q111/random_k2/source.md

## Page 1

BARIUM SWALLOW

DR.SHAIK FARID
RMMCH

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## Page 2

INTRODUCTION

¢ Barium swallow is
a radiological
study of pharynx
and esophagus
upto the level of
stomach with the
help of contrast.

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## Page 3

EMBRYOLOGY OF PHARYNX

¢ Head & neck structures
are derived from
pharyngeal arches 1 & 2.

¢ Each arch contain similar
component derived from
endoderm,ectoderm &
mesoderm.

¢ The cavity within the
pharyngeal arches forms
the pharynx.

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## Page 4

BOUNDRIES OF PHARYNX

Anteriorly-mouth & nasal choanae

Superiorly-soft palate &portion of skull

Inferiorly- postr of tongue

Posteriorly- pharnygeal constrictors

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## Page 5

PARTS

¢ Naso - ant.pharynx joins nasal cavity

¢ Oro- midportion of pharynx joins oral cavity

¢ Hypo-inferior pharynx joins larynx.

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## Page 6

NASOPHARYNX

get ph tympanic

¢ Lies behind the nasal
cavity.

¢ Postero-superiorly this
extends from the level
of the junction of the
hard and soft palates to
the base of
skull, laterally to include
the fossa of
Rosenmuller.

¢ The inferior wall
consists of the superior
surface of the soft
palate.

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## Page 7

OROPHARYNX

Nasopnaryny

Orophar nx

Larwngopharyns

Lies behind the oral
Cavity.

The anterior wall - the
base of the tongue and
the epiglottic valleculae.

the lateral wall —
tonsil, tonsillar
fossa, and tonsillar
(faucial) pillars;

the superior wall -
inferior surface of the
soft palate and the

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## Page 8

Figure 1—8wallowing Anatomy

Levels between C4 to C6, it
includes the pharyngo-
esophageal junction (postcricoid
area), the piriform sinus and the
posterior pharyngeal wall.

Lined with a stratified
squamous epithelium.

It lies inferior to the upright
epiglottis and extends to the
larynx, where the respiratory
and digestive pathways diverge.

At that point, the
laryngopharynx is contunious
with esophagus posteriorly.

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## Page 9

EMBRYOLOGY OF ESOPHAGUS

¢ Primitive gut tube forms during 4" week of
gestation.

¢ It is derived from incorporation of the dorsal
part of the definitive yolk sac into embryo due
to embryonic folding.

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## Page 10

¢ Primitive gut is divided into foregut,midgut and
hindgut.

¢ Laryngotracheal diverticulum develop in the
midline of the ventral wall of the foregut.

¢ The distal end enlarges to form lung buds,which
is separated from the foregut by tracheo-
esophageal folds.

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## Page 11

Stomodeum  Pharynx
Septum
transversum

Esophageal
region

Gastric and

duodenal region
Yolk stalk
and
Vitelline artery

Celiac artery

Liver

Superior
mesenteric artery

Allantoais
Midgut
Proctodeum

Inferior
mesenteric artery

Cloacal membrane Cloaca Hindgut

— — rc (kt it ~

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## Page 12

¢ Tracheo-esophageal fold fuse in midline to form
tracheo-esophageal septum.

¢ The foregut divide into laryngotracheal
tube(larynx,trachea,bronchi &lungs) ventrally and
esophagus dorsally.

¢ Esophagus is initially short ,out lengthens with
descent of heart and lungs.

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## Page 13

respiratory
diverticulum /

week : week 4
lateral view front view

end of week 4
front vwrewy

C—( TT —E—_ lO

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## Page 14

CONGENITAL ANOMALIES

esophageal atresia, EA,

tracheoesophageal
fistula, TEF,

esophageal stenosis,
esophageal cyst,
tracheobronchial remnant,

esophageal atresia and
tracheoesophageal
fistula, EA-TEF,

esophageal web,
esophageal muscular
hypertrophy,

esophageal duplications,
columnar epithelium—
lined lower esophagus,
Barrett's

esophagus, laryngotrache
oesophageal cleft, LTEC

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## Page 15

ANATOMY OF ESOPHAGUS

¢ Flattened muscular
tube,size 18 to 26cm
beginning at lower border
of cricoid cartilage(opp 6*
cervical vertebra) and
ending at cardiac orifice of
stomach(opp 11" cervical
vertebra)

¢ Divided into 3 anatomical
segments
i.e.,cervical,thoracic &
abdominal

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## Page 16

¢ Cervical esophagus extend from pharyngeal
junction to suprasternal notch and is abt 4-
5cm.

¢ At this level,eosophagus bordered anteriorly
by trachea,post by vetebral column and lat by
carotid sheath and thyroid gland.

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## Page 17

¢ Thoracic esophagus extend from suprasternal
notch(opp 11) to diaphragmatic hiatus(opp
T10).18cm in length.

¢ Anteriorly lies the trachea, rt pulmonary
artery, left main bronchus & diaphragm.post it
rest on vertebral column and closely related to
thoracic duct, azygous & hemiazygous vein.

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## Page 18

¢ Abdominal esophagus extend from
diaphragmatic hiatus to orifice of cardia of

stomach.size abt 1 cm.

¢ Its right border is continuous with lesser
curvature & left border is demarcated from
fundus by esophagogastric angle of
implantation(angle of His)

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## Page 19

Incisors
0

Subsite Description 4

Cermical esophagus

Upper 13 18
(Froximaly L
Upper thoracic esophagus
24
Middle 443 Mid thoracic esophagus

32

(Distal) Lower thoracic esophagus

40

Cardioesophageal
Junction

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## Page 20

ESOPHAGEAL CONSTRICTION

oe

¢ Superiorly: level of
Cricoid
cartilage, juncture with
pharynx

e Middle: crossed by aorta
and left main bronchi

e Inferiorly:
diaphragmatic sphincter

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## Page 21

SPHINCTERS

Two high pressure zones prevent the backflow
of food:

¢ Upper Esophageal sphincter.
¢ Lower Esophageal sphincter.

¢ It is located at upper and lower end of
esophagus.

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## Page 22

LAYERS OF ESOPHAGUS

Structurally, esophagus wall composed of 4
layers:

¢ Innermost mucosa,

e Submucosa,

¢ Muscularis propria

¢ Adventitia.

° No serosa.

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## Page 23

BLOOD SUPPLY

Arterial supply

Branches of inf thyroid artery - UES & cervical
esophagus.

Paired aortic esophageal arteries or terminal
br.of bronchial artery — thoracic esophagus
Left gastric & br.of left phrenic art- LES &
distal esophagus

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## Page 24

Arteries of Esophagus

, Theracic part

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## Page 25

VENOUS DRAINAGE

¢ Proximal & distal esophagus drains into azygous
veins.

¢ Mid-esophagus drains into collaterals of left
gastric vein,br. of portal vein.

¢ Submucosal connection between portal and
systemic venous system in distal esophagus form
esophageal varices in portal hypertension.

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## Page 26

Weins of Esophagu

Inferior thyroicl weim—_ a Iinkerior thyroid weir

—Internmal puget
Internal jugular vein aNtOTTWAs BUA

ween
External jugular wein

Subclay

mn Subclavian
Vertebral vein— ¢ vein

“Thoracic
duct
Right
brachiocephalic vein “Left brach

cephalic vein

Superior wena cava- -  ~Left superior

intercostal vein

Esophageal veins
plexerst

Esophagus \CCessOry
— hemiazygos vein

Goth cigght jecsteriors

—Wenac comitantes

Ivein—
aires of vagus nervy

Se Heres 2yygeos
weir ucous venous plexus

Inferior vena cava (cut)
if eft interior phrenic

Shert gastric veins

Hepatic
Wires —

Interior
wen
cavan-

bteegosatic

~Splen
or plonix

“Let

suprarennal > Omenta

ve (epiploic

Righs renal vein ; ; “Lett ene
o-ome

a
Lett gastric vein~
mp rig vlcric

Right gastric vein

~
Superior mesenteric vein Inferior mesentert

Esophageal branches of left gastric wei ht g4stro-omental (gastroepiploic) wein

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## Page 27

NERVE SUPPLY

Extrinsic network
—sympathetic & parasympathetic.
SYMPATHETIC:
-Neck - sup & inf cervical ganglion ,
-Thorax - upper thoracic and splanchnic nerve .
PARASYMPATHETIC :

- from recurrent laryngeal nerve & br of vagus
in thorax & abdomen.

Intrinsic
-from 2 intramural plexuses
- 1 in submucous layer.

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## Page 28

upenorganghon of vagus nemwe
Superior cervical sympathetic ganglion
Interior ganglion of wagus nerve
Esophagus t J Fharmyngeal branch of yagus nerve
Wagus nenre (*)
Supernorlanngeal nenre
Cervical sympathetic trunk
en hiliddle cervical sympathetic ganglion
alne aT ati ; - Cemical (sympathetic and vagal) cardiac nemes
} Wertebral ganglion of cemical sympathetic trunk
subclavia i ;| - Ansa subslawia

Se — Branch te esophagus and recument
heme from stellate ganglion

Cemicothoracic (stellate) ganglion
Srd intercostal

: ‘ ,
neve : mh Y , | Lett recunent lanngeal neme
 —aa q P Thoracic twagal and sympathetic)
Cae Z a YG = cardiac branches
Gray and white rami
communicantes —

Ord thoraci«
sympathetic
ganglion

= i) il , Esophageal plexus

Th ; + ae ' ; t = Canterior portion)

oracia =~ | : ;

sympathetic i -

trunk — ; i Branches to esophageal

<< —_—

‘ t Plexus from sympathetic
Right greater j trunk, greater splanchnic
splanchnic neve { nene and thoracic aortic
. ove plexus
Sympathetic { :
tibers along i ; Left greater splanchnic nemne
lett inferior ! \ J
PACS a ery 4 Anterior vagal trunk

Branch of

posterior vagal , F : Vagal branch to hepatic plexus
trunk to seas ent 5 fe ? wia lesser omentum
plexus ‘ ; ,

Greater
splanchnic

Wagal branch te fundus
newes

and body of stomach

Sympathetic fibers
along esophageal

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## Page 29

LYMPHATIC DRAINAGE

¢ Originate from 2 plexus-submucosal layer &
other within the muscle layer.

¢ Upper 2/3 flow in cranial direction.

¢ Lower 1/3 flow in caudal direction.

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## Page 30

Lymph Vessels and Nodes of Esophagus

Inferior deep cer
(intermal jugulart

Postenor

i parietal nodes
ar and inheric

obronchial

Juxtacsophagee
and superia

phrenic nodes

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## Page 31

BARIUM SWALLOW

¢ It is a medical imaging procedure used to
examine upper gastrointestinal tract,which
include the esophagus and to a lessr extent
the stomach.

¢ The contrast used is barium sulfate.

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## Page 32

CONTRAST

¢ TYPES Glan TRAST STUDY

(i) SINGLE CONTRAST STUDY

(ii) DOUBLE CONTRAST STUDY

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## Page 33

CONTRAST USED

100% BARIUM SULPHATE PASTE
80% BARIUM SULPHATE SUSPENSION

30% BARIUM SULPHATE SUSPENSION FOR HIGH
KV TECHNIQUE

200-250% HIGH DENSITY,LOW VISCOSITY FOR
DOUBLE CONTRAST STUDY

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## Page 34

INDICATION

Dysphagia

Heart burn, retrosternal pain, regurgitation & odynophagia.
Hiatus hernia

Reflux oesophagitis

Stricture formation.

Esophageal carcinoma.

Motility disorder like

i. Achalasia
ii. diffuse esophageal spasms.
Pressure or invasion from extrinsic lesions.
Assessment of abnormality of
i. pharyngo esophageal junction including zenkers diverticulum
ii. cricoid webs
iii. cricopharyngeal Achalasia.

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## Page 35

CONTRAINDICATION

¢ Suspected leakage from esophagus into the
mediasternum or pleura and peritoneal
cavities.

¢ Tracheo-esophageal fistula

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## Page 36

XRAY VIEW

¢ SOFT TISSUE NECK — AP & LAT — SCOUT

¢ NECK-AP & LATERAL

¢ THORAX-RAO VIEW

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## Page 37

NORMAL-AP /LAT VIEW - SCOUT

. Sia Rey

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## Page 38

AP/LAT VIEW WITH BARIUM

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## Page 39

RAO VIEW

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## Page 40

PATIENT PREPARATION

None in particular but advisable to be in NPO
prior to the procedure .

Ensured that no contraindication to the
pharmacological agent used.

Check pregnancy state.

Procedure should be explained to patient before
undergoing the procedure.

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## Page 41

TECHNIQUE

¢ PHARYNX

¢ -One mouthful contrast bolus with high
density(250% w/v).

¢ -Patient is asked to swallow once and stop
swallowing there after.
-This is to get optimum mucosal coating.

-frontal and lateral view x-ray taken.

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## Page 42

ESOPHAGUS
Single contrast

-Multiple mouthful 80% w/v barium
suspension given.
-prone swallow to assess esophageal
contraction.

-useful in esophageal
compression, displacement or disordered
motility.

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## Page 43

Double contrast
-Contrast high density,low viscosity(200-250%).
-15-20 ml given & asked to swallow.

-Then effervescent powder given with another
mouthful of barium.

-In erect posture,gas tend to stay up so
adequate distention stays longer time.
Inj.buscopan I.V given before the procedure to
keep esophagus distended for longer time.

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## Page 44

SPECIFIC CONDITION

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## Page 45

¢ PHARYNGEAL WEB

¢ 50/50 dilution of standard
high density barium.

© Film in supine for frontal
and erect for lateral view

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## Page 46

¢ Partially obstructing cervical
esophageal web. Frontal view
shows a
circumferential, radiolucent
ring (straight white arrows) in
the proximal cervical
esophagus. Partial
obstruction is suggested by a
jet phenomenon (black
arrows), with barium
spurting through the
ring, and by mild dilatation of
the proximal cervical
esophagus.

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## Page 47

FOREIGN BODY IMPACTION

* To detect the level of
obstruction in case of
radiolucent foreign
body in
esophagus,marsh
mellow coated with
barium is swallowed.

¢ Passage of marsh
mellow will be hindered
at the level of
obstruction

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## Page 48

Xray showing foreign body

¢ AP and lateral plain films
showing a metallic foreign
body in the upper
esophagus. Most foreign
bodies are found at the
level of the
cricopharyngeus muscle.

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## Page 49

Sceleroderma esophagus

¢ Upright left posterior
oblique spot image from
double-contrast
esophagography shows
two wide-mouthed
sacculations en face
(black arrows) in upper
and mid thoracic
esophagus. Note how
upper sacculation extends
superiorly just above level
of aortic arch (white
arrow).

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## Page 50

DYSPHAGIA

¢ Post swallow oral (thick
arrow) and pharyngeal
(thin arrow) stasis in a
patient with base of
tongue cancer.

Source: Cancer Conirel © 2002 H. Lee Mofil! Cancer Center and Ragearch Inetitute, Inc.

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## Page 51

MEDIASTINAL MASS

¢ Image showing anterior
mediastinal mass in
lateral view.

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## Page 52

CARCINOMA

¢ Preferably high viscosity
with normal density
barium is used.

¢ Classical finding in
carcinoma -rat tail
appearance.

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## Page 53

CA ESOPHAGUS

With shouldering

The stenotic segment is long giving a “" *rat-tail” appearance

Barium swallow shows mild dilatation of the esophagus with irregular
stenotic lesion in the lower end of the esophagus “moth eaten
appearance

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## Page 54

HIATUS HERNIA

* High abdominal pressure is
required to demonstrate.

¢ Pt has to strain.

* Lie down,straighten legs &
then raise them up.

¢* Manual compression of
abdomen.

¢ Pt stands upright,ask him to
bend downward with leg
straight.

* Stomach should be
distended to demonstrate
HH.

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## Page 55

HIATUSIMERNIA

Barium meal in Trendlenberg position
Displacement of the cardio-esophageal junction
above the esophageal hiatus

Part of the stomach is present in the chest
Reflux of barium into the esophagus

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## Page 56

ACHALASIA CARDIA

¢ Eosophagus should be
cleaned thoroughly
(aspirate &wash) —
secondary achalasia d/t
Ca esophagus not missed.

¢ Barium 80% w/v used,pt
erect position.

¢ Mecholyl test-
hyperperistalsis,pain&stre
ak of contrast entering
stomach.

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## Page 57

ACHALSIA CARDIA

¢ Barium swallow
showing dilatation of
the esophageal body

*With short segment
stricture.

* A “bird-peak " like
tapering of the
esophagus at the GE
junction. OR

*A Sigmoid “ Mega
esophagus

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## Page 58

DIFFUSE ESOPHAGEAL SPASM

Barium swallow shows
irregular areas of
narrowing and
dilatation ----- “Shish
kebab” “corkscrew”
“rosary bead"
esophagus

The esophageal muscle
is hypertrophied, but
histologically normal

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## Page 59

ESOPHAGEAL VARICES

¢ Supine right side up
position, high
density thin barium
should be used.

e Varices are best
demonstrated in
mucosal relief study
after using
Buscopan/ valsalva
maneuver.

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## Page 60

ESOPHAGEAL VARICES

¢ Mild dilatation of the
esophagus

with multiple
persistent filling
defects in the lower
third of the
esophagus and/or
longitudinal furrows.

A

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## Page 61

TRACHEOESOPHAGEAL FISTULA

¢ Congenital/Acquired
¢ Ideal contrast non ionic
water soluble media

¢ Barium fluid like & pt
lying laterally.

¢ Incase fistula not
identify laterally, put in
prone.

¢ If fistula seen, stop
procedure as barium
aspiration result in
inflammation and
granuloma.

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## Page 62

TRACHEOESOPHAGEAL FIST(INFANT)

A Ryle’s tube is introduced to the level of mid
esophagus & contrast is injected.

The tube is withdrawn slowly.
This will force the contrast thro’ any small fistula.

Both lat & prone views to be assessed.

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## Page 63

Oblique barium
esophagogram
demonstrates a fistula
(arrow) arising from the
anterior esophagus and
_ extending
anterosuperiorly to the
trachea.

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## Page 64

ESOPHAGEAL A-RING

¢ Esophageal A-ring
due to muscular
contraction at
junction of tubular
and vestibular
esophagus. It varies
during examination
and may not persist.

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## Page 65

ESOPHAGEAL B-RING

* The esophageal B-ring is
located at the
squamocolumnar
junction, also termed the 'Z'
line.

* On the left a patient witha
'B' ring (arrows) several cm
above diaphragm at the
apex of sliding hiatus
hernia.

Note unchanged
appearance on these two
images.

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## Page 66

GASTRO ESOPHAGEAL REFLUX

SIPHON TEST
Fill the stomach with 50% barium(150-200ml)

Follow this 1-2 mouthful of water to remove traces of
barium in esophagus

Pt in supine with left side raised 15% up
Keep one mouthful of water in pt mouth

Ask pt to swallow water-a jet of barium will shoot into
water column as it enter GO junction

Alternatively with full stomach,ask pt to roll side to
side
Reflux will be seen

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## Page 67

ESOPHAGEAL REFLUX

¢ Reflux oesophagitis
with a deep ulcer
(straight arrow). There
is also asymmetric
narrowing of the distal
esophagus with a
relatively abrupt cutoff
(curved arrow) at the
proximal border of the
narrowed segment.

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## Page 68

Barrett's Esophagus

¢ The reticular
mucosa Is
characteristic of
Barrett's columnar
metaplasia, especi
ally with the
associated web-
like (arrow)
stricture.

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## Page 69

Candida Oesophagitis

¢ The barium study
shows numerous fine
erosions and small
plaques due to
Candida albicans in
immunocompromised
patient.

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## Page 70

LEFT ATRIAL ENLARGEMENT

¢ Right anterior
oblique film and
barium swallow
demonstrates left
atrial compression
of the esophagus
confirming left
atrial dilation.

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## Page 71

COARCTATION OF AORTA

¢ Barium in the
esophagus
exhibits the
‘reverse 3 sign’
outlining the
medial site of the
aortic indentation
in the descending
aorta

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## Page 72

ZENKERS DIVERTICULUM

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## Page 73

KILLIAN JAMIESON DIVERTICULUM

* Killian-Jamieson
diverticulum is a pulsion
diverticulum, that protrudes
through a lateral anatomic
weak site of the cervical
esophagus below the
cricopharyngeus muscle.

AP view shows diverticulum
(arrow) originating laterally.
Lateral view confirms
diverticulum does not
Originate posteriorly as a
Zenkers diverticulum would.

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## Page 74

¢ An oblique view of the
pharynx shows Zenker's
diverticulum (Z) with its
opening (short arrow)
above the prominent
cricopharyngeus (C). The
Killian-Jamieson
diverticulum (K) has its
opening (long arrow) below
the prominent
cricopharyngeus.

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## Page 75

COMPLICATION

¢ Leakage of
barium from
unsuspected
perforation.

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## Page 76

COMPLICATION

¢ Aspiration

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## Page 77

ae Thank u velgiftich, ‘ot 4