that bolus all the way from the esophagus to the stomach. Those tertiary, those non-propulsive contractions are kind of just disordered, disorganized, you know, no antegrade motion. So we're looking for things like stasis. You know, it's kind of a buzzword, too, for esophageal spasm. If we're talking about tertiary contractions or that corkscrew appearance of the esophagus where we can see it collapse and contract, but it's not propelling that bolus toward the stomach. We're just kind of seeing to and fro flow, stasis of contents. You know, and so in certain situations, you know, in patients with suspected, you know, vigorous achalasia or esophageal spasm, we can be a little more specific. Oftentimes we're stuck just saying that there's some nonspecific esophageal dysmotility kind of kicking things back to manometry. Got it. Got it. So you might say absence of primary stripping wave, that tells you something big is going on. Presence of tertiary contractions tells us there's obviously something motility-wise. And then the tiebreaker would be or the next test would be manometry to help characterize that. Correct. Correct. A couple of questions on the Q&A. The first one is anyone using the one-hour esophageal string test? You know, I guess I'm not familiar with the one-hour esophageal string test. I guess I don't know what that entails. I think that might have been a holdover from our previous talk. That's a minimally invasive test that can be done where you can drop a string in there and essentially pull and get some tissue sampling. It's a less invasive method. I can tell you, we've never used it. I don't know if Sarla and Mayo, have you guys been looking at that from research purposes or for anything else? We're using it clinically for, especially in reintroduction of food elimination as a sponge where they have this sponge on the capsule and patients swallow it in the office and it gets esophageal samples. And you find it to be pretty effective? I can't. I think the jury is still out on how that's going to turn out to be. Next question is how long can a patient expect the esophagram to take in total? I would say in most cases and somebody who's able to cooperate, move pretty well, turn and roll, we can finish most of these exams in five minutes, 10 at most. If they struggle and you're trying to adequately position patients who are a little more debilitated, up to 15 minutes or so. But for the most part, it's a pretty quick test. To build on that, Dr. Olson, is this the Mayo approach to doing an esophagram or is this an esophagram protocol that we should expect if we ordered it at any hospital in the country? You know, unfortunately, it's one of those things where I think fluoroscopy is a little bit of a dying art. I think that if you read any paper on the appropriate performance of an esophagram, this is how it should be done from start to finish, kind of double con these various projections and views. I think that sometimes, you know, it sort of devolves to the point where people are, you know, taking a few swallows of barium upright and we're acquiring a few images and that's kind of the extent of it. So if you find that that is the case with some of the images you're getting, I would encourage you to reach out to your radiologists and maybe ask them for a little bit more.

esophagram

esophageal motility

eosinophilic esophagitis

radiology

barium swallow

diagnostic imaging