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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1015_Библиотеки_им_академика_М_И_Перельмана
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224 P. Pokieser and M. Scharitzer
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Fig. 41 a Left oblique projection of the lower esophagus before
b
the esophageal phase. b At 2 s after initiation of the pharyngeal
swallow.Here it isimportant to observethe timely,rapid emptying
that occurs; 10 ml of barium should be able to pass immediately.
The esophageal passagein the standing position takes place much
faster than that in the horizontal position,because of gravity. c At
2.5 s later, the bolus has passed. This is normal when the bolus
passes slowly through the esophagogastric junction. However,
‘‘10 ml barium—10 s’’ is a basic approximation of normal
esophagealtransport, in the erect and horizontal position (Schima
et al. 1992). If the bolus takes between 5 and 10 s, a fluid level
occurs for this short time span as a normal finding
Fig. 43 a This 65-year-old woman suffersfrom achalasia of the
lower esophageal sphincter. At 2 s after the pharyngeal phase,
parts of the bolus reach the esophagogastric junction. b At 8 s
after onset of swallowing, a little fluid level remains above the
esophagogastric junction (EGJ). c The passage of 10 ml of
barium takes morethan40 s inthiscase.Thepersistentfluid level
in the distal esophagus, which is characteristically seen with the
patient in standing position, moves up and down without
Symmetric Weakness of the Pharynx. The second
important functional disorder of this functional unit,
the pharynx, is weakness. It is present when residues
of contrast medium remain in the piriform sinuses and
the valleculae after swallowing.
Fig. 42 a A normal esophageal passage in right prone anterior
b
oblique position with the left shoulder raised. At the beginning
of the esophageal phase, a cranially V-shaped upper end of the
bolus (arrow) defines the peristaltic contraction, which pushes
the bolus caudally at a speed of 4 cm/s. Additionally, this view
provides excellent delineation of the PE segment during the
pharyngeal phase. b The bolus is followed through the middle
third of the esophageal tube. Small residues of contrast medium
completing the passage. This radiographic sign is also known
as a‘‘support level.’’ Establishing a delayedesophageal transport
in the erectpositionisa ‘‘must’’whenthe esophagus is examined.
Many patients with symptomatic achalasia without a marked
dilatation of the tube, such as in thiscase, arereported asnormal,
many radiologists do not know about this valuable sign. A
manometry should be performed in such cases
The coating of the pharyngeal walls differs with
the viscosity of contrast medium. Thus, the high
viscosity of barium paste facilitates the detection of
pharyngeal weakness (Figs. 29, 30).
that remain at the level of the aortic arch after the passage are
normal (arrow). Radiologically detectable motility disorders
are mainly depicted in terms of delayed passage, abnormal wall
movements, and structural lesions. Delayed passage is by far
the most common radiological functional finding in the upper
gastrointestinal tract. c 10 ml of barium suspension are
transported into the stomach at the end of the esophageal phase
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Fig. 44 a This78-year-old man suffers from achalasia.In severe
achalasia, a support level persists during the entire examination.
Onlysmallquantitiesofcontrast mediumareabletopassthrougha
beak-likeesophagogastric junction.In this case wealsosee strong
non-propulsive contractions—a further important functional
finding (arrows). b If the dilatation of the esophagus is severe
(arrows), the diagnosis of achalasia is almost always reported on
simple esophagrams. Note the inhomogeneous appearance of the
material within the massively dilated esophagus. This is due to
undigested food, that did not pass into the stomach
Fig. 45 a In this 65-year-old woman with achalasia, we have
already seen the support level (see Fig. 44) while standing. In prone
position, the contrast medium is initially transported. b Having
reached the EGJ, the contrast medium now flows back in a proximal
direction, becausetheesophageal contraction istooweak topropagate
10 ml of barium. This indirect sign of reduced contraction strength is
known as ‘‘proximal escape.’’ c The contrastmaterial has reached the
upper esophageal sphincter and flowed back to the upper esophageal
sphincter. Ingastroesophagealreflux,or even asasideeffect of various
medications, one frequently findsa motility disorderof the esophagus
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Fig. 46 a This 66-year-old post-bypass surgery patient takes
b
several different medications for his heart and has suffered from
reflux withmilddysphagia foralongtime.Theesophageal passage in
prone position has alreadybegun. b The bolus is segmented (arrow);
the upper part of the bolus is left by weak esophageal contraction.
c After the incomplete clearing of the bolus, the esophageal tube is
filled with thecontrast material, whichhad escapedproximally tothe
weak descending wave of primary peristaltic contraction
Fig. 48 a A 55-year-old woman with dysphagia and a carci-
noma of the proximal esophagus. An endoscope could not be
advanced; thereforeVF was thefirst diagnostic test.Note that the
carcinoma is invisible at the early esophageal phase. b For only
0.5 s, the narrow malignant stenosis is clearly depicted (arrows).
c A few frames later, the lesion is obscured. The dynamic
Asymmetric Pharyngeal Weakness. In the case of
pharyngeal weakness, it is important to distinguish
between unilateral or mainly unilateral pharyngeal
weakness and a bilateral symmetric pharyngeal
weakness, as the therapeutic alternatives differ.
The frontal view is most suitable for radiographic
diagnosis of a unilateral pharyngeal weakness, while
in oblique views, asymmetric retentions can be seen
with some experience (Fig. 31).
b
Fig. 47 a This 53-year-old man who has suffered from severe
dysphagia forsolidsforseveralyears, hasentirelyconstricting,nonpropulsive contractions. Three seconds after the onset of the
pharyngeal swallow, between the non-propulsive contractions,
roundsegmentsofthe tubedo notcontract(arrows).bTwoseconds
later the non-propulsive contractions have separated the noncontracting segments—‘‘cork screw’’ or ‘‘rosary bead’’ esophagus
investigation is especially advantageous in this setting, and the
lower spatial resolution of VF is compensated by the extraordinarily useful timeresolution, when esophageal stenosis has to be
diagnosed. At a frame rate of 3–4 spot films per second, digital
recording proves to be an alternative technique for structural
lesions, but not for dynamic evaluation of motility
Pharyngoceles. Pharyngoceles are usually small,
harmless, out-bulgings of the pharyngeal wall that may
become symptomatic when they trap ingested food,
which can cause mucosal irritation.Small pharyngoceles
without retentions are common and harmless (Fig. 32).
In rare cases, they can become enormous (trumpeter).
Space-Occupying Masses. Even large cervical osteophytes can be compensated without severe symptoms. A cerebrovascular accident may lead to a
are well known, but are non-specific descriptions of this severe
esophageal motor disorder. Manometry is the gold standard to
classifymotordisordersofthe esophagus.cThreeseconds later, the
esophagus shows smooth margins again. In patients with longlasting motor disorders, the non-propulsive contractions may be
shown constantly during all phases of swallowing
228 P. Pokieser and M. Scharitzer
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films; in symptomatic patients, endoscopy is usually
performed first.
4.3.6 Pharyngoesophageal segment
Normal Function. We will now discuss the sixth
functional unit of the swallowing act, namely the
pharyngoesophageal sphincter or segment (PE segment). It is closed by its resting pressure between
swallowing acts. Thus, it can be identified videofluoroscopically between the air column of the pharynx
at rest and the air in the cervical esophagus. The PE
segment consists of oblique parts of the inferior
pharyngeal constrictor muscle, the cricopharyngeal
muscle and parts of the cervical esophagus (Fig. 35).
Cricopharyngeal Bar. There are conflicting opinions about the percentage of narrowing allowing the
diagnosis of a sphincter disorder, but more than
20–30 % seem to be pathological. Three different
patients with varying degrees of incomplete opening of
the upper esophageal sphincter are shown in Fig. 36.
In the case of milddyskinesia, the dorsal indentation
of the barium is discrete. The indentation of a cricopharyngeal bar may occur at various times during the
passage of contrast medium. Furthermore, the indentation may be present for varying periods of time.
Gaping of the PE Segment. In cases of severe
neuromuscular disease, the upper esophageal sphincter may reveal a gap, resulting from weakness. The
resting pressure is no longer sufficient to close the
sphincter (Fig. 37).
Web. Thenext is a morphological finding that isbest
seen ondynamic recordings. So-called membraneflaps
Fig. 49 The most common stenosis of the esophagus is the
Schatzki ring; this shows a typical Schatzki ring in a 30-yearold man with dysphagia for solids (arrow). The ring is located
exactly at the gastroesophageal junction and is nearly always
combined with a hernia (arrowhead). It is crucial to investigate
the patient both prone and supine, since rings and hernias of the
EGJ may be seen in prone or supine position only. The Schatzki
ring acts as a diaphragm and can cause impaction of solid food.
During bolus passage, the ring is only visible for a second or
two, depending on the bolus volume
or webs are solitary or multiple thin mucous membranes, most frequently located in the anterior wall of
the upper esophageal sphincter. They are usually seen
briefly on a few images (Fig. 38).
Zenker’s Diverticulum. In the region of the pharyngoesophageal junction we find the clinically significant
Zenker’s diverticulum, which may substantially hinder
bolus passage, depending on its size (Fig. 39).
Small Zenker’s diverticula, or pseudodiverticula in
combination with a sphincter dyskinesia, may also
decompensation in such cases. It is often very difficult
cause complaints (Fig. 40).
to decide whether a resection of the osteophytic mass
can improve a patient’s swallowing function or not
(Strasser et al. 2000) (Fig. 33).
Space-occupying masses may markedly hinder the
pharyngeal passage (Fig. 34). It is rare that pharyngeal or laryngeal tumors are detected by VF or spot
4.3.7 Esophagus
NormalFunction.Theesophagus,theseventhfunctional
unit, is very different from the others. The esophageal
passage takes about 10 s—about ten times the duration
of the pharyngealpassage.Theexaminationtechnique is
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Fig. 50 a This 42-year old patient presented with recurrence of
severe dysphagia and heartburn after repeated dilation of a
laparoscopic Nissen fundoplication 6 years ago. Videofluoroscopy revealed a marked accentuation of the physiological
also different, as one moves the device along with the
slow peristaltic wave of the tubular esophagus from
cranialtocaudal.Thedeviceiskeptstationaryonlyatthe
beginning and the end of the esophageal passage. The
analysis is focused on the dynamic movements of the
esophageal walls (Figs. 41, 42).
hasis Type="Italic">Delay of Transport in the Erect
Position. One should keep in mind that pseudoachalasia [tumor stenosis of the esophagogastric junction
(EGJ)] cannot be differentiated videofluoroscopically
narrowing at theleveloftheaorticarch(arrow). b After ingestion
of a placebo tablet with a standardized diameter of 14 mm, the
tablet gets stuck at this level, revealing a significant esophageal
stenosis withan estimated lumenwidth of lessthan 1 cm (arrow)
from achalasia with certainty—endoscopy has to be
performed (Figs. 43, 44).
Delay of transport in the Horizontal Position. The
most frequent passage disorder is delayed esophageal
transport in the prone or supine position. In oblique,
prone RAO position, a single swallow of 10 ml is
partially transported (Figs. 45, 46).
Non-propulsive Contractions. Non-propulsive or
tertiary contractions are more or less strong constrictions of theesophagus that occurinaddition to thewave
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Fig. 51 a In this 15-year-old patient with solid food dysphagia
and a history of three food impactions, drinking of several bolus
of contrast media in the prone position revealed a thin ringlike
narrowing in the distal esophagus. b The placebo tablet (arrow)
of the contraction(Fig. 47). They areusually combined
with a proximal escape or a support level.
Esophageal Stenoses. Stenoses of the esophagus,
which are usually easier to diagnose on dynamic than
static X-ray images, can be tested for their diameters
(Fig. 48). Placebo tablets of 13–15 mm in diameter
allow an exact measurement of the esophageal width.
Furthermore, the tablet may produce symptoms that
reproduce the patient’s complaints.
If standard boluses of 10 ml do not obtain a clear
delineation of the EGJ, about 150 ml of very thin
barium can be applied by a straw—in the horizontal
position. The patient may be advised to swallow
repeatedly. This causes intradeglutitive inhibition of
could not pass this stenosis, suggesting a lumen width of less
than 14 mm. Endoscopy confirmed the radiographic suspicion
of eosinophilic esophagitis
the peristaltic waves and the esophagus begins to fill
up in monocontrast. This can help diagnose subtle
stenoses and rings as an adjunct or alternative to a
placebo tablet (Fig. 49). Videofluoroscopy enables
the possibility of detecting subtle esophageal stenoses
not diagnosed by endoscopy (Fig. 50, a–b). Especially in young patients with dysphagia and a history
of recurrent impactions, VF can reveal a low-caliber
esophagus and ringlike-stenotic margins, suggestive
of eosinophilic esophagitis (Fig. 51, a–c).
Esophageal Diverticula. Diverticula of the upper
digestive tract are an important diagnosis (Fig. 52).
Whereas the Zenker’s diverticulum may be easy to
diagnose, the mid-esophageal and epiphrenic
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Fig. 53 The esophagealvestibule,a slight broadeningofthe gut
distal to the muscular A-ring should end at the level of the
diaphragm (seeFig. 56a). A hiatal hernia canbe diagnosed when
the vestibule ends at least 2 cm above the EGJ. The recess
between the vestibule and the EGJ may be diagnosedaspartofthe
stomach, protruding upward into the thorax—a hiatal hernia
Fig. 52 1) Zenker’s diverticulum; 2) mid-esophageal diver-
ticulum; 3) epiphrenic diverticulum
diverticula can be obscured by severe non-propulsive
contractions. The esophageal tube above and below a
mid-esophageal diverticulum invariably shows a
delayed esophageal transport and non-propulsive contractions. Incidentally, mid-esophageal diverticula
may be found in non-dysphagic elderly people. It is
crucial for furthertreatment,regardless of whetherfood
impaction at the level of the diverticulum is present or
not. Furthermore, it is important to note that epiphrenic
diverticula are almost always combined with achalasia
of the lower esophageal sphincter.
Esophagogastric Junction. In 80 % of patients with
reflux disease, a hiatal hernia is present, but only 50 %
of patients with hiatal hernia suffer fromreflux disease.
The radiographic diagnosis of a small hiatal hernia is
not of particular clinical importance; nevertheless, the
radiographic examination of the esophagogastric
junction is the method of choice for obtaining pertinent
topographic information (Figs. 53–56).
The radiologic contributions to suggest reflux
disease by means of functional observations, such as
reflux or the dynamic appearance of the EGJ are
controversial. This chapter does not intend to discuss
provocative tests for reflux, such as the water-siphon
test. Selected observations of authors, who had been
interested in the dynamic appearance of the EGJ
associated with gastroesophageal reflux, will be
mentioned briefly. Reporting on the dynamic EGJ can
enrich the view of VF and suggest a further work-up
with pH monitoring or endoscopy. Topographic
information can also help in planning surgical
therapy.
232 P. Pokieser and M. Scharitzer
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Fig. 54 a A 73-year-old woman with heartburn and mild
dysphagia. In the prone right anterior oblique position, a cricopharyngeal bar is visible.bThe endof the esophagealphaserevealsan
approximately 7 cm large hiatal hernia. c Turning the patient
Fig. 55 The two graphs on the left represent the normal
appearance of the esophagogastric junction, the graph on the
Most patients with heartburn can be managed symptomatically. With persistent, atypical symptoms, investigation may be required. The dynamic evaluation can
diagnose the presence of a hernia, its topographic
supine,gastroesophageal reflux to theupper third of the esophagus
was present. pH monitoring is the gold standard for directly
measuring reflux.However, if refluxto the upperesophaguscan be
demonstrated, a further clinical work-up is recommended
right demonstrates an axial hernia and an obtuse angle of His
(Fujiwara et al. 1998; Munzer 1997)
relations, abnormal esophageal peristalsis, cricopharyngeal dysfunction, and suggestive observations, such as
the cardiac rosette, the angle of His and the width of the
EGJ (Figs. 57–59).
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Fig. 56 Axial hiatal hernia is common. When a part of the
hernia reaches more cranially than the EGJ, it is called a
‘‘mixed hernia.’’ Paraesophageal hernia is characterized by an
EGJ at the level of the hiatus, and a hernia, which enters the
thorax separately left and ventrally to the EGJ. An intrathoracic
or upside-down stomach means a complete displacement of the
stomach into the mediastinum
Fig. 57 a In the supine position, the esophageal vestibule should be cleared completely when a 10 ml bolus of barium has been
swallowed with the single-swallow technique. b A subtle mucosal ring delineates the proximally sited esophageal vestibule and a
3 cm hernia between the vestibule and the EGJ. c Double-contrast radiography of a hernia can show a long-lasting gaping of the
EGJ for several seconds
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