Radiology

1. BARIUM SWALLOW
DR. ATHUL D
JR MDRD

2. • Barium swallow is the non invasive contrast procedure used in
assessing the anatomy, physiology & pathology of upper GI tract
including esophagus & GE junction.
• Barium has superior contrast qualities and unless there are specific
contraindications, its use (rather than water-soluble agents) is
preferred.

3. BARIUM SULPHATE - 250% OF HIGH DENSITY LOW VISCOSITY
• the most common material for radiographic visualisation of GIT.
• made up from pure barium sulphate.
• For stability particles are small (0.1 -3 micron)
• A non-ionic suspension medium is used to avoid clumping.
• Ph is 5.3 , which makes it stable in gastric acid.

4. • (a) Ba has a high atomic number
56. Therefore, it is highly
radioopaque
• (b) Non absorbable, non-toxic.
• (c) Insoluble in water/lipid.
• ( d) Inert to tissues.
• (e) Can be used for double contrast
studies
PROPERTIES OF AN IDEAL BARIUM
PREPARATION
1. High density for optimum study
being performed.
2. Stable suspension which does not
settle.
3. Should not flocculate with
secretions.
4. Low melting characteristics to
give a good and stable mucosal
coating.

5. ADVANTAGES & DISADVANTAGES OF BARIUM
Advantages
• Not absorbed or degraded by the
GIT.
• coat the mucosa in a thin layer
for long period of time, thus
allowing the introduction of a
second or negative contrast
agent without significant
degradation.
• Low cost
Disadvantages-
 Leakage into mediastinum or
peritoneum can cause fibrosis.
 Subsequent abdominal CT or US
are rendered difficult.
 Intravasation – this may result in
a barium pulmonary embolus,
which carries a mortality of 80 %

6. WATER SOLUBLE CONTRAST MEDIA :
 Indications:
• 1. Suspected perforation.
• 2. Suspected fistula.
• 3. History of recent biopsy.
• 4. Suspected Lower Intestinal obstruction.
• 5. Corrosive poisoning.
• 6. Meconium ileus/plug syndrome.
• 7. Immediate post operation status
 Complications:
Pulmonary edema if aspirated,
not with LOCM
Hypovolemia in children,
May precipitate in hyperchlorhydric
gastric acid,
Allergic reactions – due to absorbed
contrast media
Like Gastromiro (Iopalmidol 61% w/v) or Gastrografin (Meglumine & Sodium
diatrizoate 76% w/v)

7. Equipment's
• Rapid serial radiography or
cineradiography (2 frames
per second), or
• Video recording, or
• 100 mm roll films.
Patient preparation
• NPO for 4 hours
• Avoid smoking

8. TECHNIQUE
A. Single contrast swallow :
• Position – RAO
• Patient is asked to take a
mouthful of barium and initial
screening is done as it passes
along the whole length of
esophagus to note any gross
lesion.

9. PHARYNGOESOPHAGEAL EVALUATION :
• This includes cineradiography of oral & pharyngeal phases of
swallowing & double contrast (DC) spot films of pharynx &
upper esophagus.
• Usually films are taken in frontal & lateral projections.
• Patient is asked to swallow a mouthful of thick barium
suspension & asked to phonate with a long vowel sound or to do
modified valsalva maneuver

10. LEFT: Lateral view during Hyoid (H)
and tongue base (T) move anteriorly.
Left and right piryform sinuses are
projected on top of each other. Tip of
soft palate (SP) is seen.
RIGHT: Valleculae (V) and pyriform
sinuses (P).

11. 2. Evaluation of esophagus :
 Barium filling method
• This is the basic film obtained while examining the
full length view of esophagus distended with
barium.
• Position – RAO
• Patient is asked to swallow continuously ( so as to
reflexly inhibit the peristalsis & distend the
esophagus), & either full length view or atleast two
spot films showing the upper & mid and mid &
lower part is taken.
• This method is important to demonstrate firstly the
structural abnormalities and secondly for adequate
visualization of distal third esophagus &
esophagogastric junction.

12. MUCOSAL RELIEF FILMS
• it is defined as films taken of collapsed esophagus
with esophageal folds visible & coated with
barium suspension.
• Patient is asked to take one or two swallows of
dense barium suspension & after peristalsis has
stripped most of the barium into the stomach,
radiographs are taken.
• It is important in the diagnosis of reflux
esophagitis, infectious esophagitis & esophageal
varices.

13. DOUBLE CONTRAST SWALLOW :
• DC radiographs are obtained after the mucosal surface
has been coated with a thin layer of high density
barium & the viscus has been distended with air.
• First the patient is given
intravenous Buscopan or Glucagon
gas mixture and then,
A bolus of barium is given to be swallowed quickly.
Spot films are taken in erect RAO & LAO position to show
the body of esophagus & gastro-esophageal junction.

14. Lower esophageal rings
• A-Ring
• Muscular contraction at the junction of tubular and vestibular esophagus
• No definite anatomic correlate
• B-Ring
• Mucosal ring at anatomic squamocolumnar junction (Z-line)
• Best or only seen with vestibular distension
• Normally < 1 cm above diaphragm
• May cause episodic dysphagia if esophagus is narrowed, then termed a
Schatzki ring
• > 20 mm wide, no obstruction
• < 13 mm wide, almost always intermittent obstruction
• 13-20 mm wide, may obstruct

15. Esophageal ring due to muscular contraction. It varies
during examination and may not persist.
On the left a patient with a ring due to muscular
contraction. Notice incidental gastric diverticulum
(asterisk).

16. The esophageal B-ring is located at the squamocolumnar
junction,
The appearance does not change during the examination.
On the left a patient with a 'B' ring (arrows) several cm
above diaphragm at the apex of sliding hiatus hernia.

17. MODIFICATIONS
1. Suspected leak :
• In cases of suspected leakage of contrast into mediastinal /
pleural / peritoneal cavities, the choice of contrast medium
changes.
 Barium – problem with barium is two fold,
i. Its potential to stimulate a fibrotic reaction, and,
ii. It may remain loculated in mediastinum & obscure follow up
studies for months or even years.

18. Water soluble contrast medium eg. Gastrografin - only problem
with these agents is that details obtained are not as good as
barium & there is possibility of missing esophageal lesions.
Usual policy is to start with water soluble contrast medium

19. 2. RISK OF ASPIRATION :
• The Choice of contrast media will be :
Barium – If aspirated it doesn’t incites a reaction in the bronchial
tree and is usually coughed up without any sequel. large volumes
can however give rise to severe respiratory embarrassment and
even deaths.

20. Ionic Contrast Media – Gastrografin
It can cause a very severe form of chemical pneumonitis and
consequent acute pulmonary edema.
Non-Ionic Contrast Media – Gastromiro
No such problem.
• So best is to use Low osmolal Contrast Media and if not then little
amount of barium.

21. 3. MOTILITY DISORDER :
• Swallow in lying down position
• Position : For motility disorders, a prone swallow is essential to assess
oesophageal contraction in the absence of gravity
• Patient is asked to take single swallow at a time.
• First 5 swallows are monitored to evaluate motility and then two oblique
spot films are taken- +ve if 2 or > are abnormal

22. 4. Achlasia :
Early stage - is difficult to diagnose.
• It is suggested by the s.c. injection of
methylcholine ,which leads to
esophageal stimulation and contraction,
leading to chest pain. (mecholyl test)
• The above test should be performed
along with esophageal manometry.

23. LEFT: Dilated esophagus (arrows) is projected behind
right atrium.
MIDDLE and RIGHT: Smooth, tapered narrowing just
above diaphragm (arrows).

24. VARICES :
Prone RPO position.
High density barium paste is used
Single contrast Mucosal Relief film should be taken.
Buscopan i.v. is given to enhance variceal filling by
making esophagous atonic, which results in decreased
intra luminal pressure and so enhancing filling of
submucosally located varices.
Spot films are taken in between the peristalsis

25. UPHILL VARICES
• With portal hypertension, elevated portal
venous pressure leads to reversed
(hepatofugal) flow bypassing the liver through
the left gastric vein to dilated esophageal and
periesophageal veins that anastamose with the
azygos and hemiazygos veins which drain uphill
into the superior vena cava.
•
Filling defects due to varices are characterized
by change in appearance during the
examination related to breath holding and
thoracic pressure.
uphill varices.

26. Varices- These may be
demonstrated on a
barium swallow as
typical serpiginous
filling defects in the
lower oesophagus
when caused by uphill
varices .

27. DOWNHILL VARICES•
With superior vena caval
obstruction, upper body venous
blood flows
caudally downhill through
esophageal veins to the azygos
vein which empties into the
superior vena cava caudal to the
obstruction.
If the obstruction is at or below
the azygos, the blood flow extends
further caudally to the portal
system and then the hepatic veins
to the inferior vena cava and the
right atrium.
On the barium study inconstant filling defects (arrows)
represent downhill varices in upper esophagus.
The angiogram demonstrates collateral vessels including a
dilated left superior intercostal vein (arrow).

28. Aberrant right subclavian artery
This is the most common thoracic
arterial anomaly and rarely causes
symptoms.
The artery extends up and to the right
producing a dorsal diagonal
impression on the esophagus
(arrows).
The CT demonstrates that the aberrant
artery (arrow) is last vessel from arch
and extends dorsal to trachea and
esophagus.

29. CT shows right arch (R) and aberrant left subclavian artery (arrow) arising low off
arch and extending to left dorsal to esophagus and trachea.
On the left the esophagram of a patient with a right arch that produces a dorsal
indentation on this lateral view (blue arrow).
The diagram shows the aberrant left subclavian artery (L SCA) dorsal to the
trachea and esophagus.

30. Double Arch
Double arch most often
presents with airway
obstruction, dysphagia,
aspiration in children.
The arches indent esophagus
at different levels.
Double Arch
LEFT: Right and left arch indent esophagus (arrows) at
different levels
RIGHT: Angiogram with double arch in asymptomatic 65-
year-old

31. Tortuous aorta
A tortous descending aorta is a
common cause of extrinsic
impression on the esophagus.
The image on the far left shows a
narrowed distal esophagus.
Oblique view shows esophageal
indentation by aorta with obtuse
margins (arrows) characteristic of
extrinsic compression.

32. Coarctation
On the left 3 images of a patient with a
coarctation.
On the chest film the 'Figure 3' shape
of aortic knob due pre and post
stenotic dilatation (arrows).
The barium study demonstrates the
'Reverse 3 figure' indention of
esophagus by pre and post stenotic
aortic dilatation (arrows).
An angiogram demonstrates a
coarctation with pre and post stenotic
dilatation in another patient.

33. Table is kept in head down position.
Patient is first placed in Lt decubitus and
then turned supine; which causes Barium to
accumulate in fundus of stomach. Patient is
then slowly turned to Right causing Barium
in fundus to pour over Cardia;during this
maneuver reflux may be seen.
Abdominal compression can also be given to
help precipitate reflux and using a DC
technique.
Siphon test. Fill the stomach with 50%
Barium (150-200 ml). Follow this with 1-2
mouthfuls of water to remove traces of
barium in the oesophagus. Make the
patient supine with left side raised 15 up.
Keep one mouthful of water in the patients
mouth. Ask the patient to swallow the
water-a jet of barium will shoot into the
water column as it enters the G.O. junction.
Reflux :

34. Air-contrast esophagram shows thick esophageal mucosal folds (arrows)
and an ulcer (arrowhead) due to GERD.
Single contrast esophagram shows stricture (arrow) and sliding hiatus
hernia

35. On the left Irregular stricture (arrowhead) and erosions (arrows) due to
GERD.

36. Barrett's esophagus with reticular mucosa and web-like (arrow) stricture

37. On the left a patient with a Barrett's esophagus with an adenocarcinoma.
There are abnormal distal mucosal folds.
The upper margin of adenocarcinoma makes right angle with esophageal
wall (arrow) indicating a mural lesion in patient with GERD and Barrett's
esophagus.

38. Infectious esophagitis
Candida esophagitis
On the left a patient with an
infectious esophagitis due to
candida.
The barium study shows
numerous fine erosions and
small plaques due to Candida
albicans in
immunocompromised patient.

39. Cytomegalovirus esophagitis
an AIDS patient with an infectious
esophagitis due to Cytomegalovirus.
Such giant ulcers can also be due to
HIV alone.

40. Crohn's esophagitis
On the left a patient with
Crohn's disease.
There is a granulomatous
esophagitis with aphthous
ulcers (arrows).
This is an uncommon
manifestation of Crohn's
disease.
The figure on the right shows
the more common colonic
aphthous ulcers.

41. TB esophagitis
a patient with an infectious
esophagitis due to primary TB.
There is an irregular sinus tract
from proximal esophagus (arrow).
Chest radiograph shows enlarged
lymph nodes widening
mediastinum due to primary
tuberculosis.

42. Pseudodiverticulosis
Dilated mural glands or
pseudodiverticulosis, is usually
associated with histologic or
endoscopic signs of inflammation, and
many patients have strictures due to
GERD.
On the left a patient with esophageal
pseudodiverticulosis.

43. Hiatus :
.
• Patient has to strain.
• Patient is asked to lie down, straighten
the legs and then raise them up.
• Manual compression of the abdomen.
• Patient stands upright, ask him to bend
downwards with legs straight.

44. Sliding hernia
GE junction is below the
esophageal hiatus.
Later, stomach protrudes
through hiatus.
Neither the hernia or stricture
(arrow) due to reflux esophagitis
were visible early in the
examination.

45. View of a large
sliding hiatal hernia
that demonstrates
gross spontaneous
gastro-oesophageal
reflux when the
patient lifts the left
side whilst in the
supine position.
Note also the
marked oesophageal
inco-ordination
produced by the
reflux.

46. An example of a
fixed sliding hiatal
hernia together with
several B or Schatski
rings.

47. PARAESOPHAGEAL HERNIA
•
Large hernias can cause symptoms,
and with progressive hiatal
widening, increasing protrusion
and rotation of the stomach can
lead to gastric volvulus that can be
complicated by hemorrhage,
obstruction, strangulation,
perforation. On the left gas filled gastric fundus (asterisk) protrudes through
hiatus but GE junction (arrow) is below diaphragm.
Next to it a paraesophageal hernia with most of 'upside down'
stomach in chest with greater curvature (arrows) flipped up.

48. Distal esophagus is adjacent to the herniated gastric fundus, but unlike a
paraesophageal hernia, the gastroesophageal junction (arrow) is above
rather than below the diaphragm.

49. 9) Bread Barium :
Indication :
 when a stricture is suspected but can’t be
adequately demonstrated, or
questionable motility disorder.
Patient is asked to swallow a piece of bread
soaked with barium.
This gives useful information about localized
non- distentability or areas of poor contraction.

50. A. Initial nonpropulsive tertiary contractions B. Three
images during examination show collections resembling
diverticula C. Image later in examination shows resolution
of tertiary contractions

51. ESOPHAGEAL WEB
• Can be congenital or acquired
• Most in hypopharynx and proximal esophagus
• Majority protrude from anterior esophageal wall
• Symptoms if lumen > 50% compromised
• Sideropenic dysphagia (Plummer-Vinson syndrome)
• Iron deficiency anemia
• Esophageal web with dysphagia
• Increased incidence of carcinoma
• Validity of syndrome debatable

52. • Webs usually occur at the level of the hypopharynx or the upper
esophagus, producing dysphagia for solids.
Liquids usually pass well, but in many cases a 'jet' is seen.
The passage of solid food may produce irritation or damage to the
mucosa, resulting in a globus feeling.
They are best diagnosed on the lateral projection of the barium
swallow.

53. Web (small blue arrow). Contrast passage causes a
jet phenomenon (broad arrow)

54. images of a 42-year-old woman with
dysphagia due to web.
There is > 50% luminal narrowing

55. On the left a patient with a Zenker's diverticulum as a
result of premature closure of the cricopharyngeal
muscle.

56. LEFT: Small diverticulum (arrow) in asymptomatic patient
RIGHT: Large diverticulum (arrow) in patient with aspiration

57. On the left small aortopulmonary diverticula (arrows), that are
incidental findings in two patients.

58. Pseudodiverticula can be seen in reflux esophagitis. On
the left a patient with a hiatus hernia, reflux
esophagitis, and pseudodiverticula (arrows) at site of
proximal stricture

59. Barium swallow demonstrating
the typical appearances of
oesophageal intramural
pseudodiverticulosis. The small
flask-shaped pits of contrast
(arrowheads) represent dilated
mucous glands and are
associated with a stricture at
the level of the aortic knuckle.

60. On the far left a stricture (arrow) with irregular mucosal folds at stricture site on
air-contrast view.
This patient had Barrett's esophagus.
Mid esophageal strictures and ulcers are suspicious for Barrett's esophagus.
The two images on the right show a Barrett's esophagus with an irregular
stricture due to adenocarcinoma.
STRICTURE

61. symmetric tapered benign stricture months after
radiotherapy.

62. images of a patient with a benign stricture high in
the esophagus (arrow).
There is bilateral lower lobe lung consolidation due
to repeated aspiration.

63. a high stricture (arrow) following caustic
ingestion

64. On the left a patient with benign pemphigoid.
Mucosal bullae have led to multiple strictures
(arrows).

65. Thank you