'['he esophagus extends from the lower pharynx at the upper esophageal sphincter to the lower esophageal sphincter at the esophageal vestibule, or phrenic ampulla, just above the gastroesophageal (GE) junction, it consists of inner circular and outer longitudinal muscle layers. 'There is striated (voluntary) muscle for the upper third and smooth muscle for the lower two thirds, and the esophagus has no serosa! covering at any point. It is lined by squamous columnar epithelium throughout. 'The course of the esophagus is normally indented bv the aortic arch, left main bronchus, and left atrium.
The esophageal vestibule, or phrenic ampulla, is normally slightly distended (Fig. 1-1). At the upper end of the vestibule is a slight narrowing, or A-ring, caused by smooth muscle (internal esophageal sphincter), which can be normal or may cause slight dysphagia if hypertrophied. The B-ring is at the (iE junction itself (at the lower end of the vestibule, also known as phrenic ampulla) and is not seen unless a hiatal hernia is present. 'The Z line may be seen as a slight narrowing at the lower end of the phrenic ampulla and represents the epithelial junction between the esophagus (squamous) and stomach (columnar) and will not be seen unless a hiatal hernia is present. Dysphagia will not occur unless the B ring in the lower esophagus is less than 12 to 13 mm, when it is known as a Schatzki* ring (sec discussion later in chapter).
TECHNIQUES Oral Contrast Studies
w-q. мп-j. , vc-Tiona1 - aw;; .civ . jtie ,,-x critic,;' fie die evaluation ol malign, m esophaticui disease foi staging pui-ooscs. most esophageal aimmmalitic * ait (<»• ,mal! and fine m fie accuiateb evaluated b\ them ' entrust examination oi the esophagus (usually with barium) is an appropnutc mol foi the evaluation of most esophageal ilmoust out the i.uhologisM iole has been greatly diminished siiu-. the advent and murine use of lireet optical endoscopy. IJnwetei gi\eu that the barium swallow and upper gjstrommntnul (I Gi) studio- can be exqur ire moU foi rlu assessment of 1 .off 'ooip!.-,logical q'los- ipp. limit e ol the pharynx, esopnagus. of ninctmm and function.!-esophageal abnormalities (pharyngeal function, esophageal oh snuilility, gastroe vophagtai ;ctiu.. disease pd EDI', .-adiulu . e.t.i should .will be familial with then use am. maging endings.
\ l G! swallow exammatioii is best pem nned > ith both ungk- am1 -j.imirk -contri ‘r icchm ;ues Ref re begi'-^mg the examination, the radiologist should ) irthcr question the patient about his or her symptoms and history. The information gleaned • the patient can offer clue, and g:eater specificity about -. hat the radiologin night expect an'1 the radiologist mighr then modify or tailor the examination accordingly. At this point, the radiologist should explain the procedure to the patient because compliance e crucial to obtain an optimal examina-ooi For instance, after the initial ingestion of effervescent gas granules the patienr Tonic* try hcsr as possible to refrain from епк ration, which mml.- da k л the purpose of performing a double-contrast examination Maximal esophageal and gastric
FIGURE 1-1. Schematic representation of lower esophageal anatomy (in the presence of a small hiatal hernia).
distention prowdes bettci images and thmefore л gieatei aml-
J a mgests the gas ciaiiules followed 1ь., roall l.q wiwateiio aid iapid swallow jiip The goal t.> m piiwnt the gianule1- lium ‘ r /mg" n the mouth, which reduces meir d'stensne efieet m rh esophagus and stomach The pat ie o: then sv, allows a , u,> of it-ph o^nsii' thk t " i b.iiimii, at wdin I om 'nuip4 uc e" of the gas-dist nded esophagus and ,14 1; a.iwnsal .dmoi main ties can be identified 11 any abmemahn 1 identified ,r thr. jv mt, multiple tangcntul vic-m T ad 1 lx take to all л the ia m-logiw tti v lu.ua the lesirni in mw ch tail on- c tin t . топлиш n tmisheo. loo oltet . inadequate oblique and t.mgenna \iews ate taken, lesultimi m rlie lesion bring \ isibk m bmited plan^., viiucii in. - mak- . , ukem,-, .n.icu. 01 c\ impos slide I lecjlicnily die e .Jminatiu,, is pcilulibru n. соаршеnon with a TGI series witl gastne and duodenal c\ablation mo :1 e radiologist will no* ' to rhex eoncer.rnrc -ч these rgan* a hik they arc ma\im.nb distended with aii The mdmlogist should return later to a final evaluation of the esophagus using .. .ingle-conuusi examination with low-density (“thin”) barium, v 'th the patient ty nically in the right anterior or pn ne oblique position. The patient rakes sc* eral sip-- '-f barium and esopha-gcxd motilin and distensibilify are evaluare'd as the radioing!,sr obvenes the snipping v.e.cs of esophageal led us j r< 'pi bioli. The lower esophagus i- final!', evaluated to; hernias and the "'--icos,;1 ;■ ring Grkl' < - a b .ral hernia n; c no; in.:* . ’■ * be e. ide 1 t. mid the patient sh'Mik. be asked to pc Tori" a Mondva'’ maneuver as a provocative measure to increase iiitouilrdoinina!