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Hiatal Hernias
Patients with GERD often are found to have hiatal hernias, which
can be identied on the barium esophagram. There are four types
of hiatal hernias. A type I hernia is also referred to as a sliding
hernia and involves displacement of the gastroesophageal junction (GEJ) above the diaphragm. A type II hernia is characterized
by the GEJ xed below the diaphragm with herniation of the gastric fundus above the diaphragm. A type III hernia involves both
the GEJ and gastric fundus herniating above the diaphragm and a
type IV hiatal hernia involves both gastric and non-gastric viscera
herniating above the diaphragmatic hiatus [22]. Hiatal hernias can
be identied on esophagography when the gastric rugal folds or a
gastric bubble is noted to be above the level of the diaphragmatic
hiatus (Fig.4.4). Esophagography has superiority over endoscopy
in identifying hiatal hernias, especially type I sliding hernias. The
improved identication of sliding hiatal hernias is a result of
increased intraabdominal pressure while being in the prone position causing the hernia to be more apparent than when the stomach is insufated with air [23]. Identication of hiatal hernias in
the workup of foregut disorders is very important as their identication can alter the therapeutic plan for patients. Radiologists
should be discouraged from characterizing hiatal hernias as small,
medium, or large as no such standard exists. Rather, they should
be described in terms of axial and transverse length, as well as
relative positioning of the LES, fundus, and give information
regarding evidence of organo-axial or meso-axial volvulus.
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Fig. 4.4 Type III paraesophageal hernia. The red line represents the outline
of a type III paraesophageal hernia. The blue line represents the diaphragm
E. J. Furay et al.
Esophageal Diverticula
The esophagus can develop multiple types of diverticula, such as
Zenker’s, pulsion, and traction diverticula. A Zenker’s diverticulum
is an acquired outpouching of mucosa and submucosal layers
between the cricopharyngeal and the inferior pharyngeal constrictor muscles resulting in a false diverticulum [24]. On esophagography, the diverticulum usually arises from the midline of the posterior
wall and is best identied on the lateral view of the esophagram
(Fig. 4.5) [25]. Pulsion diverticula typically occur in the distal
esophagus and are usually associated with motility disorders of the
esophagus. They do not contain the muscular layer of the esophagus, thus making them a false diverticulum. On the esophagram,
they appear as broad-based contrast-lled outpouchings and typically retain barium after the esophagus has emptied [26, 27]. In
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Fig. 4.5 Zenker’s diverticulum
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contrast, traction diverticula are typically seen in the mid-esophagus and contain all the layers of the esophagus and thus are considered a true diverticulum. They are caused by mediastinal scarring
secondary to infectious processes, leading to traction on the adjacent esophagus [27]. On barium swallow, traction diverticula tend
to have a triangular and tented appearance [27, 28]. Esophagram
allows for safe identication of this diverticulum and in some cases
is enough workup to warrant operative intervention.
Neoplasms
Other structural abnormalities such as malignant and nonmalignant tumors are able to be identied on an esophagram. These
present as crescent-shaped lling defects. More benign tumors are
characterized by smooth edges without irregularity or ulceration,
whereas more malignant tumors commonly result in irregular
luminal narrowing and ulcerations (Fig.4.6) [29]. It is important
to note that these ndings and alarm symptoms for malignancy
must be further evaluated using endoscopy.
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E. J. Furay et al.
Fig. 4.6 Mid-esophageal tumor seen as a crescent-shaped lling defect on
the esophagram
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Perforation
Iatrogenic, spontaneous, and traumatic esophageal perforations
may have different management strategies, but their diagnostic
approach remains fairly similar. In an unstable patient with a high
index of suspicion for esophageal perforation, regardless of etiology, operative intervention should not be delayed. In those patients
who are stable and further workup is reasonable, utilizing esophagography is useful. Although we commonly advocate using barium for most esophagrams, when investigating for a perforation
we advocate for the initial use of a water-soluble contrast because
barium extravasation into the mediastinum carries a risk of mediastinitis/pleuritis and is harder to washout during surgical exploration [30]. If no perforation is identied using water-soluble
contrast, further evaluation using barium should be considered if
there is a high clinical suspicion for perforation. The identication of contrast extravasation from the esophageal lumen conrms
the diagnosis of esophageal perforation.
Motility Disorders
Esophageal motility disorders are commonly seen in patients with
GERD, with some sources quoting esophageal dysmotility in up
to 44% of patients with GERD [31]. Schima etal. reported that
esophagram has about a 79% sensitivity rate for identifying dysmotility in patients with dysphagia [32]. During an esophagram, a
radiologist not only assesses structural abnormalities, but also
evaluate the esophagus for functional disorders. In a normal
esophagus, the primary peristaltic wave and occasionally a secondary peristaltic wave are able to clear a contrast bolus [13]. For
a radiologist to consider clearance of the contrast bolus to be normal, the patient should clear the bolus in two or fewer strippings
from the esophagus [12]. Tertiary contractions are one of the ndings suggestive of disordered esophageal motility, but when
patients with tertiary contractions were further evaluated with
high-resolution manometry (HRM), only about 47% had conrmed dysmotility [33].
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E. J. Furay et al.
In addition to minor motility disorders, barium esophagrams
can be useful in diagnosing more severe forms of motility disorders such as achalasia and diffuse esophageal spasm. While highresolution manometry remains the gold standard for these
diagnoses, barium esophagrams have proven to be a practical and
benecial initial diagnostic test.
Achalasia is a condition associated with the loss of myenteric
plexus ganglion cells in the distal esophagus and lower esophageal sphincter (LES) leading to impaired relaxation of the LES
and aperistalsis in the esophageal body. On the esophagram, the
most diagnostic nding is a dilated esophageal body and distal
narrowing at the LES creating the classic “bird’s beak” appearance (Fig. 4.7). Patients with achalasia will demonstrate bolus
retention in the distal esophagus [34]. Blonski etal. examined different characteristics of the barium esophagram in patients with
achalasia and proposed that a barium column height of >2cm at
5min from ingestion of barium be used as a cutoff point for identifying patients with achalasia [35]. When ndings on the esophagram suggest achalasia, the diagnosis should be conrmed and
categorized using HRM.
Diffuse esophageal spasms (DES) are characterized by abnormal
esophageal peristalsis with multiple simultaneous non- peristaltic
contractions [36], often leading to chest pain and dysphagia This
disorder is classically seen with a distinct “corkscrew appearance” caused by intermittent bouts of nonpropulsive contractions
causing alternating areas of narrowing and normal esophageal
diameter [36]. Similar to achalasia, esophagography ndings suggestive of DES should be conrmed with HRM prior to initiating
therapy.
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Fig. 4.7 Typical bird’s beak appearance in a patient with achalasia
Utilization inPre- andPost-surgical
Management
The esophagram plays an important role in surgical planning for
patients undergoing antireux surgery (ARS). During the upright
double-contrast phase of an esophagram, the radiologist is
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E. J. Furay et al.
sometimes able to identify a foreshortened esophagus. This
becomes important in surgical planning as patients with signicant esophageal foreshortening occasionally require esophageal
lengthening procedures such as a Collis gastroplasty. The knowledge of this prior to the operation can prepare the surgeon for this
possibility or refer to a provider with the knowledge and skill in
performing esophageal lengthening procedures [37].
Although a small sample size, Kahrilas and colleagues were
able to show a correlation between normal esophageal motility in
barium studies and normal peristalsis on manometry [38].
Alicuben etal. also demonstrated that an esophagram is a good
screening tool for esophageal motility disorders. They were able
to show that a normal esophagram, which they dened as stasis of
liquid barium on less than three of ve swallows, can reliably rule
out the presence of clinically signicant esophageal dysmotility
in preoperative patients [39]. Overall, we do not recommend
omitting manometry in the workup of a patient undergoing antireux surgery, but there is a select subset of patients who are unable
to tolerate catheter placement during manometric studies or have
a large paraesophageal hernia in which the catheter may coil in
the stomach, and an esophagram may aid in surgical decisionmaking.
Esophageal dysmotility has been suggested as a reason many
surgeons avoid complete Nissen fundoplication and instead perform partial fundoplications because of the fear of signicant
postoperative dysphagia. Two small randomized controlled trials
were able to refute this notion, both showing no signicant difference in outcomes between patient surgery tailored to their preoperative esophageal motor function compared with those whose
surgery was not tailored to their esophageal function [40, 41].
Baigrie etal. advocated that laparoscopic Nissen fundoplication
(LNF) should not be considered a contraindication in patients
with disordered peristalsis as they were able to show similar satisfaction between those with and those without disordered esophageal peristalsis after LNF [42].
After ARS, esophagrams are extremely valuable in assessing
dysphagia or recurrent GERD symptoms. They are able to evaluate the integrity and positioning of a fundoplication, conrm the
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Fig. 4.8 Recurrent hernia after previous Nissen fundoplication
adequate position of a magnetic sphincter augmentation device,
and can identify recurrent hiatal hernias (Figs. 4.8 and 4.9).
During the double-contrast portion of the esophagram positioning, the patient supine or in a slight Trendelenburg position can
allow contrast to reux into the fundoplication and assess its position and ensure its integrity [37]. A form of secondary achalasia
can develop in patients whose fundoplication was created too
tightly and an esophagram may show the characteristic ndings of
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Fig. 4.9 Wellpositioned magnetic
sphincter augmentation
device on the distal
esophagus below the
hiatus
E. J. Furay et al.
a patient with achalasia without the associated dilation of the
more proximal esophagus [43]. Diagnosis of this early is important as treatment for this may involve dilation of the wrap or even
surgical revision of the fundoplication [43].
Conclusion
The humble esophagram is an excellent initial imaging modality
for the evaluation of suspected esophageal diseases or to evaluate
postoperative complications in ARS. It provides excellent structural detail and gives insight into esophageal function. When
properly utilized and interpreted by the foregut surgeon, the
esophagram is integral in the evaluation of patients with diseases
of the esophagus and stomach.
Author Contributions EF involved in the literature review; EF
wrote the study; and EF, SD, and FPB involved in critical revision.
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