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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1033_Библиотеки_им_академика_М_И_Перельмана
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R. Lamm and F. Palazzo
Further Reading
Kristo I, et al. Modern esophageal function testing and gastroesophageal
reux disease in morbidly obese patients. Obes Surg. 2019;29(11):3536–
41.
Nam SY. Obesity-related digestive diseases and their pathophysiology. Gut
Liver. 2017;11(3):323–34.
Tack J, Pandolno JE.Pathophysiology of gastroesophageal reux disease.
Gastroenterology. 2018;154(2):277–88.
Valezi AC, et al. Gastroesophageal reux disease in obese patients. J
Laparoendosc Adv Surg Tech A. 2018;28(8):949–52.
Xing J, Chen JD.Alterations of gastrointestinal motility in obesity. Obes Res.
2004;12(11):1723–32.
Part II
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Diagnostic Testing: Diagnostic
Imaging
Esophagram
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ElisaJ.Furay, StephanieDoggett,
andFrancisP.Buckley III
Introduction
Diagnostic investigation of esophageal disorders commonly utilizes pH studies, endoscopy, and high-resolution manometry. The
barium esophagram is another important diagnostic tool that tends
to be underutilized and misused by surgeons and gastroenterologists. An esophagram combines both static and dynamic imaging
techniques to allow for the evaluation of both structural and functional abnormalities within the esophagus and stomach. With specialized protocols, trained clinicians are able to gather important
data on esophageal anatomy and even esophageal motility with
the correct protocol. This study has the benet of being noninvasive, inexpensive, and readily available, and it does not require
sedation.
In order for this study to have the greatest utility, the radiologist
performing it should be trained on standard techniques and protocols, as well as familiar with the imaging ndings of varying esophageal diseases. An esophagram combines both single- and
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E. J. Furay (*) · S. Doggett · F. P. BuckleyIII
Dell Medical School, University of Texas at Austin, Austin, TX, USA
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_4
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double-contrast techniques to give the most comprehensive evaluation of the esophagus. The single-contrast load aids in the dilation
of the esophagus and reveals structural abnormalities including
masses, strictures, and diverticula. The double-contrast technique
utilizes an effervescent agent after ingesting barium, which allows
radiologists to see subtle irregularities in esophageal mucosa and
improves the diagnostic yield of the study [1–3]. The study also
utilizes both single-frame X-rays and uoroscopy. Fluoroscopy is
the more dynamic portion of the study and allows for the evaluation
of esophageal motility by taking continuous X-ray images, while
the patient performs multiple swallows using different contrast
loads with varying consistencies [4]. The most commonly used
contrast medium is barium sulfate as it provides improved mucosal
detail compared with water-soluble contrasts [5]. There are certain
situations in which you would want to evaluate the esophagus with
a water-soluble contrast medium and those are discussed later.
E. J. Furay et al.
How toPerform anEsophagram andVariations
inTechnique
An esophagram is a multiphasic study, which generally starts with a
single-contrast bolus followed by a spot lm captured in the upright
position 1min following barium ingestion. This assesses the emptying of the esophagus into the stomach. If the barium has not emptied
from the esophagus after 1 minute, then subsequent 2- and 5-min
lms are taken and compared with the 1-min lm. A normal esophagus should empty approximately 250 mL of low- density barium
within seconds [6]. If there is signicant liquid dysphagia, then the
study should conclude the study to prevent patient aspiration. If there
is no signicant liquid dysphagia, then the radiologist should proceed
with the upright double-contrast (also known as air contrast) phase of
the study. In this portion, the patient is given an effervescent medium
allowing air to ll the lumen of the esophagus and enhance the visualization of the mucosa, which has been coated with barium. This
technique improves the sensitivity for detecting subtle mucosal irregularities [7, 8]. This is then followed by the motility portion of the
study, where the patient is placed in a semi-prone position and asked
to swallow barium. The radiologist images multiple swallows using
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uoroscopy and focuses on the end of the barium column to evaluate
bolus transit through the esophagus. Previous studies have compared
esophageal motility ndings on barium esophagram to manometric
ndings and have shown concordance between a normal manometry
and ve normal swallows on a properly performed barium esophagram [9, 10]. The next step of the esophagram is a distended esophageal phase, in which the patient drinks a larger bolus of barium in
order to distend the esophagus and identify any subtle narrowing
along the esophagus. This is again performed in a semi-prone position and is typically evaluated by using uoroscopy. The patient is
then positioned supine and upright until the barium has cleared the
esophagus. In order to completely clear the barium from the esophagus, the patient may need to take a few swallows of water. The patient
is then again placed horizontally and the esophagus is evaluated with
uoroscopy. If barium is seen in the distal esophagus, then a reux
episode can be inferred. If no barium is seen, some centers perform
provocative maneuvers to try and elicit a reux event [6]. Performing
these maneuvers increases the sensitivity of identifying clinically signicant reux [11]. Following evaluation for reux, the solid food
phase of the esophagram begins. The patient ingests a barium tablet,
and its movement through the esophagus and into the stomach is
evaluated. Stomach emptying is also commonly observed at this
time, although much of this interpretation is subjective and should be
evaluated formally with a gastric emptying study if specic pathology is suspected.
There have been several slight modications to the solid food
phase of the esophagram to improve the evaluation of esophageal
function. Using alternatives to the barium tablet, such as marshmallow or hamburger-impregnated mediums, has been shown to
better assess esophageal motility and bolus transport abnormalities [12]. The addition of an alternative solid bolus more accurately assesses esophageal motility because the contraction
amplitude of the esophagus is highly dependent on the size and
consistency of the bolus [13]. About 14% of patients who demonstrate abnormal transit of liquids will show normal transit of a
solid bolus, supporting the need for more viscous mediums in the
evaluation of esophageal function [14]. This modication to the
classic esophagram has been adopted at many large institutions to
better establish esophageal function during the routine workup of
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foregut disorders, particularly in the evaluation of motility in
patients undergoing antireux surgery.
D’Alessio et al. evaluated patients with esophageal dysmotility
demonstrated on manometry who in addition had either GERD and/
or symptomatic hiatal hernias. Their group evaluated these patients
with specialized esophagography to determine their ability to clear
food boluses of different consistencies. This technique observes
esophageal peristalsis and emptying in both the prone horizontal and
prone slight Trendelenburg position. Patients consumed a single large
bolus swallow of barium and were subsequently examined for uninterrupted progression of the contraction wave and complete emptying
of the esophagus with two or fewer stripping waves. Each patient was
then challenged with a food bolus using a marshmallow followed by
a bite of bagel food bolus. Again, normal clearance was dened as the
passage of the food bolus with two or fewer stripping motions. In this
study, patients with ndings of esophageal dysmotility on manometry but normal esophageal clearance on food boluses on esophagography underwent laparoscopic Nissen fundoplication. These patients’
outcomes were then compared to patients with normal esophageal
motility in manometry who underwent laparoscopic Nissen fundoplication. They found that these two groups had functionally similar
outcomes, which suggests that preoperative solid challenge esophagrams can be utilized as a predictor of positive postoperative outcomes in antireux surgery patients [15].
E. J. Furay et al.
Diagnostic Implications
GERD
An esophagram is an excellent initial test for patients with a wide
variety of esophageal complaints. As the name implies, gastroesophageal reux disease (GERD) results from the retrograde
reux of caustic gastric juices into the esophagus. These reux
events are able to be captured on an esophagram, and radiologists
commonly report gastroesophageal reux as ndings on an
esophagram. Serna-Gallegos et al. looked at patients found to
have reux on the esophagram and investigated if they had objective evidence of reux on pH study. They showed a very poor
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correlation between reux reported on the esophagram and objective evidence of acid reux on pH studies [16]. It is important to
remember that the diagnosis of GERD must be made using objective evidence of acid reux in the form of positive pH study or
signicant endoscopy ndings.
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Mucosal Irregularities
Patients with chronic reux can develop reux esophagitis, which
is irritation of the esophageal mucosa from caustic juices of the
stomach leading to mucosal edema and inammation. This can be
identied best on the double-contrast phase of the barium esophagram because of the ne mucosal detail provided. Figure4.1 demonstrates the grainy appearance of the proximal esophagus seen
on an esophagram secondary to edema and inammation [17].
Peptic strictures are caused by chronic reux and are most
commonly located in the distal esophagus and often above a hiatal hernia. On an esophagram, strictures are best seen during the
esophageal distention portion of the study. Ott etal. were able to
show that the addition of the esophageal distention phase to the
esophagram improved the accuracy of detecting peptic strictures
to a nearly 95% sensitivity rate [18]. Some studies suggest that,
when performed properly, esophagrams can be as effective as
endoscopy for diagnosing peptic strictures or rings [18]
(Fig.4.2).
Barrett’s esophagus is a condition in which cells of the distal
esophagus undergo metaplastic changes from stratied squamous
epithelium to simple columnar epithelium-containing goblet cells.
These metaplastic changes increase patients’ risk of undergoing
dysplastic changes and ultimately developing esophageal adenocarcinoma. The diagnosis of Barrett’s esophagus is based on a
tissue sampling obtained during endoscopy, but esophagography
may be able to identify patients at higher risk for Barrett’s esophagus. Gilchrist etal. were able to demonstrate that patients with a
high esophageal stricture, ulcer, or reticular mucosal pattern had a
90% chance of having Barrett’s mucosa at endoscopy [19].
Although we do not advocate for this as a screening method for
intestinal metaplasia, we do recognize that some esophagram
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E. J. Furay et al.
Fig. 4.1 Esophagitis. The red arrow demonstrates the grainy appearance of
esophagitis on an esophagram
ndings may be suggestive of Barrett’s esophagus and may warrant endoscopic evaluation.
Eosinophilic esophagitis (EoE) is a relatively new diagnosis in
esophageal pathology. It is characterized by symptoms similar to
GERD in association with mucosal biopsy demonstrating 15
eosinophils/HPF in one or more biopsy specimens, absence of
pathologic GERD on pH study, and lack of response to high dose
PPI therapy [20]. Like Barrett’s esophagus, a diagnosis of EoE is
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Fig. 4.2 Stricture. Seen here as an abrupt narrowing in the distal esophagus
heavily reliant on tissue sample, but there are some features on an
esophagram, which can suggest the presence of EoE. Radiologic
features of EoE include the presence of xed rings, sometimes
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E. J. Furay et al.
Fig. 4.3 Eosinophilic esophagitis. You can see the “stack of coins” appearance shown in the red bracket
described as a “stack of coins” (Fig.4.3), either diffusely throughout the esophagus or at xed segments and strictures [21]. These
ndings should be further investigated with endoscopy and biopsies.
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