Introduction
More emphasis on cross-sectional imaging modalities in recent years has decreased
the use of barium procedures. However, barium swallow can provide valuable information
regarding functional evaluation of pharynx, mucosal abnormalities of the esophagus,
and its motility disorders. It has the advantage of easy availability and inexpensive
as compared with cross-sectional imaging modalities. Barium swallow still continues
to be the initial imaging modality in the evaluation of dysphagia, gastroesophageal
reflux, and other esophageal diseases beyond the scope of endoscopies. Also, simultaneous
structural and functional evaluation of esophagus provides additional advantage over
endoscopy and cross-sectional imaging. Barium swallow can be performed as single-
or double-contrast study. Double-contrast swallow is useful in conditions requiring
better mucosal details such as gastroesophageal reflux disease (GERD) and its complications,
carcinoma of esophagus, and infectious esophagitis. Single-contrast swallow is useful
in evaluation of motility disorders and strictures. The purpose of this article is
to review imaging findings of various esophageal diseases on barium swallow. Various
esopahgeal diseases are discussed under five subheadings, viz., oesophageal webs,
rings, and diverticulae; motility disorders; esophagitis; esophageal tumors; and miscellaneous
esophageal diseases.
Imaging technique
All the barium examinations were carried out over a span of 10 years (2004--2013)
in the Department of Radiology. The examinations were performed after per oral administration
of high density barium sulphate (200% w/v) suspension obtained after diluting commercially
available high density barium sulphate powder (microbar-HD; Eskay chemicals, Mumbai)
with 70 ml of water. For double-contrast studies, patients were made to ingest effervescent
granules followed by ingestion of barium suspension. Upright left posterior oblique
(LPO) views were taken, followed by mucosal relief views to evaluate for fold thickness.
Patients were asked to turn 360° so as to coat gastric fundus. Recumbent right lateral
views were taken to evaluate cardiac rosette and gastric fundus. Prone right anterior
oblique (RAO) views were taken to evaluate esophageal motility. Finally, patients
were turned from supine to right posterior oblique and right lateral position under
fluoroscopy to see for gastroesophageal reflux.
Esophageal webs, rings, and diverticulae
Webs
Webs are thin folds of mucosa seen along anterior wall of hypopharynx and proximal
cervical esophagus.[1] On barium swallow, they manifest as shelf-like filling defect (1--2 mm in thickness)
along the anterior wall of cervical esophagus [Figure 1]A. In cases of partial obstruction, jet phenomenon can be seen [2],[3]
[Figure 1]B. Occasionally, prominent cricopharyngeal muscle, seen as protrusion from posterior
pharyngeal wall, can be confused for esophageal web [Figure 1]C.
Figure 1 (A-C): (A) Upright LPO view of single-contrast barium swallow demonstrates a shelf-like
filling defect along the anterior wall of hypopharynx, at pharyngioesophageal junction
s/o web. (B) Jet phenomenon associated with cervical web, usually seen in cases of
partial obstruction. (C) Prominent cricopharyngeus muscle may mimic a web. However,
it is seen along the posterior wall
Rings
Lower esophageal rings are a common finding on barium swallow, mostly being asymptomatic.
Schatzki’s ring is a symptomatic esophageal ring, presenting as dysphagia. It is thought
to develop from scarring in cases of reflux esophagitis. On barium swallow, ring manifests
as smooth concentric segment of luminal narrowing (2--3 mm in thickness), usually
located above hiatal hernia [Figure 2].[4] Rings more than 20 mm in diameter are asymptomatic, whereas rings having diameter
less than 13 mm invariably cause dysphagia.[4]
Figure 2: Prone RAO view of single-contrast barium swallow demonstrating Schatzki ring
Diverticulae
Diverticulae of esophagus have been categorized as pulsion diverticulae, traction
diverticulae, and intramural pseudodiverticulosis.
Pulsion diverticulae occur in lower esophagus and are usually associated with motility
disorders of esophagus. These are false diverticulae, lacking the muscular layer.
On barium swallow, they manifest as broad-based contrast-filled outpouchings showing
barium retention after emptying of esophagus [Figure 3]A, [Figure 3]B.[5]
Figure 3 (A-C): (A) Upright AP view of single-contrast barium swallow shows a pulsion diverticulum.
Also, note multiple nonperistaltic contractions associated with motility dysfunction.
(B) Upright AP view of single-contrast barium swallow showing a large epiphrenic diverticulum.
(C) Upright lateral view of single-contrast barium swallow demonstrating a traction
diverticulum arising from anterior wall of mid esophagus. Note the triangular appearance
of traction diverticulum
Traction diverticulae on the other hand are true diverticulae, seen in mid esophagus.
They are usually caused by scarring in perihilar lymph nodes caused by tuberculosis
or histoplasmosis.[5] On barium swallow, traction diverticulae have a triangular and tented appearance
and show emptying with collapse of esopahgus [Figure 3]C (as they contain all the esophageal layers).[5]
Esophageal intramural pseudodiverticulosis can be associated with esophageal strictures
or occur in isolation. When occurring alone, it is asymptomatic. Intramural pseudodiverticulosis
is dilatation of ducts of esophageal deep mucosal glands. On barium swallow, it appears
as multiple contrast-filled outpouchings parallel to long axis of esophagus.[6]
Motility disorders of esophagus
Motility disorders can be of primary or secondary types. In primary motility disorders,
esophagus is the main organ involved. Secondary motility disorders occur as manifestation
of a variety of systemic diseases or secondary to injury to esophagus.[7] Primary motility disorders include achalasia and its variants, diffuse esophageal
spasm (DES), nutcracker esophagus, nonspecific esophageal motility disorder, and hypertensive
lower esophageal sphincter (LES).[7]
Achalasia
Primary achalasia is idiopathic condition occurring because of defect in myenteric
plexus. On manometry, it is characterized by incomplete relaxation of LES, increased
resting pressure of LES, and absent primary peristalsis. On barium swallow, esophagus
is dilated with absent primary peristalsis and shows distal smooth beak-like tapering
near GE junction [Figure 4]A. Sometimes, esophagus is grossly dilated and tortuous termed as “sigmoid esophagus”[Figure 4]B.[7] Primary achalasia should be differentiated from secondary achalasia, which can occur
secondary to tumors of GE junction or cardiac that can destroy the ganglion cells
in GE junction, thereby interfering with normal peristaltic activity. In secondary
achalasia, narrowed segment is greater in length (>3.5 cm) than in primary achalasia
with presence of mucosal irregularity, nodularity, and ulceration [Figure 4]C.[8] Also clinically, the patients with secondary achalasia are old (usually more than
60 years) and present with recent onset dysphagia (duration less than 6 months) with
weight loss, in contrast to primary achalasia patients who present with history of
long standing dysphagia at younger age.[9] Two variants of achalasia with atypical manometric findings have been described:
vigorous achalasia and early achalasia.[7] In vigorous achalasia, multiple repetitive contractions of LES are present and patient
may complain of chest pain. In early achalasia, there is normal relaxation of LES
with absent primary peristalsis. In both these variant, patients tend to present at
younger age with less dilatation of esophagus on barium studies.[7]
Figure 4 (A-C): (A) Primary achlasia: Prone single-contrast barium swallow showing dilated esophagus
with tapered beak-like narrowing at GE junction (arrow). On fluoroscopy, primary peristalsis
in esophagus was absent. (B) Dilated and tortuous esophagus in a case of primary achlasia
(C) Secondary achlasia: Prone RAO view showing mildly dilated esophagus with narrowing
involving lower thoracic esophagus and GE junction, with mucosal irregularity (arrow).
Note greater length of narrowed segment and less dilatation of esophagus in comparison
to (A)
Diffuse esophageal spasm (DES)
DES is characterized by intermittent absence of primary peristalsis with simultaneous
nonperistaltic contractions, producing classic “corkscrew” or “rosary bead” appearance
of esophagus on barium [Figure 5].[10] However, Prabhakar et al.[11] found that lumen obliterating nonperistaltic contractions were found in only 15%
of patients. In rest of the patients, nonperistaltic contractions of mild to moderate
severity were present without classic corkscrew esophagus.[11]
Figure 5: Diffuse esophageal spasm: upright single-contrast barium swallow image showing multiple
nonperistaltic contractions in esophagus giving classic “corkscrew appearance”
Other motility disorders such as nutcracker esophagus and nonspecific esophageal motility
disorder are diagnosed on manometric studies. Barium swallow in these patients may
be normal or may have nonspecific findings of nonperistaltic contractions.[7]
Secondary esophageal motility disorders can occur because of a variety of causes (collagen
vascular diseases, infections, diabetes mellitus, alcoholism, endocrine diseases,
neuromuscular disorders, physical and chemical agents)[7],[12],[13],[14],[15],[16],[17],[18] and often have nonspecific radiographic findings. Most common collagen vascular
disorders leading to esophageal motility disorder are scleroderma, mixed connective
tissue disease, polymyositis, and dermatomyositis.[16],[17],[18],[19],[20] Manometric and radiological findings in these diseases are similar. Motility abnormalities
in scleroderma occur because of fibrosis of smooth muscles in lower esophagus. Primary
peristalsis is absent in smooth muscle portion of esophagus in scleroderma mimicking
achalasia.[7] However, in scleroderma, LES is patulous (in contrast to narrowing at LES in achalasia)
with presence of gastroesophageal reflux and hiatus hernia [Figure 6]. Peptic stricture secondary to reflux esophagitis can also be seen in these patients.[7]
Figure 6: Upright single-contrast barium swallow in a patient of scleroderma showed dilated
esophagus with absent primary peristalsis in mid and lower esophagus. Also GE junction
was patulous with presence of reflux and sliding hiatus hernia (differentiating it
from achalasia)
Esophagitis
Reflux esophagitis
Reflux esophagitis is most common manifestation of GERD and is the most common inflammatory
condition of the esophagus. Because of its ability to provide better mucosal details,
sensitivity of double contrast barium swallow has been shown to approach 90% in diagnosing
reflux esophagitis.[21],[22] In mild reflux esophagitis, finely nodular or granular mucosa is seen on barium
swallow, which manifests as continuous area extending proximally form gastroesophageal
junction.[23],[24] Ulceration, erosions, longitudinal fold thickening, and esophagogastric polyp can
be seen in moderate to severe reflux esophagitis. Ulceration in GERD is almost always
seen in lower third of esophagus extending proximally from GE junction. On barium
swallow, it can have a linear, stellate, or punctate configuration surrounded by edematous
mucosa or radiating folds.[25] Longitudinal fold thickening is nonspecific feature of reflux esophagitis occurring
because of extension of inflammation and edema to submucosa. Scarring of esophagus
in reflux esophagitis manifests as puckering, flattening, or sacculations of adjacent
esophageal wall. Fixed transverse folds can develop because of scarring, resulting
in shortening of esophagus. This usually manifests as step ladder configuration on
barium studies.[26]
Peptic stricture formation is the most significant finding in reflux esophagitis.[27] Peptic stricture is almost always present with associated sliding hiatus hernia
and is seen as area of concentric luminal narrowing with smooth tapering [Figure 7]. Sometimes it can manifest as ring-like narrowing, mimicking Schatzki’s ring in
patients with dysphagia.[25] If stricture is associated with mucosal irregularity, nodularity, or ulceration,
malignancy should be ruled out.
Figure 7: Peptic stricture (arrow) in a patient with long standing history of gastroesophageal
reflux. Upright double-contrast barium swallow shows sliding hiatus hernia with segment
of smooth, concentric narrowing in lower esophagus. Also note proximal hold up of
the barium
Barrett’s esophagus occurs from columnar metaplasia of distal esophagus in reflux
esophagitis. It develops in ~ 10% of all patients with reflux esophagitis,[28] and manifests as mid esophageal stricture [Figure 8], ulceration, and reticular mucosal pattern.[29] Reticular mucosal pattern is seen as small barium-filled crevices in esophagus resembling
area gastricae, and is most specific finding in Barrett’s esophagus. However, it is
seen in only 5-10% of patients.[30],[31]
Figure 8: Barrett’s esophagus: Upright LPO image of double-contrast barium swallow showing
mild narrowing (arrow) and reticular pattern in columner epithelium at mid thoracic
esophagus. Gastroesophageal reflux was also present in the same patient. Endoscopic
biopsy revealed columnar metaplasia
Infectious esophagitis
Candida albicans is commonest cause of infectious esophagitis occurring in immunocompromised
patients, particular in acquired immunodeficiency syndrome (AIDS). However, it can
also be secondary to local stasis in esophageal motility disorders [32] or diabetes mellitus. On barium swallow, candida esophagitis presents with multiple
irregular plaque such as lesions, oriented along the long axis of the esophagus with
intervening normal mucosa.[33] A fulminant form can occur in AIDS patients producing a “shaggy esophagus” characterized
by numerous plaques and pseudomembranes with trapping of barium.[34] “Foamy esophagus” can occur in patients with motility disorders (like achlasia,
scleroderma), seen as numerous tiny bubbles in column of barium.[35] This results from yeast infection.
Herpes esophagitis occurs as opportunistic infection in immunocompromised patients.
However, occasionally, it can occur in immunocompetent patients with a self-limiting
course.[36] In herpes, esophagitis multiple small ulcers, surrounded by radiolucent halo, are
seen on double-contrast barium swallow on a background of normal mucosa.[37],[38] The ulcers can have a ring-like, stellate, or punctate configuration. In immunocompetent
patients, multiple tiny clustered ulcers are seen in mid esophagus below the level
of left main bronchus.[36]
Cytomegalovirus (CMV) is another important cause for esophagitis in AIDS patients.
It manifests as multiple small or giant oval or diamond-shaped ulcers (several centimetres
in length) on double-contrast barium swallow, surrounded by radiolucent halo (representing
oedematous mucosa).[39]
HIV esophagitis also presents as giant ulcers on double-contrast barium swallow [Figure 9], surrounded by rim of edematous mucosa and is indistinguishable from CMV esophagitis.
Sometimes, satellite ulcers can be seen around the giant ulcer.[40],[41] Endoscopy with brushings or biopsy is required for differentiation between CMV and
HIV esophagitis, as treatment of former entity requires relatively toxic antiviral
drugs.[42]
Figure 9: HIV esophagitis: Upright single-contrast barium swallow image showing giant flat
ulcer (arrow) arising from left posterolateral wall of mid esophagus in an HIV-positive
patient
Radiation-induced esophagitis
High dose external beam radiotherapy used for treatment of malignant tumors involving
lung, esophagus, or mediastinum can cause damage to the esophagus. A radiation dose
of 45--60 Gy can cause severe esophagitis with irreversible damage. Smaller doses
of 20--45 Gy can cause milder form of self-limiting esophagitis without permanent
sequelae.[43] Acute radiation esophagitis usually occurs 2--4 weeks after the completion of radiotherapy
and is self-limiting. On double-contrast studies, esophageal mucosa has granular appearance
with ulceration and reduced luminal distensibility.[44] Chronic esophagitis manifests at 4--8 months after completion of radiotherapy in
form of radiation strictures. On barium swallow, radiation strictures appear as long
segments of concentric and smooth narrowing [Figure 10].[45]
Figure 10: Stricture secondary to radiation: Case of squamous cell carcinoma of mid esophagus,
postradiotherapy status. Barium swallow done 9 months after the completion of radiotherapy
revealed long segment of concentric smooth narrowing involving distal esophagus
Caustic esophagitis
Ingestion of lye and other corrosives can cause severe esophagitis with formation
of stricture at later stages. Endoscopy is considered the best modality to assess
for esophageal damage. Contrast study in acute phase is performed with water-soluble
contrast agent if perforation is suspected.[43] The study may demonstrate reduced distensibility of esophagus with ulceration and
leak of contrast from the esophagus.[43] 10--40% of patients with caustic esophagitis develop strictures,[46],[47] usually 1--3 months after the injury. Barium swallow in these cases reveals long
segment narrowing of esophagus with smooth tapering [Figure 11], usually in upper and mid esophagus. Eccentric narrowing and sacculations can be
seen because of asymmetrical scarring.[43] In severe cases, esophagus may have thread-like filiform appearance.[48]
Figure 11 (A-C): Caustic esophagitis: Upright frontal (A and B) and lateral (C) single contrast barium
swallow images demonstrating long segment stricture involving distal esophagus in
a patient with history of accidental lye ingestion. Also note presence of intramural
pseudodiverticulae associated with the stricture (B)
Drug-induced esophagitis
Doxycycline and tetracycline are most common drugs responsible for drug-induced esophagitis.
The radiographic findings are small, superficial ulceration in upper or mid esophagus
[Figure 12].[49],[50] These ulcers usually heal without scarring. Other drugs responsible for esophagitis
include potassium chloride, NSAIDs, quinidine, and alendronate sodium.[51],[52],[53]
Figure 12: Drug-induced esophagitis: Upright barium swallow image demonstrating ulceration (arrow)
in mid esophagus with esophageal spasm. The esophagitis was related to intake of doxycycline
Tumors of esophagus
Benign tumors
Benign tumors comprise ~ 20% of all tumors of esophagus at autopsy,[54] but only [55] Common imaging features of all benign tumors on barium swallow are smooth intraluminal
or intramural filling defect without any ulceration or nodularity.
Leiomyomas are most common benign tumor of esophagus as well as most common mesenchymal
tumor of esopahgus.[56] Leiomyomas on barium swallow appear as smooth semilunar filling defect [Figure 13], forming right angle or slightly obtuse angle with esophageal wall.[57] On barium studies, these lesions are indistinguishable from other mesenchymal tumors
of esophagus (like fibroma, neurofibromas, and hemangiomas).
Figure 13: Leiomyoma: Upright double-contrast barium swallow image showing smooth crescentic
filling defect in distal esophagus forming obtuse angle with esophageal wall (arrow)
characteristic of a submucosal mass
Fibrovascular polyps are rare benign tumors of esophagus, arising from cervical esophagus,
near cricopharyngeus. These patients may give typical history of regurgitation of
fleshy mass in mouth which may at times cause asphyxia and death if the mass occludes
the larynx.[58] On barium swallow, they appear as a smooth, expansile sausage-shaped mass [Figure 14], arising from cervical esophagus.[58]
Figure 14: Fibrovascular polyp: Upright barium swallow image showing expansion of cervical and
proximal thoracic esopahgus with polyploidal filling defect (arrow)
Squamous papillomas are most common mucosal tumors of esophagus, appearing as small,
smooth sessile polyp on barium swallow [59] that at times may be difficult to distinguish from esophageal carcinoma.
Malignant tumors
Malignant esophageal tumours account for ~ 80% of all esophageal tumours, 90% of them
being esophageal carcinoma (squamous cell or adenocarcinoma).[56] All malignant esophageal tumors have common imaging features of a mass or stricture
with mucosal irregularity, ulceration, and nodularity.[56]
Esophageal carcinoma
Esophageal carcinoma can be squamous cell type or adenocarcinoma with their relative
proportion varying by geographical location.[56] It is difficult to distinguish between squamous cell carcinoma (SCC) and adenocarcinoma
on imaging. SCC usually involves upper or mid esophagus, whereas adnocarcinoma involves
lower esophagus with propensity to extend into gastric fundus.[60] Sensitivity of double-contrast barium swallow in diagnosing esophageal cancers has
been reported to be greater than 95%.[61] Early esophageal cancers may appear as plaque-like lesions [Figure 15]A, small lobulated sessile polyp, or focal wall irregularity on double-contrast barium
swallow.[62] Superficial spreading carcinoma can appear as poorly defined nodules, merging with
one another.
Figure 15 (A-D): Esophageal carcinoma: (A) Early esophageal cancer seen as plaque-like lesion with
mucosal irregularity and mild reduce distensibility (arrow) in mid thoracic esophagus
on double-contrast barium swallow. (B) Infiltrative lesion: Prone RAO barium swallow
image showing irregular infiltrative lesion (arrow) with shouldering in distal esophagus
extending till GE junction. Also note proximal dilatation of esophagus. Endoscopic
biopsy revealed the lesion to be adenocarcinoma. (C) Ulcerative lesion: Upright single-contrast
barium swallow image demonstrating irregular ulcerative lesion in upper esophagus
(arrow) without significant luminal narrowing. (D) Polypoidal lesion: Upright lateral
view of single-contrast barium swallow showing polyploidal filling defect in upper
esophagus (arrow). Patient had severe dysphagia and aspirated small amount of barium
during the procedure
Advanced esophageal cancers can appear as infiltrative, ulcerative, polyploidal, or
varicoid type on double-contrast barium swallow.[63] Infiltrative lesions (most common appearance) appear as luminal narrowing with mucosal
irregularity, nodularity, and ulceration with shouldering of margins [Figure 15]B. Ulcerative carcinomas appear as giant ulcers with [Figure 15]C surrounding tumor rind.[64] Polypoid lesions appear as lobulated intraluminal masses with or without ulceration
[Figure 15]D. Varicoid type appears as fixed, thickened longitudinal defects because of submucosal
infiltration of tumor.[65]
Other esophageal tumors
Spindle cell carcinoma
It contains both carcinomatous and sarcomatoid components. On barium examination,
it appears as a large polypoidal, expansile mass [Figure 16] with scalloped margins in mid and distal esophagus.[66],[67] Unlike esophageal carcinoma, it expands the esophagus without causing obstruction.[68] Leiomyosarcoma, it is another rare esophageal tumor which appears as intramural
polypoidal filling defect [Figure 17] with exophytic component and areas of calcification.[69] Primary malignant melanoma of the esophagus may appear as large polypoidal mass
indistinguishable from spindle cell carcinoma [Figure 18].[70] Lymphoma can also involve the esophagus (more commonly non Hodgkin’s lymphoma),
which manifests on imaging as polypoidal lesions, submucosal masses, fold thickening,
and strictures [Figure 19].[71]
Figure 16: Spindle cell carcinoma: Upright frontal and LPO images of barium swallow demonstrating
irregular polyploidal filling defect (arrow) in mid esophagus causing expansion of
esophageal lumen
Figure 17: Leiomyosarcoma: Prone RAO double-contrast barium swallow image showing semilunar
filling defect (arrow) in distal thoracic esophagus s/o submucosal mass. Endoscopic
biopsy revealed leiomyosarcoma
Figure 18: Malignant melanoma: Upright frontal single-contrast barium swallow image showing
irregular, large, polyploidal, expansile filling defect in distal esopahgus (arrow).
This may be difficult to distinguish from spindle cell carcinoma
Figure 19: Non-Hodgkin’s lymphoma of stomach involving GE junction: Concentric smooth narrowing
involving distal esophagus (arrow). Multiple small polyploidal filling defects were
also seen noted in stomach
Miscellaneous abnormalities of the esophagus
Hiatus hernia
Hiatus hernia can be sliding type, rolling type (or paraesophageal), or mixed type.
On barium swallow, sliding hiatus hernia is diagnosed when mucosal ring or B ring
is ~ 2 cm above the hiatus with presence of gastric folds above the hiatus [Figure 20]A.[72] On the other hand, in paraesophageal hernia, GE junction is usually normal in position
with herniation of fundus of stomach into the thorax. In mixed hernia, GE junction
is displaced upwards with herniation of fundus of stomach [Figure 20]B.
Figure 20 (A and B): (A) Sliding hiatus hernia: Upward migration of GE junction with herniation of stomach
into thoracic cavity. (B) Mixed hernia: Upright barium swallow image showing paraesophageal
herniation of fundus and body of stomach (arrow). Also note higher position of GE
junction
Esophageal tuberculosis
Esophageal tuberculosis is rare and usually secondary to tuberculous infection at
other sites. Most common site for involvement is mid third of esopahgus, adjacent
to tracheal bifurcation. Most common finding is extrinsic impression by adjacent lymph
nodes [Figure 21]. Traction diverticulum may be seen because of adventitial involvement. Mucosal irregularity
and ulceration can be seen because of involvement of esophageal mucosa. Rupture of
necrotic mediastinal lymph nodes may lead to formation of sinus or fistula.[73]
Figure 21: Esophageal tuberculosis: Upright barium swallow image of a patient with history of
dysphasia showing extrinsic impression in mid esophagus with presence of mild mucosal
ulceration and displacement of esophagus towards right side (arrow)
Crohn’s disease of esopahgus
Esophageal involvement is rare and is associated with Crohn’s disease elsewhere in
gastrointestinal tract. Imaging findings are cobblestone mucosa with ulceration.[74] Stricture formation can be present in some cases [Figure 22], seen in distal third of esophagus and is usually greater than 1 cm in length.[74]
Figure 22: Esophageal Crohn’s disease: Upright barium swallow image showing stricture of mid
and lower esophagus (arrow)
Esophageal perforation
Esophageal perforation can be iatrogenic or spontaneous. Spontaneous esophageal perforation
(also known as Boerhaave’s syndrome) is usually a result of full thickness esophageal
wall tear because of forceful vomiting or retching. In cases of perforation, contrast
study by water-soluble contrast is indicated. This may be followed by barium swallow,
provided no leak is seen on initial study. Mallory--Weiss tear is a partial mucosal
and submucosal tear (without transmural perforation), seen in lower esophagus near
GE junction. Contrast swallow reveals intramural leak of contrast [Figure 23].
Figure 23: Mallory Weiss tear: Upright single-contrast barium swallow image showing intramural
contrast extravasation from esophagus at level of GE junction (arrow), in a patient
with history of violent episode of vomiting
Congenital short esophagus
Congenital short esophagus is a very rare condition, associated with intrathoracic
stomach [Figure 24].[75],[76] It is thought to be due to underlying developmental anomaly. It needs to be differentiated
from congenital hiatal hernia with intrathoracic herniation of stomach.[77]
Figure 24: Congenital short esophagus: LPO view in an infant showing short esophagus with intrathoracic
stomach
Foreign body in esophagus
Although chest radiography is the initial investigation in patients with suspected
esophageal foreign body, radiolucent foreign bodies may not be detected on plain radiography.
Barium swallow in these cases may demonstrate intraluminal filling defect [Figure 25].
Figure 25: FB sequelae: LAO view barium swallow image of a patient with past history of denture
impaction showing stricture at proximal esophagus with restricted passage of barium.
Also note H-shaped tracheoesophageal fistula with opacification of trachea
Conclusion
Barium swallow is the initial imaging modality of choice for evaluation of suspected
esophageal diseases. Besides providing excellent mucosal detail, it helps in functional
evaluation of esophagus and accurate diagnosis of a variety of neoplastic and non-neoplastic
conditions. Radiologist should be familiar with standard techniques and protocols
of the procedure and imaging findings of various esophageal diseases on barium swallow.
