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GI Studies

39 Esophagus

Anatomy

  • Mouth
  • Pharynx
  • Esophagus
  • Stomach
  • Esophagogastric junction
  • Cardiac antrum

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

Projections

PA or AP Esophagus

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine or upright; MSP centered to IR
  • Adjustments: Arms down at sides, shoulders level
  • CR: Perpendicular to IR, centered at level of T5–T6 (≈ 3″ below jugular notch)
  • Pt. Instructions: “Drink, drink, drink…” (Swallow contrast while exposure is made)
  • Exposure: During swallowing

Evaluation Criteria

  • Entire esophagus filled with barium
  • No body rotation (SC joints symmetric)

RAO Esophagus

CR Location & Positioning

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

Evaluation Criteria

  • Esophagus projected between spine and heart
  • Entire esophagus filled with contrast
  • Arms not obscuring field

Lateral Esophagus

CR Location & Positioning

  • SID: 40 inches
  • Patient position: True lateral, MCP centered to IR
  • Adjustments: Arms raised forward to avoid superimposition
  • CR: Perpendicular to IR, centered at T5–T6
  • Pt. Instructions: “Drink, drink, drink…” (Swallow contrast while exposure is made)
  • Exposure: During swallowing

Evaluation Criteria

  • Esophagus seen between spine and heart shadow
  • Posterior ribs superimposed (true lateral)
  • Entire esophagus filled with contrast

LAO Esophagus (Optional)

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Prone, rotated 35–40° into LAO
  • Adjustments: Left arm down, right arm up across chest
  • CR: Perpendicular to IR, centered at T5–T6
  • Pt. Instructions: “Drink, drink, drink…” (Swallow contrast while exposure is made)
  • Exposure: During swallowing

Evaluation Criteria

  • Esophagus projected between hilar region and T-spine
  • Entire esophagus filled with contrast
  • Arms not superimposing field

Procedure Adaptation

  • Preferred oblique: RAO → provides better visualization of esophagus between spine and heart compared to LAO.
  • Pediatrics: Smaller volumes of contrast; may require immobilization.
  • Trauma / immobile patients: AP supine with horizontal beam.
  • Motility studies: Multiple swallows may be recorded to evaluate peristalsis.

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

Hows & Whys of Esophagus Radiography

Anatomy & Function

  • What are the boundaries of the oral cavity?
    The teeth, hard and soft palates, and tongue.
  • What is the medical term for chewing?
    Mastication.
  • What is the medical term for swallowing?
    Deglutition.
  • Where does the oral cavity connect posteriorly?
    To the pharynx.
  • At what level does the pharynx transition into the esophagus?
    C6.
  • Where are the indentations of the esophagus located?
    At the aortic arch and where it crosses the left primary bronchus.
  • What is the esophageal hiatus, and at what level is it located?
    An opening in the diaphragm where the esophagus passes through at T10.
  • What is the cardiac antrum?
    The portion of the esophagus below the diaphragm, just before it joins the stomach.
  • Where does the esophagus join the stomach, and what is this opening called?
    At the esophagogastric junction, also called the cardiac orifice, at level T11.

Contrast & Technique

  • What types of contrast media are used in an esophagram?
    Positive (radio-opaque, e.g., barium sulfate) and negative (radiolucent, e.g., air from gas crystals).
  • What is positive contrast?
    Material that appears white on images, such as barium or iodinated agents.
  • What is negative contrast?
    Material that appears black on images, such as air.
  • Who performs the fluoroscopy during an esophagram?
    The radiologist, with the technologist assisting the patient.
  • Why is the RAO position usually preferred over the LAO position?
    It places the esophagus between the spine and heart, giving the clearest visualization.
  • What is the Valsalva maneuver?
    Forcing exhalation against a closed glottis, as if straining to have a bowel movement.
  • What does the Valsalva maneuver demonstrate?
    Increases intra-abdominal and thoracic pressure, which may demonstrate esophageal reflux.

Indications & Safety

  • What are the common indications for an esophagram?
    Anomalies, foreign body obstruction, reflux, esophageal varices, motility disorders.
  • Are there any contraindications to an esophagram?
    No major ones. Avoid barium sulfate if perforation is suspected or after recent surgery.
  • When might water-soluble contrast be used instead of barium?
    When perforation or post-surgical leakage is suspected.
  • What allergies should be checked if water-soluble contrast is used?
    Iodine, seafood, “x-ray dye.”
  • Is there any special preparation before an esophagram?
    No preparation unless combined with an Upper GI study (then patient must be NPO for 8 hours).

 

 

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Radiographic Procedures Review Guide Copyright © 2025 by Carla M. Allen and Taylor M. Otto. All Rights Reserved.