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Scharitzer M, Pokieser P, Ekberg O. Oesophageal fluoroscopy in adults-when and why? Br J Radiol 2024; 97:1222-1233. [PMID: 38547408 PMCID: PMC11186568 DOI: 10.1093/bjr/tqae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/18/2024] [Indexed: 06/21/2024] Open
Abstract
Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.
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Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Peter Pokieser
- Teaching Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Inga Marie Nilssons gata 49, 205 02 Malmö, Sweden
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Hamada S, Ihara E, Muta K, Wada M, Hata Y, Ikeda H, Tanaka Y, Ogino H, Chinen T, Ogawa Y. Onigiri esophagography as a screening test for esophageal motility disorders. J Neurogastroenterol Motil 2021; 28:43-52. [PMID: 34312324 PMCID: PMC8748848 DOI: 10.5056/jnm20138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/13/2020] [Accepted: 11/10/2020] [Indexed: 11/24/2022] Open
Abstract
Background/Aims No screening test for esophageal motility disorder (EMD) has been established, the objective of this study is to examine the potential usefulness of our newly developed “Onigiri esophagography” combined with an obstruction level (OL) classification system in screening for EMD. Methods A total of 102 patients with suspected EMDs who underwent both high-resolution manometry (HRM) and Onigiri esophagography between April 2017 and January 2019 were examined. The EMD diagnosis was performed based on the Chicago classification version 3.0 by HRM. Onigiri esophagography was performed using a liquid medium (barium sulfate) followed by a solid medium, which consisted of an Onigiri (a Japanese rice ball) with barium powder. The extent of medium obstruction was assessed by the OL classification, which was defined in a stepwise fashion from OL0 (no obstruction) to OL4 (severe obstruction). Results The patients with OL0 (32.3%), OL1 (50.0%), OL2 (88.0%), OL3 (100.0%), and OL4 (100.0%) were diagnosed EMDs by HRM. The area under the curve, as determined by a receiver operating characteristic analysis, for the OL classification was 0.86. Using the cutoff value of OL1, the sensitivity and specificity were 87.3% and 61.3%, respectively, while using a cutoff value of OL2, the sensitivity and specificity were 73.2% and 90.3%, respectively. Conclusion In conclusion, Onigiri esophagography combined with the OL classification system can be used as a screening test for EMDs with a cutoff value of OL1.
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Affiliation(s)
- Shohei Hamada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan.,Department of Gastroenterology and Metabolism Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Kazumasa Muta
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Masafumi Wada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Hiroko Ikeda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshimasa Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Takatoshi Chinen
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
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Debi U, Sharma M, Singh L, Sinha A. Barium esophagogram in various esophageal diseases: A pictorial essay. Indian J Radiol Imaging 2021; 29:141-154. [PMID: 31367085 PMCID: PMC6639862 DOI: 10.4103/ijri.ijri_465_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Recent years have seen a decline in number of barium procedures due to wider availability of cross sectional imaging modalities. Though use of barium esophagography/barium swallow has decreased in day to day clinical practice, it still remains a valuable test for structural and functional evaluation of esophagus. It can be performed as single or double contrast examination or as a multiphasic examination comprising upright double contrast views followed by prone single contrast views. This pictorial essay demonstrates imaging features of various esophageal diseases on barium esophagogram.
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Affiliation(s)
- Uma Debi
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
| | - Madhurima Sharma
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
| | - Lokesh Singh
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
| | - Anindita Sinha
- Department of Radiodiagnosis and Imaging, PGIMER Chandigarh, India
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Biggemann L, Uhlig J, Gliem N, Al-Bourini O, Wedi E, Ellenrieder V, Ghadimi M, Uecker M, Frahm J, Lotz J, Hosseini ASA, Streit U. Assessment of esophageal motility disorders by real-time MRI. Eur J Radiol 2020; 132:109265. [PMID: 33010683 DOI: 10.1016/j.ejrad.2020.109265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/08/2020] [Accepted: 08/10/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate imaging findings of esophageal motility disorders on dynamic real-time. MATERIAL AND METHODS 102 patients with GERD-like symptoms were included in this retrospective study between 2015-2018. Dynamic real-time MRI visualized the transit of a 10 mL pineapple juice bolus through the esophagus and EGJ with a temporal resolution of 40 ms. Dynamic and anatomic parameters were measured by consensus reading. Imaging findings were compared to HRM utilizing the Chicago classification of esophageal motility disorders, v3.0. RESULTS All 102 patients completed real-time MRI in a median examination time of 15 min. On HRM, 14 patients presented with disorders with EGJ outlet obstruction (EGJOO) (13.7 %), 7 patients with major disorders of peristalsis (6.9 %), and 32 patients with minor disorders of peristalsis (31.4 %). HRM was normal in 49 patients (48.0 %). Incomplete bolus clearance was significantly more frequent in patients with esophageal motility disorders on HRM than in patients with normal HRM (p = 0.0002). In patients with motility disorders with EGJOO and major disorders of peristalsis, the esophageal diameter tended to be wider (23.6 ± 8.0 vs. 21.2 ± 3.5 mm, p = 0.089) and the sphincter length longer (19.7 ± 7.3 vs. 16.7 ± 3.0 mm, p = 0.091) compared to patients with normal HRM. 3/7 patients with achalasia type II were correctly identified by real-time MRI and one further achalasia type II patient was diagnosed with a motility disorder on MRI films. The other 3/7 patients presented no specific imaging features. CONCLUSION Real-time MRI is an auxiliary diagnostic tool for the assessment of swallowing events. Imaging parameters may assist in the detection of esophageal motility disorders.
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Affiliation(s)
- Lorenz Biggemann
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany.
| | - Johannes Uhlig
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Nina Gliem
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Germany
| | - Omar Al-Bourini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Center, Göttingen, Germany
| | - Martin Uecker
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Jens Frahm
- Biomedical NMR, Max-Planck-Institute for Biophysical Chemistry, Göttingen, Germany
| | - Joachim Lotz
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Ulrike Streit
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
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Chan MQ, Balasubramanian G. Esophageal Dysphagia in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:534-553. [PMID: 31741211 DOI: 10.1007/s11938-019-00264-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia. RECENT FINDINGS Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.
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Affiliation(s)
- Megan Q Chan
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA
| | - Gokulakishnan Balasubramanian
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.
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Abstract
The barium esophagogram is a global test for patients with dysphagia that can simultaneously detect morphologic abnormalities in the pharynx and esophagus, pharyngeal swallowing dysfunction, esophageal dysmotility, and gastroesophageal reflux. The barium esophagram is an inexpensive, noninvasive, and widely available procedure that can serve as the initial diagnostic test for dysphagia and facilitate selection of other diagnostic studies such as endoscopy. This article addresses 10 questions about barium esophagography and dysphagia that should help gastroenterologists gain a better perspective about the utility of barium studies in this clinical setting.
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Affiliation(s)
- Marc S Levine
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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8
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Abstract
Barium upper GI series performed by an interested and competent radiologist is still a very useful study to evaluate a variety of esophagogastric disorders. It usually provides information complementary to upper endoscopy and other foregut studies. Barium upper GI series is an important part of the diagnostic workup for gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders including achalasia. It is also an important part of the follow-up after operation for these common problems and after other operations such as resection or bariatric surgery. The GI radiologist should be an important member of the foregut surgery team.
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Levine MS, Rubesin SE. History and Evolution of the Barium Swallow for Evaluation of the Pharynx and Esophagus. Dysphagia 2017; 32:55-72. [PMID: 28101664 DOI: 10.1007/s00455-016-9774-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/21/2016] [Indexed: 12/18/2022]
Abstract
This article reviews the history of the barium swallow from its early role in radiology to its current status as an important diagnostic test in modern radiology practice. Though a variety of diagnostic procedures can be performed to evaluate patients with dysphagia or other pharyngeal or esophageal symptoms, the barium study has evolved into a readily available, non-invasive, and cost-effective technique that can facilitate the selection of additional diagnostic tests and guide decisions about medical, endoscopic, or surgical management. This article focuses on the evolution of fluoroscopic equipment, radiography, and contrast media for evaluating the pharynx and esophagus, the importance of understanding pharyngoesophageal relationships, and major advances that have occurred in the radiologic diagnosis of select esophageal diseases, including gastroesophageal reflux disease, infectious esophagitis, eosinophilic esophagitis, esophageal carcinoma, and esophageal motility disorders.
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Affiliation(s)
- Marc S Levine
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Stephen E Rubesin
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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10
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Lipe DN, Borden N. Rare radiological pattern of diffuse esophageal spasm. West J Emerg Med 2015; 16:426-7. [PMID: 25987921 PMCID: PMC4427218 DOI: 10.5811/westjem.2015.3.25826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/06/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Demis N Lipe
- Martin Army Community Hospital, Department of Emergency Medicine, Fort Benning, Georgia
| | - Nathan Borden
- Carl R. Darnall Army Medical Center, Department of Emergency Medicine, Fort Hood, Texas
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Ravi K, Katzka DA. Diagnosis and medical management of esophageal dysmotility. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.
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Affiliation(s)
- Sami R Achem
- Divisions of Gastroenterology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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13
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Abstract
The concept of esophageal spastic disorders encompasses spastic achalasia, distal esophageal spasm, and jackhammer esophagus. These are conceptually distinct in that spastic achalasia and distal esophageal spasm are characterized by a loss of neural inhibition, whereas jackhammer esophagus is associated with hypercontractility. Hypercontractility may also occur as a result of esophagogastric junction outflow obstruction or inflammation. The diagnosis of jackhammer esophagus as a primary motility disorder is based on the characteristic manometric findings after ruling out mechanical obstruction and eosinophilic esophagitis. Despite the differences in pathophysiology among the esophageal spastic disorders, their management is similar.
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Affiliation(s)
- Sabine Roman
- Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, Claude Bernard Lyon I University, Pavillon H, 5 place d'Arsonval, F-69437 Lyon Cedex 03, Lyon, France
| | - Peter J. Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 Saint Clair Street, 14th Floor, Chicago, IL 60611-2951, USA
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Roman S, Kahrilas PJ. Distal Esophageal Spasm. Dysphagia 2012; 27:115-23. [DOI: 10.1007/s00455-011-9388-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Accepted: 12/16/2011] [Indexed: 11/29/2022]
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Functional magnetic resonance in the evaluation of oesophageal motility disorders. Gastroenterol Res Pract 2011; 2011:367639. [PMID: 21904543 PMCID: PMC3166566 DOI: 10.1155/2011/367639] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/24/2011] [Accepted: 06/25/2011] [Indexed: 11/23/2022] Open
Abstract
Functional magnetic resonance imaging (fMRI) has been recently proposed for the evaluation of the esophagus.
Our aim is to assess the role of fMRI as a technique to assess morphological and functional parameters of the esophagus in patients with esophageal motor disorders and in healthy controls. Subsequently, we assessed the diagnostic efficiency of fMRI in comparison to videofluoroscopic and manometric findings in the investigation of patients with esophageal motor disorders. Considering that fMRI was shown to offer valuable information on bolus transit and on the caliber of the esophagus, variations of these two parameters in the different types of esophageal motor alterations have been assessed. fMRI, compared to manometry and videofluoroscopy, showed that a deranged or absent peristalsis is significantly associated with slower transit time and with increased esophageal diameter. Although further studies are needed, fMRI represents a promising noninvasive technique for the integrated functional and morphological evaluation of esophageal motility disorders.
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Abstract
Diffuse esophageal spasm (DES) has been reported as a potential cause of dysphagia or chest pain; however, the patho-physiology of DES is unclear. The aim of this study was to examine the manometric correlates of dysphagia and chest pain in this patient population. All patients undergoing manometry at our institution are entered into a prospectively maintained database. After institutional review board approval, the database was queried to identify patients meeting criteria for DES (≥20% simultaneous waves with greater than 30 mm Hg pressure in the distal esophagus). The patient-reported symptoms and manometric data, along with the results of a 24-hour pH study (if done), were extracted for further analysis. Out of 4923 patients, 240 (4.9%) met the manometric criteria for DES. Of these, 217 patients had complete manometry data along with at least one reported symptom. Of the patients with DES, 159 (73.3%) had dysphagia or chest pain as a reported symptom. Patients reporting either dysphagia or chest pain had significantly higher lower esophageal sphincter (LES) pressure than patients without these symptoms (P= 0.007). Significant association was noted between reported dysphagia and percentage of simultaneous waves. Chest pain did not correlate with percent of simultaneous waves, mean amplitude of peristalsis, or 24-hour pH score. The origin of reported chest pain in patients with DES is not clear but may be related to higher LES pressure. Simultaneous waves were associated with reported dysphagia. Using current diagnostic criteria, the term DES has no clinical relevance.
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Affiliation(s)
- K Tsuboi
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska, USA
| | - S K Mittal
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska, USA
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Porter RF, Gyawali CP. Botulinum toxin injection in dysphagia syndromes with preserved esophageal peristalsis and incomplete lower esophageal sphincter relaxation. Neurogastroenterol Motil 2011; 23:139-44, e27-8. [PMID: 20939855 DOI: 10.1111/j.1365-2982.2010.01604.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Botulinum toxin injection into the lower esophageal sphincter (LES) treats dysphagia syndromes with preserved peristalsis and incomplete LES relaxation (LESR). We evaluated clinical and esophageal motor characteristics predicting response, and compared duration of efficacy to similarly treated achalasia patients. METHODS Thirty-six subjects (59 ± 2.2 years, 19F/17M) with incomplete LESR on high resolution manometry (HRM) treated with botulinum toxin injection were identified. Individual and composite symptom indices were calculated, and HRM characteristics extracted. Symptom resolution for 6 months was a primary outcome measure, and repeat botulinum toxin injection, dysphagia recurrence or employment of alternate therapeutic approaches were secondary outcome measures. Duration of response was compared using Kaplan-Meier survival curves to a historical cohort of similarly treated achalasia subjects. KEY RESULTS Response lasted a mean of 12.8 ± 2.3 months. Symptom relief for >6 months was seen in 58.3%; short (<6 months) response was associated with younger age, higher chest pain index, and esophageal body spastic features (P ≤ 0.04). On multivariate logistic regression, chest pain, younger age and contraction amplitudes >180 mmHg independently predicted <6 months relief (P < 0.05 for each). On survival analysis, relief with a single injection extended to 1 year in 54.8% and 1.5 years in 49.8%, statistically equivalent to that reported by 42 similarly treated achalasia subjects (59 ± 3.2 years, 24F/18M). Symptom relief was more prolonged compared to achalasia when repeat injections were performed on demand (P = 0.003). CONCLUSIONS & INFERENCES Botulinum toxin injections can provide lasting symptom relief in dysphagia syndromes with incomplete LESR. Prominent perceptive symptoms and non-specific spastic features may predict shorter relief.
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Affiliation(s)
- R F Porter
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Abstract
OBJECTIVE The purpose of this study was to determine the frequency and appearance of esophageal wall thickening on CT scans in a series of patients with findings of diffuse esophageal spasm on barium studies. CONCLUSION CT revealed marked esophageal wall thickening in seven (21%) of 33 patients who had findings of diffuse esophageal spasm on barium studies. CT showed significantly greater esophageal wall thickening in the lower thoracic esophagus 5 cm above the gastroesophageal junction than in the upper thoracic esophagus at the level of the aortic arch or in the midthoracic esophagus at the level of the carina (p < 0.01). This esophageal wall thickening corresponded to the presence of multiple strong nonperistaltic contractions in the lower thoracic esophagus on barium studies. Our findings suggest that diffuse esophageal spasm should be included in the differential diagnosis when CT shows smooth circumferential wall thickening in the lower half of the thoracic esophagus, particularly in elderly patients with dysphagia or chest pain.
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Cook IJ. Diagnostic evaluation of dysphagia. ACTA ACUST UNITED AC 2008; 5:393-403. [PMID: 18542115 DOI: 10.1038/ncpgasthep1153] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 03/28/2008] [Indexed: 12/11/2022]
Abstract
Taking a careful history is vital for the evaluation of dysphagia. The history will yield the likely underlying pathophysiologic process and anatomic site of the problem in most patients, and is crucial for determining whether subsequently detected radiographic or endoscopic 'anomalies' are relevant or incidental. Although the symptoms of pharyngeal dysphagia can be multiple and varied, the typical features of neurogenic pharyngeal dysphagia are highly specific, and can accurately distinguish pharyngeal from esophageal disorders. The history will also dictate whether the next diagnostic procedure should be endoscopy, a barium swallow or esophageal manometry. In some difficult cases, all three diagnostic techniques may need to be performed to establish an accurate diagnosis. Stroke is the most common cause of pharyngeal dysphagia. A videoradiographic swallow study is vital in such cases to determine the extent and timing of aspiration and the severity and mechanics of dysfunction as a prelude to therapy.
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Affiliation(s)
- Ian J Cook
- Gastroenterology Department, St George Hospital, Gray Street, Kogarah, NSW 2217, Australia.
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Abstract
Although a variety of diagnostic procedures are often performed on patients with pharyngeal or esophageal symptoms, barium esophagography is a noninvasive, inexpensive, and readily available test that can simultaneously evaluate swallowing function, esophageal motility, gastroesophageal reflux, and a host of structural abnormalities in the pharynx and esophagus. This article reviews the role of barium esophagography for assessing swallowing function, morphologic abnormalities of the pharynx (diverticula, webs, and carcinoma), esophageal motility disorders (achalasia and diffuse esophageal spasm), and morphologic abnormalities of the esophagus (reflux esophagitis, Barrett's esophagus, infectious esophagitis, drug-induced esophagitis, eosinophilic esophagitis, Schatzki's ring, and esophageal carcinoma).
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Affiliation(s)
- Marc S Levine
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Secondary Achalasia and Other Esophageal Motility Disorders After Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease. AJR Am J Roentgenol 2007; 189:1464-8. [DOI: 10.2214/ajr.07.2582] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Panebianco V, Habib FI, Tomei E, Paolantonio P, Anzidei M, Laghi A, Catalano C, Passariello R. Initial experience with magnetic resonance fluoroscopy in the evaluation of oesophageal motility disorders. Comparison with manometry and barium fluoroscopy. Eur Radiol 2006; 16:1926-33. [PMID: 16639496 DOI: 10.1007/s00330-006-0246-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2005] [Accepted: 03/09/2006] [Indexed: 10/24/2022]
Abstract
The aim of this paper was to assess the diagnostic value of magnetic resonance (MR) fluoroscopy in the study of oesophageal motility disorders and to compare MR fluoroscopy results with those of manometry and barium contrast radiography. Twenty-five subjects referred for dysphagia and three patients in follow-up after pneumatic dilatation of the lower oesophageal sphincter to treat severe achalasia underwent esophageal manometry, barium contrast radiography and MR fluoroscopy. Examinations were performed on a 1.5 T scanner. Dynamic turbo- fast low angle shot (turbo-FLASH) sequences acquired during oral contrast agent administration were used to perform MR fluoroscopy. MR fluoroscopy correctly diagnosed achalasia in nine patients, uncoordination of esophageal body motility in ten and scleroderma oesophagus in one. Diagnostic performance was satisfactory, with a sensitivity of 87.5% and a specificity of 100% in the general depiction of motility alterations. Our work demonstrates that MR fluoroscopic examination in subject affected by oesophageal motility disorders is feasible and can properly depict motility and morphology alterations, achieving correct diagnosis in the majority of cases. Studies on larger populations are necessary to obtain statistically significant results.
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Affiliation(s)
- Valeria Panebianco
- Department of Radiological Sciences, University of Rome La Sapienza, Viale Regina Elena 324, 00161, Rome, Italy.
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Abstract
The barium esophagram is a valuable diagnostic test for evaluating structural and functional abnormalities of the esophagus. The study is usually performed as a multiphasic examination that includes upright double-contrast views with a high-density barium suspension, prone single-contrast views with a low-density barium suspension, and, not infrequently, mucosal-relief views with either density of barium suspension. The double-contrast phase optimizes the ability to detect inflammatory or neoplastic diseases, whereas the single-contrast phase optimizes the ability to detect hiatal hernias and lower esophageal rings or strictures. Fluoroscopic examination of the esophagus is also important for assessing motility disorders such as achalasia and diffuse esophageal spasm. This article is a review of gastroesophageal reflux disease, other types of esophagitis, benign and malignant esophageal tumors, varices, lower esophageal rings, diverticula, and esophageal motility disorders, all of which can be diagnosed with the aid of esophagography.
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Affiliation(s)
- Marc S Levine
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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