Indications, Contraindications, and Patient Preparation

Indications

• Anatomical anomalies (e.g., birth defects, strictures)
• Foreign body obstruction
• Esophageal reflux (GERD)
• Esophageal varices (dilated veins in the esophagus)
• Motility disorders

Contraindications

• No absolute contraindications
• Do not use barium sulfate if recent surgery or suspected perforation → substitute water-soluble iodinated contrast (e.g., Gastrografin)

Patient Preparation

• No prep required if esophagram only
• If combined with Upper GI: patient should be NPO for at least 8 hours
• Always check for contrast allergies: iodine, seafood, x-ray dye if iodinated contrast will be used

Routine Projections (ARRT Required)

PA or AP Esophagus

CR Location & Positioning

• SID: 40 inches
• Patient position: Supine or upright; midsagittal plane centered to IR
• Adjustments: Arms at sides, shoulders level and relaxed
• CR: Perpendicular to IR, centered at level of T5–T6 (approximately 3 inches below jugular notch)
• Patient instructions: “Drink, drink, drink…” — patient swallows contrast during exposure
• Exposure: During swallowing

Evaluation Criteria

• Coverage (what anatomy must be included and how you verify it’s complete): Entire esophagus visualized from oropharynx to gastroesophageal junction.
• Rotation checks (how symmetry or alignment tells you if positioning is correct): Sternoclavicular joints symmetric; spine aligned with midline.
• Motion checks  (how sharpness confirms patient cooperation/exposure timing): Esophageal walls sharp; contrast column well defined during peristalsis.
• Technique checks (what contrast, density, soft tissue visibility, and artifacts to look for): Adequate penetration through mediastinum; contrast density consistent.
• Clinical aim (when applicable, e.g., reflux, obstruction, displacement, etc.): Evaluate for strictures, foreign bodies, and reflux.

RAO Esophagus

CR Location & Positioning

• SID: 40 inches
• Patient position: Prone, rotated 35–40° into RAO
• Adjustments: Right arm down, left arm flexed; head slightly turned toward IR
• CR: Perpendicular to IR, centered at T5–T6 (3 inches below jugular notch)
• Patient instructions: “Drink, drink, drink…” (exposure made during swallowing)
• Exposure: During swallowing

Evaluation Criteria

• Coverage: Entire esophagus from oropharynx to stomach.
• Rotation checks: Esophagus projected between spine and heart; no overlap with vertebral column.
• Motion checks: Sharp mucosal borders without blur from swallowing motion.
• Technique checks: Adequate exposure through mediastinal structures; no clipping of distal esophagus.
• Clinical aim: Best demonstrates esophagus between heart and spine; primary view for reflux and motility disorders.

Lateral Esophagus

CR Location & Positioning

• SID: 40 inches
• Patient position: True lateral; midcoronal plane centered to IR
• Adjustments: Arms raised forward; shoulders, hips, and knees superimposed
• CR: Perpendicular to IR, centered at T5–T6
• Patient instructions: “Drink, drink, drink…” during exposure
• Exposure: During swallowing

Evaluation Criteria

• Coverage: Entire esophagus from oropharynx to gastroesophageal junction.
• Rotation checks: Posterior ribs superimposed; shoulders aligned vertically.
• Motion checks: Sharp esophageal margins; no blur or ghosting from peristalsis.
• Technique checks: Adequate contrast between esophagus and mediastinal structures; no excessive density.
• Clinical aim: Demonstrates posterior relationship of esophagus to trachea and heart.

Supplemental Projections

LAO Esophagus

CR Location & Positioning

• SID: 40 inches
• Patient position: Prone, rotated 35–40° into LAO
• Adjustments: Left arm down, right arm up across chest; head slightly turned toward IR
• CR: Perpendicular to IR, centered at T5–T6
• Patient instructions: “Drink, drink, drink…” (exposure made during swallowing)
• Exposure: During swallowing

Evaluation Criteria

• Coverage: Entire esophagus visualized.
• Rotation checks: Esophagus projected between hilar region and thoracic spine.
• Motion checks: Sharp margins, contrast column well defined.
• Technique checks: Sufficient density to penetrate mediastinum; no shoulder superimposition.
• Clinical aim: Alternative to RAO; demonstrates esophagus away from spine for comparison.

Procedure Adaptation

• Preferred oblique: RAO provides better visualization of esophagus between spine and heart compared to LAO.
• Pediatrics: Use smaller volumes of contrast; may require immobilization.
• Trauma / immobiled patients: AP supine with horizontal beam.
• Motility studies: Record multiple swallows to evaluate peristaltic function.

Exposure Factors & Technical Considerations

• SID: 40 inches
• kVp: 100–110 for single contrast; 90–100 for double contrast
• mAs: Low, short exposures to freeze swallowing motion
• Collimation: Include entire esophagus from oropharynx to stomach
• Contrast:
  • Positive contrast → barium sulfate
  • Negative contrast → air (effervescent crystals)
• Shielding: Gonadal shielding when possible

Memory Aids

• RAO = Right Arm Out – Rotate right side toward the table to separate the esophagus from the spine.
• “Drink, drink, drink…” – Exposure during active swallowing ensures visualization of peristalsis.
• C6–T11 Rule – Remember: C6 (start), T10 (diaphragm), T11 (stomach).
• Air = Black / Barium = Bright – Think “Airway black, Anatomy bright.”