Spotters

Barium

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 ANSWERS

Spot 1

Spot 1. Hiatus hernia

Spot radiograph from the single-contrast phase of an upper GI
series, obtained with the patient in a prone position.
The A ring, also known as the muscular ring, is at the
transition between the tubular esophagus and the esophageal
vestibule. This is a transiently seen, contractile ring.
The B ring is a ring composed of mucosa and submucosa at the
transition between esophagus and stomachthe
esophagogastric junction. A Schatzki ring would occur at this
site.
The C ring is seen in patients with a hiatal hernia. This is a
broad-based, smooth extrinsic impression by the diaphragm on
the stomach. The C ring identifies the location of the
diaphragm

Spot 2

Spot 2. Esophageal web

In the upper cervical esophagus, 12 mm shelf like
filling defects are seen on the anterior wall or
circumferentially.
Partial obstruction is suggested clinically by solid
food dysphagia or radiographically by luminal
narrowing of 50%, a jet of barium spurting
through the web, or dilation of the proximal cervical
esophagus.
Redundant mucosa is undulating, is vertically
oriented, and changes size with varying degrees of
luminal distention by the bolus. Webs are shelflike
narrowings

Spot 3

Spot 3. Ballooning of Distal

Esophagus.

In about half of patients operated on for

achalasia, the mucosa balloons through
the wall of the esophagus at the site of
cardiomyotomy. Radiographically, an
eccentric outpouching is seen. If the
patient has a fundoplication wrap, this
appears as a smooth soft tissue mass in
the midportion of the gastric fundus
circumferentially enveloping the distal
esophagus.

Spot 4

Spot 4.Schatzki ring

The esophagogastric junction often has a ringlike
configuration, termed the mucosal ring or B
ring. The ring is smooth, symmetric, and 24 mm
in height, and has a variable luminal diameter. The
term Schatzki ring is used for mucosal rings of
narrow enough caliber to cause dysphagia. The
pathogenesis of Schatzki rings is uncertain, but may
be related to chronic gastroesophageal reflux and
reflux-related scarring.
Peptic strictures at the esophagogastric junction are
ringlike, but are thicker than 4 mm in height, have
slightly tapered edges and frequently are slightly
irregular in contour and asymmetric, with longer
tapered edges indicating vertically oriented

Spot 5

Spot 5. Paraesophageal
Hernia
In a true paraesophageal
hernia, the esophagogastric junction is
below the esophageal hiatus of the diaphragm.
More commonly, the esophageal hiatus of the diaphragm is
extremely wide, allowing superior axial migration of the gastric
cardia (a routine axial hiatal hernia) and a portion of mid
stomach going back through the esophageal hiatus of the
diaphragm alongside the gastric cardia. This situation is often
described as a form of gastric volvulus.
In our case presented here, there is a rent in the left
hemidiaphragm just lateral to the esophageal hiatus of the
diaphragm This diaphragmatic rent allows a small portion of
gastric fundus to herniate into the chest. Because there was no
history of even remote trauma, this hernia could not be
described as a traumatic hernia
Some surgeons and radiologists would describe this as a
paraesophageal hernia. It is better to describe the anatomic
location of the herniation and what portion of stomach is above
the diaphragm.

Spot 6

Spot 6. Foreign body

Impaction
A polypoid carcinoma is a finely lobulated tumor that
superficially mimics a foreign body, but the stalk of the
tumor is usually visible. A meniscus is not present.
A fibrovascular polyp is a smooth, elongated, polypoid
mass, usually arising from the anterior wall of the
cervical esophagus.
Spindle cell carcinoma is a large, lobulated, mainly
intraluminal polypoid mass, typically seen in the
midesophagus. Dysphagia may be of recent onset, but
would not be as hyperacute as the dysphagia in most
patients with a food impaction.
Primary malignant melanoma of the esophagus is
another rare tumor that mimics spindle cell carcinoma

Spot 7

Spot 7. Achlasia
Primary peristalsis is absent. Some patients exhibit
shallow nonperistaltic contractions; a few patients have
relatively higher amplitude nonperistaltic contractions
so-called vigorous achalasia.
The distal esophagus has a short, smooth, beaklike
tapered arrowing that eventually opens to a variable
degree; this reflects the lower esophageal sphincter
dysfunction. The esophagus is variably dilated.
In early achalasia, esophageal dilation may be subtle. In
these patients, diagnosis depends on evaluation of
peristalsis and lower esophageal sphincter opening.
With longer duration of disease, the esophagus dilates.
With end-stage disease, the esophagus is massively
dilated and tortuous, assuming a sigmoid shape in
some patients.

Spot 8

Spot 8. Pseudo-Achlasia
Pseudoachalasia typically results from
submucosal infiltration of the distal
esophagus and cardia by cancer.
Pseudoachalasia can be differentiated
from achalasia by clinical findings and
by asymmetry, abrupt transitions,
mucosal nodularity, and associated
mass and ulceration in the former.

Spot 9

Spot 9. Varices
Varices are manifested on barium studies as smooth, thick,
undulating, scalloped folds that change size with various
degrees of esophageal distention, peristalsis, or respiration.
Enlarged folds in Reflux esophagitis are not smooth, but have
a slightly irregular contour.
Submucosal spread of squamous cell carcinoma may produce
thick undulating folds; however, the surface of the folds is
often nodular,mand the tumorous folds do not change size or
shape with various degrees of luminal distention.
Dysphagia is more frequent in patients with varicoid
carcinoma than in patients with varices.
Lymphoma infiltrating the esophagus can mimic varices, but is
usually midesophageal and does not change size or shape
with various degrees of luminal distention. Lymphoma
infiltrating the esophageal mucosa is exceedingly rare

Spot 10.

Spot
10.
Reflux
esophagitis
Reflux esophagitis is typified by tiny, ill-defined elevations of the

mucosal surface , termed mucosal granularity or granular

mucosa. The nodules or granules of reflux esophagitis are
confluent, located in the distal esophagus.
The nodules in reflux esophagitis are poorly defined and located in
the lower esophagus.
The nodules of glycogenic acanthosis, an aging variant, are more
discrete, of variable size up to 3-4 mm, and are located in the
upper and mid thoracic esophagus. These nodules are usually
separated by normal smooth mucosa.
The mucosa may be finely ulcerated or nodular in patients with
acute radiation esophagitis. The esophagitis is confined to the
radiation portal
Barretts esophagus has varying forms of columnar metaplasia
arranged into tufts. Therefore, the reticular pattern of Barretts
esophagus mimics the reticular configuration of the areae
gastricae of the stomach, though the tufts are smaller, about 1
mm in size. About 10% of patients with Barretts esophagus
demonstrate a reticular pattern, often adjacent to the distal
aspect of a reflux-induced stricture.
Superficial spreading carcinoma is a confluent patch or longer