Esophagram

Question 1

Indications for an Esophagram

Answer 1

• Dysphagia/trouble swallowing/globus sensation
• H/O TEF/EA repair—eval for leaks in the immediate postop period, f/u leaks if any seen, eval for stricture development in the long term
• Achalasia
• Foreign body and after foreign body removal

Question 2

Achalasia path, pt, dx

Answer 2

Path: idiopathic proximal loss of Auerbach’s plexus -> inc LES pressure
Failure of LES relaxation -> obstruction and lack of peristalsis

Pt: dysphagia to BOTH solids and liquids

Dx:
- Esophagram: Bird’s beak apperance of LES (LES narrowing) w/ proximal esophageal dilation, loss of peristalsis distally.
- Esophageal Manometry-> gold standard; >40mmHg

Question 3

Esophagram contrast type and amount

Answer 3

• Barium for most
• Omnipaque 300 (we do not dilute) for follow-up or rule-out TEF/EA, f/u h/o recent leaks, f/u after foreign body removal, recent postop (4-6 weeks)—note that simple EGD with biopsies do not fall under postop
• No fizzies
• Barium tablet IS available in radiology OmniCell but almost never used (docs never use it at all)

Amount:
- tiny babies usually need about 10-15 mL (or even less)
- infants/toddlers 15-30 mL
- older kids 30-90 mL
no restriction on volume.

Question 4

Esophagram table set up

Answer 4

• Horizontal, HOB flat
• Start LATERAL, 2-3 sequential drinks if able-> Look for posterior impressions (vascular rings)
• AP, 2-3 drinks
  The end :)

VERY RARELY will I stand a patient up (usually if they’re older teenagers, special needs such as autism and unable to lie down). Posterior impressions which are so important are not well-visualized in the upright position so try to at least get the lateral with patient lying down.
No fizzies

Question 5

Esophagram machine settings

Answer 5

usually done by the tech, but confirm
- 3 p/s, 0.5 f/s (if looking for a postop leak I usually increase this to 2 f/s)
- Cine loop and/or last image hold for most
- If looking for a non-metallic foreign body (ie: bottle cap) then will need to use exposures
- If abnormal/interesting finding, take an exposure

Question 6

Pearls: Esophagram for TEF/EA pts and NGT/OGT

Answer 6

TEF/EA patients will usually have an NGT/OGT in place. DO NOT MANIPULATE THIS.

• On occasion these patients will not have NGT/OGT in place and one will be requested by the ordering service to be placed under fluoro at the time of the esophagram.
• Can try to get them to drink contrast but most of the time they can’t (intubated, too sick, too young) so will need to drop a 5 Fr tube into the proximal esophagus above the level of the surgical repair and inject contrast from there. This is the time I set the machine to 2 f/s and run exposure loops instead of fluoro cine loops to better visualize small perfs/leaks

Question 7

Pearls: Esophagram for vascular rings

Answer 7

cannot always differentiate the exact underlying cause on fluoro alone; pt will need a CT Chest Angiogram or Echo to further eval. In general:
- If a normal left aortic arch, the impression tends to be either an aberrant right subclavian artery or (much less likely) a double aortic arch
- If pt has a right sided aortic arch, the impression on the esophagus is then likely an aberrant left subclavian artery

Question 8

Pearls: Esophagram on follow up foreign body removals

Answer 8

esp button batteries
- Esophagus will be VERY friable—do not attempt to place an NG tube or a tube in the proximal esophagus to deliver contrast in these patients. If you can’t get contrast in orally, discuss with radiologist.
- Contained perforations can be seen in this setting, more so than true extraluminal extravasations