This article discusses the extraesophageal manifestations of gastroesophageal reflux disease, focusing primarily on the gamut of pharyngeal abnormalities that can be detected on barium swallows. Abnormalities of pharyngeal swallowing caused by gastroesophageal reflux are illustrated. We particularly emphasize how pharyngoesophageal relationships can guide the radiologist for performing tailored barium swallows to optimally evaluate pharyngeal abnormalities in patients with underlying gastroesophageal reflux disease.

Objective: To determine the clinical, radiographic, and endoscopic findings of sleeve stenosis after sleeve gastrectomy and to correlate treatment with outcomes. Methods: We identified 43 patients who underwent barium studies to evaluate upper GI symptoms after laparoscopic sleeve gastrectomy. The clinical, radiographic, and endoscopic findings were reviewed and correlated with treatment and outcomes. Results: 26 patients (60%) had sleeve stenoses. All stenoses appeared as short segments of smooth, tapered narrowing, with a mean length of 8.0 mm and mean width of 7.5 mm, and 24 (92%) were located in the proximal or distal third of the sleeve. 23 patients (88%) had upstream dilation, and 1 (4%) had retained food proximal to the stenosis. 23 (70%) of 33 patients with obstructive symptoms and 3 (30%) of 10 without obstructive symptoms had sleeve stenoses. Endoscopy revealed sleeve stenosis in 8 (67%) of 12 patients with radiographic stenosis. Endoscopic dilation resulted in improvement/resolution of symptoms in seven (88%) of 8 patients. Conclusion: Sleeve stenosis after sleeve gastrectomy was characterized radiographically by a short segment of smooth, tapered narrowing, typically in the proximal or distal third of the sleeve. Approximately, 70% of patients with obstructive symptoms and 30% with non-obstructive symptoms had sleeve stenosis. One-third of radiographically diagnosed stenoses were not seen at endoscopy. The barium study, therefore, is a useful test for sleeve stenosis in patients with obstructive or nonobstructive symptoms after sleeve gastrectomy. Advances in knowledge: This article describes the appearance and location of sleeve stenoses after laparoscopic sleeve gastrectomy and the clinical presentation and treatment options for these patients.

OBJECTIVE:The purpose of this study is to present the clinical and radiographic findings of esophageal lichen planus.MATERIALS AND METHODS:A search of computerized medical records identified 15 patients with pathologic findings of esophageal lichen planus on endoscopic biopsy specimens. Three other patients had presumed esophageal lichen planus, although no biopsy specimens were obtained. Twelve of these 18 patients (67%) had double-contrast esophagography performed at our institution; for eight of the 12 patients (67%), the studies revealed abnormalities in the esophagus. These eight patients constituted our study group. The barium esophagrams and medical records of these eight patients were reviewed to determine the clinical, radiographic, and endoscopic findings of esophageal lichen planus as well as the treatment and patient outcome.RESULTS:All eight patients were women (median age, 66.5 years), and all eight presented with dysphagia (mean duration, 3.2 years). Four patients had previous lichen planus that involved the skin (n = 1), the oral cavity (n = 2), or both (n = 1), and one patient later had lichen planus that involved the vagina. Five patients had a small-caliber esophagus with diffuse esophageal narrowing. The remaining three patients had segmental strictures in the cervical (n = 1), upper thoracic (n = 1), and distal thoracic (n = 1) esophagus.CONCLUSION:Esophageal lichen planus typically occurs in older women with longstanding dysphagia and often develops in the absence of extraesophageal disease. Barium esophagrams may reveal a small-caliber esophagus or, less commonly, segmental esophageal strictures. Greater awareness of the radiographic findings of esophageal lichen planus hopefully will lead to earlier diagnosis and better management of this condition.

PURPOSE:To characterize clinical and radiographic features of a hyperirritable stomach after sleeve gastrectomy.MATERIALS/METHODS:Radiology reports revealed that 10/76 patients (13%) with obstructive symptoms after sleeve gastrectomy had a hyperirritable stomach.RESULTS:All 10 patients presented with nausea, vomiting, and/or regurgitation. All 10 had emesis on barium studies in the absence of gastric outlet obstruction, gastroparesis, or small bowel obstruction/ileus. Five had extraintestinal causes of nausea/vomiting. Eight had improvement/resolution of symptoms on medical treatment.CONCLUSION:In 13% of patients with nausea/vomiting after sleeve gastrectomy, barium studies revealed a hyperirritable stomach, which likely is multifactorial and self-limited in most patients.

The esophagus may be involved by a variety of morphologic abnormalities, including nodules and plaques, ulceration, distal esophageal strictures and rings, upper or midesophageal strictures, and diffuse narrowing (also known as a small-caliber esophagus). The use of a pattern approach for evaluating esophageal disease on barium studies facilitates diagnosis of a host of pathologic conditions associated with these morphologic abnormalities. This article therefore presents an approach for diagnosing esophageal disease on barium studies that emphasizes the radiographic and clinical features used to differentiate the underlying causes of disease and the diagnostic pitfalls associated with performing and interpreting these studies.

This article reviews the history of the barium swallow from its early role in radiology to its current status as an important diagnostic test in modern radiology practice. Though a variety of diagnostic procedures can be performed to evaluate patients with dysphagia or other pharyngeal or esophageal symptoms, the barium study has evolved into a readily available, non-invasive, and cost-effective technique that can facilitate the selection of additional diagnostic tests and guide decisions about medical, endoscopic, or surgical management. This article focuses on the evolution of fluoroscopic equipment, radiography, and contrast media for evaluating the pharynx and esophagus, the importance of understanding pharyngoesophageal relationships, and major advances that have occurred in the radiologic diagnosis of select esophageal diseases, including gastroesophageal reflux disease, infectious esophagitis, eosinophilic esophagitis, esophageal carcinoma, and esophageal motility disorders.

Abdominal radiographs often play an important role in the evaluation of patients with abdominal pain or distension or clinical signs of an acute abdomen. This chapter aims to review radiographic findings such as bowel dilation, pneumoperitoneum, and pneumatosis, and to discuss their significance. However, computed tomography and magnetic resonance imaging are recognized as more sensitive techniques than abdominal radiography for diagnosing a host of conditions in patients with acute abdominal symptoms. Contrast studies of the gastrointestinal tract can be performed using single- or double-contrast techniques. Single-contrast studies entail filling the lumen with a relatively low-density barium suspension and evaluating for contour abnormalities or filling defects in the barium pool, whereas double-contrast studies utilize a smaller amount of high-density barium and gas to evaluate the en face appearance of the mucosal surface.

OBJECTIVE:The purpose of this study is to better characterize the findings of esophagography after peroral endoscopic myotomy for achalasia.MATERIALS AND METHODS:We evaluated 25 patients who underwent peroral endoscopic myotomy for achalasia. The findings noted on pre- and postprocedural esophagrams were reviewed retrospectively and were correlated with clinical outcomes.RESULTS:None of the patients had esophageal perforation noted on esophagrams obtained after myotomy, and all but two patients had a hospital stay that lasted 1 day only. Esophagrams obtained on postoperative day 1 revealed endoscopic clips in 25 patients (100%), pneumoperitoneum in 18 (72%), retroperitoneal gas in 10 (40%), gastric pneumatosis in nine (36%), intramural dissections in seven (28%), and pneumomediastinum in four (16%). Repeat esophagrams obtained 3 weeks later for 22 of the patients revealed endoscopic clips in 16 patients (73%) and intramural dissections in five patients (23%), but the remaining findings had resolved. Eighteen patients (72%) had a successful myotomy and seven (28%) had suboptimal results on the basis of clinical outcomes. Observation of a distal esophageal width of 5 mm or less on postprocedural esophagrams was often associated with suboptimal results.CONCLUSION:Peroral endoscopic myotomy is a novel procedure that is less invasive than is laparoscopic Heller myotomy for the treatment of achalasia, with fewer complications and shorter recovery times. Radiologists should be aware of the findings expected on esophagography (including pneumoperitoneum, retroperitoneal gas, gastric pneumatosis, intramural dissections, and pneumomediastinum) and should also know that fluoroscopic studies may be helpful for predicting patient outcomes on the basis of the width of the distal esophagus after myotomy.

OBJECTIVE The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition. CONCLUSION Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.

We describe an elevated Z line as a new radiographic sign of Barrett's esophagus characterized by a transversely oriented, zigzagging, barium-etched line extending completely across the circumference of the midesophagus. An elevated Z line is rarely seen in other patients, so this finding should be highly suggestive of Barrett's esophagus on double-contrast barium esophagograms. If the patient is a potential candidate for surveillance, endoscopy and biopsy should be performed to confirm the presence of Barrett's esophagus.

Purpose: To assess the diagnostic performance of esophagography and chest computed tomography (CT) for detecting leaks after esophagectomy and gastric pull-through. Materials and Methods: Our database revealed 29 patients who had undergone esophagography and chest CT after esophagectomy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for postoperative leaks were determined for esophagography and CT, separately and combined, on the basis of a retrospective image review. Patients were also stratified for esophagograms with water-soluble contrast alone versus water-soluble contrast and high-density barium and for CT with and without oral contrast. Our findings were retrospectively compared with those reported at initial image interpretation. Results: Clinically relevant leaks were present in 14 (48%) of 29 patients after esophagectomy. Esophagography had a sensitivity of 79%, specificity of 73%, PPV of 73%, and NPV of 79% for detecting leaks, whereas CT had a sensitivity of 86%, specificity of 33%, PPV of 55%, and NPV of 71% and esophagography and CT combined had a sensitivity of 100%, specificity of 27%, PPV of 56%, and NPV of 100%. The sensitivity of esophagography increased with high-density barium, whereas the sensitivity of CT was the same with and without oral contrast agent. Finally, esophagography and CT were seen to have a higher sensitivity and lower specificity on retrospective review compared with the results reported at initial image interpretation. Conclusions: Esophagography had a slightly lower sensitivity and substantially higher specificity compared with CT for detecting leaks after esophagectomy, whereas esophagography and CT combined had a sensitivity of 100% for detecting leaks. Therefore, postoperative leaks can be excluded with confidence after esophagectomy when both tests are negative.

Purpose: To assess the findings of recurrent Crohn's disease in the neoterminal ileum on small bowel follow through (SBFT) and computed tomography (CT) as well as the overall diagnostic performance of these imaging tests.Methods: Our radiology database yielded 52 patients with an ileocolic anastomosis for Crohn's disease who underwent SBFT and CT. The images were reviewed to determine the sensitivity, specificity, PPV, and NPV for individual findings of recurrent Crohn's disease in the neoterminal ileum. The overall sensitivity, specificity, PPV, and NPV of these tests for recurrent Crohn's disease were determined by comparing imaging reports to endoscopic and surgical findings in 45 patients (87%) and clinical response to treatment in seven (13%).Results: SBFT had a sensitivity of 90%, specificity of 85%, PPV of 95%, and NPV of 73% for detecting recurrent Crohn's disease, and CT had a sensitivity of 77%, specificity of 69%, PPV of 88%, and NPV of 50%. These tests combined had a sensitivity of 95%, specificity of 69%, PPV of 90%, and NPV of 82%. The most common findings were luminal narrowing, thickened folds, and ulcers (especially aphthoid lesions) on SBFT and bowel wall thickening on CT. CT also revealed extraenteric collections not visualized on SBFT in three patients (8%).Conclusions: Our experience suggests that SBFT is more sensitive and specific than CT for detecting recurrent Crohn's disease in the neoterminal ileum, mainly because of the ability of barium studies to depict aphthoid lesions not visualized on CT. Conversely, CT is better for detecting extraenteric findings such as abscesses. When combined, these tests have a higher sensitivity for detecting recurrent Crohn's disease than either test alone. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

AIM:To present the gastrointestinal (GI) complications associated with bevacizumab therapy and their findings on abdominal imaging studies.METHODS:A computerized search identified 11 patients with GI complications of bevacizumab therapy on abdominal CT (n = 11) and fluoroscopic GI contrast studies (n = 4) who met our study criteria (including five patients with ovarian cancer, five with colon cancer, and one with cervical cancer). The medical records and imaging studies were reviewed to determine the clinical and radiographic findings in these patients.RESULTS:All 11 patients had findings of GI perforation on CT, or CT and GI contrast studies. CT revealed a localized extraluminal collection containing gas, fluid, and/or contrast material in eight patients (73%) with focal perforation, and free abdominal air and fluid in three (27%) with free perforation The imaging studies also revealed seven fistulas, including two colovaginal, one rectovaginal, one enterocutaneous, one colocutaneous, one gastrocolic, and one colorectal fistula. Eight (73%) of the 11 patients died within 1 year of the development of GI perforation, and the perforation was felt to be the cause of death in four patients (36%).CONCLUSION:Abdominal CT and fluoroscopic GI contrast studies are useful imaging tests for the diagnosis of potentially life-threatening GI perforation as a complication of bevacizumab therapy. When GI perforation is detected on abdominal imaging studies, treatment with bevacizumab should immediately be discontinued.