SpottersBarium Spot 1 Spot 2 Spot 3 Spot 4 Spot 5 Spot 6 Spot 7 Spot 8 Spot 9 Spot 10. • 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 stomach—the 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, 1–2 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 2–4 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 Barrett’s esophagus has varying forms of columnar metaplasia arranged into tufts. Therefore, the “reticular pattern” of Barrett’s 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 Barrett’s 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