 Hello friends and welcome to this tutorial on barium solos. Now this study and the study of barium is honestly long past the cell by date. However, we still do barium solos once in a while as well as barium enemas. Barium stomach deodorants as well as the follow-through examinations are almost extinct. However, on this examination and on this tutorial what I'm going to try to do is make you understand how we do the procedure. We'll try to understand the radioanatomy. We'll try to understand the pathologies and the images that we get while performing this study. I wish to thank and acknowledge Dr. Suresh Sabu, Dr. Rajesh Kamle, as well as Dr. Chandrasekhar Kinsley for providing some important images that made up this tutorial. Now usually patients come to us with symptoms of dysphagia which is difficulty in swallowing food. We always want to look for a stricture or some obstruction to the esophagus. This dysphagia might be a progressive one, a slowly progressive one that occurs over periods of weeks or months and sometimes may be due to solids first and then to liquids or sometimes it may be quite sudden. So we have to ask for this pertinent history before starting the investigation. Obviously, when the person is not eating, the patient will have weight loss and we also have to ask for history of hematomyces as well as any post-operative status. Now before we start the barium solo, you have to know a little bit of the anatomy of the esophagus which is a flattened muscular tube that extends from the lower border of the cricoid cartilage which is at C6 up to the cardiac orifice of the stomach which is at D11. There are three anatomical parts, cervical, dorsal and abdominal. Now barium solo is of course a study of the esophagus that starts from the oral cavity and goes up to the stomach. Sometimes the barium solo is replaced by the examination called the upper GI series in which we take pictures of the esophagus as well as that of the stomach which includes pictures of the stomach as well as the diurnal bulb and the C loop. But for practical purposes today's tutorial is going to be on barium solos. So when the patient comes usually it's an overnight fasting. There are two, three simple steps that we have to do before we start giving the patient large amounts of bolus and stata examination. First make the patient lie down and conduct a quick fluoroscopic check of the chest to look for signs of aspiration mnemonitis or any radioopic lesions that you might see in the chest. We give a thick bolus in the lying down position and look for esophageal peristalsis. So you can look at mortality disorders that can occur in the esophagus pictures of which I will be showing you later. Once the bolus is taken, you got to make the patient back again in erect position and start taking the images. So we evaluate the valioqually and the pyreform forza. We evaluate the dorsal part of the esophagus as well as the abdominal part of the esophagus by giving bolus and taking pictures in oblique positions. And the reason we take it in oblique positions is so that the esophagus column of barium goes off the spine. If you take it in AP view, you will have it superimposing on the spine. So a slight oblique which we can check on a fluoroscopic examination, confirm the position and then give the bolus. Now the images that we want of the esophagus are again in three phases. You want the single contrast phase with the full bolus of barium running through the esophagus. We want also a double contrast with air seen in the column so that you can look for mucosal irregularities as well as small erosions which will be missed on the single column barium examination. And thirdly, we also want to see the mucosal phase. There are three stripes that we see, vertical stripes that run down and we have to see this mucosal phase as well. So first, give a large bolus, make the patient swallow it and sometimes you ask them to take two, three mouthfuls of barium boluses quickly so that there's an air column that comes behind the single contrast barium column and hence you get a double contrast and once that air column disappears, the esophagus actually collapses and then you can get the mucosal interface or the three stripes of the esophagus. So before we examine the images of the barium swallow, we should know about the normal esophageal constrictions that occur while performing the barium swallow study. So there are three anterior indentations which come in front of the esophagus. The first is of the aortic arch and the next is of the left main bronchus and lastly the third one is of the left atrium. These are normal indentations and not to be confused with any extrinsic mass lesions. There is also the cricofaryngeal bar that occurs at the C6 level. This is a posterior indentation on the esophagus and that can come sometimes when there is some motility disorder related to the cricofaryngeus. Sometimes of course even a normal prominent cricofaryngeus can come as a slight indentation on the posterior part of the esophagus, the cervical esophagus and this is usually at C6 level. So these are the normal indentations or constrictions that come on the esophagus. These are normal variants. We then turn our attention to the cervical esophagus and then we want to see these few important structures. We look at the valuculae which are seen here. We see the lateral pharyngeal wall as well as the pyreform force. We take these pictures in both AP as well as lateral view and we try the puffed cheek technique or the modified valsalma maneuver so that the pharyngeal walls can get pushed out and we can see the mucosal lining very clearly. So this image is again of some motility disorders that we can see in the first image on the left. You can see tertiary contractions of the esophagus and this image is usually seen only in a lying down position. So that's the first picture we take on fluoroscopic examination where we make the patient lie down, give a thick bolus and then watch the peristalsis of the esophagus and if you get these tertiary contractions you can understand that these are motility disorders which you can see in patients who have neuro muscular disorders and sometimes even with the pseudo vulva or vulva palsy. Central image is of the cricofaryngeal muscle. You can see that posterior indentation shown by the green arrow with an indentation coming on the posterior aspect of the esophagus. Again you can see a slight motility disorder along the anterior part of the pharynx. And the third image is that of a Shatsky ring which is a thin smooth symmetrical mucosal ring which narrows the G junction just above a tiny sliding Hydesonia. And it's believed to occur due to G reflux disease. So these again are small indentation or motility findings that we can see on an esophageogram. So we start with the pathologies now and we can see here a cervical esophagus film both in the APN lateral view. And what we can see is a smooth out pouching that is coming out of the posterior part of the esophagus filled up with barium and extending inferiorly. This happens to be a zhankar diverticulum. Now the zhankar diverticulum is different from a chelion diverticulum and we are going to understand that a little shortly. So zhankar's diverticulum are actually pulsion diverticulum that occur through the chelion's dehiscence which is an area of congenital weakness in the region of the cricofaryngeal muscle. It begins actually just above the cricofaryngeal muscle is usually posterior and slightly to the left. This condition is associated with gastroesophageal reflux as well as hiatus hernia cannot be mistaken for a chelion jmesan diverticulum or pouch. The chelion diverticulum comes from the entrolateral wall of the proximal cervical esophagus and starts just below the level of the cricofaryngeal whereas the zhankar diverticulum actually starts just above the cricofaryngeal and extends inferiorly. Now we come to our next case and you can again see two small out pouchings on either side along the lateral aspect of the pharynx and these are known as lateral pharyngeal pouches or pharyngosomes. These are usually found in trumpet blowers and are asymptomatic. The actually protrusion of the mucosa of the pharynx through the thyroid membrane where laryngeal vessels pierce. They're usually bilateral and more often they're not asymptomatic. Now here is our next case and I've shown you two films. One is that of a chest PA view with again barium taken in the AP view and hence we need to see this better and take it in an oblique or almost true lateral view where you can actually see a large hiatus hernia which is occupying the retrocardiac space and you can see it filled with barium. This is sometimes also seen as a spot film given to you with an air fluid level seen in the retrocardiac space. Our next case and what you see is the lower esophagus with a very large dilated esophagus seen a characteristic deke-like tapering of the distal esophagus when the sphincter is closed. This is a classic case of achilles acardia. You must understand that this is a condition that comes usually between 30 and 50 years of age and is a motor disorder where there is actually a dysfunction of the lower esophageal sphincter. This causes incomplete relaxation and elevated resting pressure of the esophagus hence leading to build up of food and secretions in the esophagus. These patients can also present with aspiration pneumonitis. Now achilles acardia is often associated with other pharyngeal abnormalities such as cricofaryngeal dysfunction as well as Zenker's diverticulum. This condition must be separated from and differentiated from secondary achilles acardia. So what is secondary achilles acardia? Secondary achilles acardia is castrum of the gastricardium metastasis involving the G-junction which causes a radiological picture that simulates achilles acardia. Now secondary achilles acardia should be considered in older people especially if symptoms have come up in an acute fashion or if the tapered G-junction shows mucosal nodularity or a mass effect. Now here's another unusual or rare case. What you can see is a picture of cervical esophagus in fact there are three spots but if you look at the last one on the right very closely you can see almost a shelf like leucency at the level of the lower part of the cervical esophagus and this happens to be an esophageal web. If you can see very closely you can see a little spurt of barium that is running through the central part of the web that is the open part and sometimes webs may be seen only with large boluses and can be missed also sometimes on the barium solos so you have to look at the lateral views very carefully. Another question that is asked is that which syndrome is this condition associated with and the answer is plumber-bincent syndrome. It occurs in those patients with long-term chronic iron deficiency anemia. Now we saw the zincous diverticulum earlier in the cervical esophagus but there are two more types of diverticulum that you have to be aware of. One is this the epiphenic diverticulum which occurs just above the G-junction and there's another one which is seen at the mid-level usually around the carina and this is a traction diverticulum and usually traction diverticulum are associated with tuberculosis or lesions involving the pleura or the lung which can cause a pull on the esophagus and lead to this little diverticulum formation in the mid-esophagus. And now we come to strictures so you may see different types of strictures in the esophagus and they may come with smooth mucosa or they may come with mucosal irregularity. They may come with esophageal dilatation but sometimes if the growth of the cancer is very fast you may not get esophageal dilatation as much as you would get in a lesion that is slow growing which is you can see here a long segment stricture seen in the mid-esophagus with mild proximal dilatation it appears smooth but you cannot exclude a castoma and you will be advising an OGD scoping and here is another picture where in the first one you can see a polypoidal mass lesion in fact getting coated by the barium and the next one in the middle you can almost see a huge irregular deformity in the mid-esophagus not enough time for esophageal dilatation and in the third picture on the right you can see again a smooth almost like a rat tail appearance of the esophagus with gross esophageal dilatation with an air fluid level that is forming just above the stricture so the dilatation depends on the duration of the lesion if it's a very fast growing lesion there's not enough time for esophageal dilatation but if it's a slow growing lesion then you may have time for esophageal dilatation and that air fluid level that shown here now sometimes the lesion may be very subtle and if you look at this picture at first glance you may say it's almost normal but there is a very subtle mid-esophageal dilatation and if you look closely and I'm going to zoom this image you can see a mucosal irregularity along the posterior wall of the esophagus this turned out to be a very early carstoma of the esophagus on ogd scoping now corrosive ingestion is a common form of poisoning and it can damage any segment of the gi tract but especially the oropharynx the esophagus and the stomach and that is the lesser curvature of the stomach now this usually occurs because of accidental intake in kids and also suicidal intake in adults the roses are either acidic or alkaline and both have almost an equal impact on the gi tract where there it may not be mortality but they might be almost lifetime morbidity bizarre pictures are seen on examination of the esophagus with barium and it would depend on the timing of the study you may get a smooth concentric narrowing of the esophagus or a beaded appearance of the esophagus that can extend up to the stomach you also may get very tight strictures with gross dilatation and sometimes even tracheoesophageal fistulas if we take a quick look at what what we have seen on this tutorial you will get pictures like this of sliding hiatus hernia we can also see here a very tight stricture in the mid and lower third of the esophagus causing proximal esophageal dilatation and hold up of barium in the upper part of the esophagus if you see more pictures you can again see another stricture here a pretty tight one with proximal esophageal dilatation and again here subtle lesions are not to be missed that is the end of this tutorial i hope you have liked it and i hope this will help you in your exams and in reviewing barium swallows a little better thank you