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Gastroesophageal Reflux Disease: Integrating the Barium Esophagram before and after Antireflux Surgery¹

¹ From the Cleveland Clinic Center for Swallowing and Esophageal Disorders, Department of Diagnostic Radiology (M.E.B., D.M.E., B.R.H., E.M.R., G.A.M., E.E.), Department of Cardiovascular Surgery, Section of Thoracic Surgery (T.W.R.), and Department of Gastroenterology and Hepatology (J.E.R.), the Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. Received January 13, 2005; revision requested March 17; revision received October 7; accepted November 7; final version accepted January 30, 2006; final review and update by M.E.B. November 22. Address correspondence to M.E.B. (e-mail: Bakerm{at}ccf.org).

View larger version (17K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Instructions for timed barium swallow technique.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Timed barium swallow phase of esophagography after ingestion of 250 mL of low-density barium in a patient with achalasia. Anteroposterior three-on-one spot radiographs in upright position (1, 2, and 5 = 1, 2, and 5 minutes, respectively) after barium ingestion show poor esophageal emptying.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: Large nonreducible hiatal hernia with high-volume reflux in a patient with heartburn and dysphagia. (a) Upright anteroposterior air-contrast esophagram shows large (>5 cm in size) nonreducible hiatal hernia (HH); findings indicate a foreshortened esophagus. The arrows point to the diaphragm. (b) Supine anteroposterior esophagram during reflux identification portion of esophagography shows spontaneous, high-volume reflux (arrow), which did not clear rapidly. Motility portion of the examination showed aperistalsis.

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: Large nonreducible hiatal hernia with high-volume reflux in a patient with heartburn and dysphagia. (a) Upright anteroposterior air-contrast esophagram shows large (>5 cm in size) nonreducible hiatal hernia (HH); findings indicate a foreshortened esophagus. The arrows point to the diaphragm. (b) Supine anteroposterior esophagram during reflux identification portion of esophagography shows spontaneous, high-volume reflux (arrow), which did not clear rapidly. Motility portion of the examination showed aperistalsis.

View larger version (55K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Long distal peptic esophageal stricture strongly suggesting foreshortened esophagus. (a) Upright anteroposterior air-contrast esophagram shows stricture (arrow) and nonreducible hernia (HH). (b) Upright anteroposterior esophagram after ingestion of 13-mm tablet (T) and barium shows obstruction of tablet at the stricture.

View larger version (57K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Long distal peptic esophageal stricture strongly suggesting foreshortened esophagus. (a) Upright anteroposterior air-contrast esophagram shows stricture (arrow) and nonreducible hernia (HH). (b) Upright anteroposterior esophagram after ingestion of 13-mm tablet (T) and barium shows obstruction of tablet at the stricture.

View larger version (17K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Issues that should be addressed in an esophagram report in a patient suspected of having GERD.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Timed barium swallow phase of esophagography after ingestion of 250 mL of low-density barium in a patient with liquid dysphagia after Collis gastroplasty and Nissen fundoplication. Anteroposterior three-on-one spot radiographs in upright position (1, 2, and 5 = 1, 2, and 5 minutes, respectively) after barium ingestion show poor esophageal emptying.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 7a: Normal laparoscopic Nissen fundoplication. (a) Semiprone (right anterior oblique) esophagram during distended single-contrast phase shows that fundoplication (arrows) primarily surrounds the distal esophagus (arrowhead). (b) Spot radiograph of gastric fundus with patient in right lateral 45° erect position shows the leaves of fundoplication (arrows) surrounding distal esophagus and small portion of the stomach (arrowhead). Even appropriately placed fundoplications include small portion of the stomach. This case shows that in normal fundoplication, it is often difficult to completely fill these leaves of the wrap with barium and air.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 7b: Normal laparoscopic Nissen fundoplication. (a) Semiprone (right anterior oblique) esophagram during distended single-contrast phase shows that fundoplication (arrows) primarily surrounds the distal esophagus (arrowhead). (b) Spot radiograph of gastric fundus with patient in right lateral 45° erect position shows the leaves of fundoplication (arrows) surrounding distal esophagus and small portion of the stomach (arrowhead). Even appropriately placed fundoplications include small portion of the stomach. This case shows that in normal fundoplication, it is often difficult to completely fill these leaves of the wrap with barium and air.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 8: Normal Toupet, or partial, fundoplication. Anteroposterior spot radiograph of gastric fundus in semiupright position after air-contrast portion of esophagography shows that blind-end leaves of the wrap (arrows) are not directly opposed.

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 9a: Long, twisted, tight fundoplication surrounding the stomach in a patient with solid food dysphagia after surgery. (a) Semiprone (right anterior oblique) esophagram during distended single-contrast phase shows leaves of fundoplication (arrows) surrounding only gastric folds (arrowheads). Wrap length is at least 4 cm, as estimated when compared with 13-mm tablet. Position of arrowheads roughly approximates superior and inferior extent of fundoplication. Gastric folds surrounded by the wrap do not have straight linear appearance (arrowheads) but a somewhat spiral appearance indicating a twist, which is a very subtle finding and difficult to see. (b) Upright anteroposterior spot radiograph of fundus after ingestion of 13-mm tablet (T) shows that tablet is obstructed above the level of the wrap (arrow). Poorly coated fundus is seen in lower right quarter.

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 9b: Long, twisted, tight fundoplication surrounding the stomach in a patient with solid food dysphagia after surgery. (a) Semiprone (right anterior oblique) esophagram during distended single-contrast phase shows leaves of fundoplication (arrows) surrounding only gastric folds (arrowheads). Wrap length is at least 4 cm, as estimated when compared with 13-mm tablet. Position of arrowheads roughly approximates superior and inferior extent of fundoplication. Gastric folds surrounded by the wrap do not have straight linear appearance (arrowheads) but a somewhat spiral appearance indicating a twist, which is a very subtle finding and difficult to see. (b) Upright anteroposterior spot radiograph of fundus after ingestion of 13-mm tablet (T) shows that tablet is obstructed above the level of the wrap (arrow). Poorly coated fundus is seen in lower right quarter.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 10a: Long, twisted, partially supradiaphragmatic fundoplication surrounding the stomach in a patient with dysphagia and gas bloat after surgery. (a) Semiprone (right anterior oblique) esophagram during distended single-contrast phase esophagography shows fundoplication (long arrows) surrounding gastric folds (arrowheads). As in Figure 7a, the folds surrounded by the wrap do not have a straight linear appearance but a spiral appearance indicating a twist, which is a very subtle finding and difficult to see. Position of arrowheads roughly approximates the superior and inferior extent of fundoplication. A portion of fundoplication (short arrow) has herniated above the diaphragm in paraesophageal location. (b) Retroflexed endoscopic view of fundus shows twist in gastric folds (arrows) caused by the fundoplication.

View larger version (156K): [in this window] [in a new window] [Download PPT slide]   Figure 10b: Long, twisted, partially supradiaphragmatic fundoplication surrounding the stomach in a patient with dysphagia and gas bloat after surgery. (a) Semiprone (right anterior oblique) esophagram during distended single-contrast phase esophagography shows fundoplication (long arrows) surrounding gastric folds (arrowheads). As in Figure 7a, the folds surrounded by the wrap do not have a straight linear appearance but a spiral appearance indicating a twist, which is a very subtle finding and difficult to see. Position of arrowheads roughly approximates the superior and inferior extent of fundoplication. A portion of fundoplication (short arrow) has herniated above the diaphragm in paraesophageal location. (b) Retroflexed endoscopic view of fundus shows twist in gastric folds (arrows) caused by the fundoplication.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 11: Disrupted supradiaphragmatic fundoplication with small recurrent hiatal hernia in a patient with recurrent reflux symptoms. Semiprone (right anterior oblique) esophagram during distended single-contrast phase of esophagography shows both herniated paraesophageal fundoplication (arrows) and recurrent hiatal hernia (arrowhead).

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 12a: Completely disrupted fundoplication with recurrent hernia in a patient with recurrent reflux symptoms. (a) Upright anteroposterior air-contrast esophagram shows that recurrent hiatal hernia (HH) does not reduce in upright position. Fixed transverse folds (arrowheads) in distal esophagus suggest longitudinal scarring from reflux esophagitis. The patient likely has a foreshortened esophagus. (b) Upright anteroposterior air-contrast esophagram during barium ingestion shows barium-filled distal esophagus, recurrent hiatal hernia (HH), and no fundoplication where one should exist (arrows).

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 12b: Completely disrupted fundoplication with recurrent hernia in a patient with recurrent reflux symptoms. (a) Upright anteroposterior air-contrast esophagram shows that recurrent hiatal hernia (HH) does not reduce in upright position. Fixed transverse folds (arrowheads) in distal esophagus suggest longitudinal scarring from reflux esophagitis. The patient likely has a foreshortened esophagus. (b) Upright anteroposterior air-contrast esophagram during barium ingestion shows barium-filled distal esophagus, recurrent hiatal hernia (HH), and no fundoplication where one should exist (arrows).

View larger version (24K): [in this window] [in a new window] [Download PPT slide]   Figure 13: Issues that should be addressed in an esophagram report in a symptomatic patient after antireflux surgery.