David J. Ott, M.D.

, is Professor of Radiology at the Bowman Gray School of

Medicine of Wake Forest University in Winston-Salem, North Carolina. Afrer
graduating from the University of Michigan Medical School, he received post-
graduate training in internal medicine and diagnostic radiology at the Bowman
Gray School of Medicine. He is a member of many professional organizations,
including the American Gastroenterological Association and the Society of Gas-
trointestinal Radiology. Dr. Ott and his colleague, Dr. David W. Gelfand, have
published numerous papers primarily related to endoscopic correlation and the
eficacy of radiology in the gastrointestinal tract. He is also a coeditor with his
gastroenterologic colleagues of the books Gastroesophageal Reflux Disease and
Polypoid Disease of the Colon.

Cur-r Probl Diagn Radial, January/February 1988

 RADIOLOGIC EVALUATION OF
ESOPHAGEAL DYSPHAGIA

Dysphagia refers to the sensation of food being RADIOLOGIC TECHNIQUES

hindered in its normal passage from the mouth to
the stomach’ and is a common complaint in pa- Effective radiographic evaluation of the esopha-
tients presenting for radiologic examination of the gus requires the use of a combination of different
esophagus. Dysphagia is usually caused by struc- examining techniques.6-s These methods include
tural or functional abnormalities of the oropharynx the (1) full-column technique; (2) mucosal relief
or esophagus.‘, 3 Although the pharynx and esoph- technique; (3) double-contrast technique; and (41
agus are often considered separately, abnormali- various motion recording methods. Each tech-
ties may occur at both levels, particularly in cer- nique has its advantages and limitations, and no
tain neuromuscular disorders. Furthermore, the single method provides an optimal examination of
patient may be unreliable in pinpointing the site the esophagus.
of functional or structural disease.4,5 For example,
Edwards’ found that about one third of those with
FULL-COLUMN TECHNIQUE
distal esophageal obstruction localized their dys-
phagia to the neck. This is the basic single-contrast method of ex-
Therefore, a meticulous examination of the amining any hollow viscus and simply requires fill-
esophagus is needed in all patients presenting ing the esophagus w&h barium suspension. The
with dysphagia, regardless of the level of their patient is best examined in the prone oblique po-
symptoms. This monograph will emphasize the sition while drinking barium through a straw. In
radiologic evaluation of the esophagus for struc- this position primary esophageal peristalsis is as-
tural and functional causes of dysphagia. Radio- sessed by observing individual swallows of barium
graphic techniques and their efficacy in diagnos- traversing the entire length of the organ. Hiatal
ing common structural and functional disorders hernias are optimally demonstrated with the pa-
are discussed. When appropriate, comparison is tient prone because the increased intra-abdominal
made with endoscopy and esophageal manometry pressure produced in this position promotes dis-
to clarify the advantages and limitations of the ra- placement of the esophagogastric junction above
diographic method in assessing patients with dys- the diaphragmatic hiatus (Fig l).” An abdominal
phagia. bolster is of further value in increasing intra-

Cur-r Probl Diagn Radio& January/February 1988 7

FIG 1. FIG 2.
Normal upright double-contrast view (A) in a patient with hiatal her- 6 x 8-mm small esophageal carcinoma only partly shown (arrow)
nra and a mucosal ring shown on full-column examination (B). on full-column view (A) but clearly seen on double-contrast protec-
(From Chen YM, Ott DJ, Gelfand DW, et al: Multiphasic examina- tion (B).
tion of the esophagogastric region for strictures, rings and hiatal
hernia: Evaluation of individual techniques. Gastrointest Rad/ol
1985; lo:31 1-316. Used by permission.) press primary peristalsis and exert a pinch-cock
effect at the level of the diaphragmatic hiatus,
abdominal pressure and is particularly useful in thereby causing the barium to accumulate in the
thinner patients. esophagus. Deep inspiration also draws the dia-
Demonstration of small contour defects requires phragm downward, permitting better visualization
two or more films of the barium-filled esophagus of the esophagogastric region.
exposed at different degrees of obliquity. The den- Several additional techniques can be incorpo-
sity of the barium suspension also affects the po- rated into the full-column technique, particularly
tential accuracy of the full-column examination, if adequate distention of the lower esophagus is
especially for smaller contour abnormalities. With not achieved on routine examination. Inadequate
dense barium suspensions, small lesions not ex- distention most commonly occurs in patients un-
posed in profile may be obscured and remain un- able to swallow barium rapidly and is a particular
detected; hence it is important to supplement this problem in the elderly. A chilled or iced barium
technique with other methods (Fig 2). A dense bar- suspension reduces primary peristalsis and im-
ium suspension, however, is best for the mucosal proves distention of the esophagus and esophago-
relief and double-contrast portions of the exami- gastric region (Fig 5).‘3-‘5 Solid boluses, such as
nation. barium tablets or marshmallows, are also useful in
The efficiency of this method in detecting detecting esophageal narrowings and dysmotility,
esophageal narrowings, such as mucosal ring and especially if the examination with liquid barium is
peptic stricture, depends on obtaining maximal unremarkable (Figs 6 and 7).*6-2o
distention of the esophagus and esophagogastric The full-column technique is effective for dem-
region (Figs 3 and 41.10-12 Maximal distention is onstrating circumferential carcinomas, peptic
achieved by having the patient swallow barium strictures, large esophageal ulcers, mucosal rings,
rapidly and perform inspiratory breath holding or and hiatal hernias (Fig 8). Extrinsic lesions adja-
the Valsalva maneuver. These efforts together sup- cent to the esophagus can be detected if they con-
8 Curr Probl Diagn Radial, January/February 1988
 FIG 3.
A and B, two full-column views of the esophagogastric region
during same examination. A mucosal ring is clearly seen In B with
better distention. (From Ott DJ: Radiologic evaluation of the
esoohaaus. in Castell DO, Johnson LF (eds): Esoohaaeal Func-
tion‘in Health and Disease. New York, Elsevier North-&land, Inc,
1983. Used by permission.)

FIG 4.
Normal double-contrast examination (A) in a patient with dys-
phagia and a 13-mm peptic stricture shown on prone full-column
evaluation (B) (From Chen YM, Ott DJ, Gelfand DW, et al: Multi-
phastc examination of the esophagogastric region for strictures,
rings and hiatal hernia: Evaluation of individual techniques. Gas-
trointest f?ad/ol 1985; 10311-316. Used by permission.)

Curr Probl Diagn Hadioi, January/February 1988

 FIG 5.
A, no abnormality is seen at the esophagogastric junction when
barium is used at room temperature. B, well-demonstrated lower
esophageal mucosal ring and hiatal hernia with iced barium.
(From Ott DJ, Gelfand DW, Munitz HA, et al: Cold barium suspen
sions in the clinical evaluation of the esophagus. Gastrointest Ra-
dio/ 1984; 9:193-l 96. Used by permission.)

FIG 6.
A, patient with Intermittent dysphagia to solid food. Full-column
examination shows no abnormality. B, repeat examination with di-
lute barium and marshmallow (M) shows impaction of a solid
bolus by a mucosal ring (arrows) measuring 13 mm in caliber.
(From Ott DJ, Gelfand DW, Wu WC, et al: Radiological evaluation
of dysphagia. JAMA 1986; 256:2718-2721. Used by permrssron )

Cum Pmbl Diagn Radio& January/February 1988

 FIG 7.
A, full-column vrew of a 13.mm mucosal ring. 8, repeat examina-
tton with a bartum tablet (T) that Impacted at the ring, rIsproduc-
rng the patient’s symptoms.

FIG 8.
Full-column (A) and double-contrast (B) views of an ulcerated cir-
cumferentral carcrnoma of the esophagus (From Ott DJ, Radic
logrc evaluation of the esophagus, in Caste11 DO, Johnson LF
(eds). Esophageal Function m Health and Dsease. New York, El-
sevter North-Holland, Inc, 1983 Used by permissron.)
tact the wall of the distended esophagus. On the
other hand, a number of important disorders may
go undetected unless other techniques are used in
conjunction with the full-column examination.
These disorders include small and eccentric
esophageal neoplasms, milder cases of infectious
and reflux esophagitis, and esophageal vat-ices (Fig
9). Thus, the full-column technique must be com-
bined with mucosal relief or double-contrast films
to enhance detection of these smaller or more
subtle esophageal abnormalities.6m11

MUCOSAL RELIEF TECHNIQUE

Mucosal relief films are taken with the esopha-

gus collapsed and coated with a dense barium
suspension or a barium paste.6’ ‘, ‘I8 ” Barium sus-
pensions of moderate or lesser density (less than
100% w/v) coat the mucosa less consistently and
result in poorer visualization of the esophageal
folds. The smooth, longitudinal folds are seen on
the mucosal relief film and suggest abnormality if
irregular or thickened (Fig 10). Normal esophageal
folds measure as much as 2 to 3 mm in thickness
when the esophagus is completely collapsed.23

FIG 10.
A, normal esophageal folds (< 2 mm). Hiatal hernia is present. B,
thickened esophageal folds in moderate reflux esophagitis. (From
Ott DJ, Gelfand DW, Wu WC: Reflux esophagitis: Radiographic
and endoscopic correlation. Radiology 1979; 130:583-588. Used
by permission.)

Normal folds, however, may appear wider if the or-

gan is only partially collapsed, and this appear-
ance may be misinterpreted as esophagitis or
esophageal vat-ices (Fig 11).
Esophageal disorders best shown on mucosal
relief films include small plaque-like or polypoid
lesions, various types of esophagitis, and esopha-
geal varices (Fig 12). In fact, varices are best shown
with the mucosal relief technique, particularly if
the patient is prohibited from swallotving and par-
enteral anticholinergic agents are used to furthei
relax the esophagus (Fig 13).24-27 However, this
technique will not demonstrate lesions requiring
maximal distention of the esophagus such as pep-
tic strictures or mucosal rings.‘0-‘2

DOUBLE-CONTRAST TECHNIQUE

Double-contrast films are obtained by coating

the esophageal surface with a dense barium sus-
FIG 9.
A, full-column view of a patient with leukemia and dysphagia
pension and then distending the organ with gas or
showing a mild marginal irregularity in the lower esophagus only air (Fig 14). Most commonly, the patient is exam-
and the presence of a hiatal hernia. B, double-contrast examina- ined in the upright oblique position using the
tion demonstrating more extensive esophagitis due to candidiasis. same gas-producing agent and barium suspension
12 Curr Probl Diagn Radiol, January/February 1988
 FIG 11.
Two mucosal relief views exposed moments apart showing nor-
mal folds in A but wider irregular folds in B (arrows) due to in-
complete collapse of the esophagus.

FIG 12.
A and B, two different patrents with mild endoscoprc esophagitis
and fold thrckening on mucosal relief films. Full-column and dou-
ble-contrast views were normal. (From Ott DJ, Chen YM, Gelfand
DW, et al Analysis of a multiphasic radiographic examination for
detecting reflux esophagrtrs Gastro/ntest &d/o/ 1986, 11 l-6
Used by permission.)

Curr Probl Diagn Radial, January/February 1988

FIG 13.
A, standard mucosal relief view showing no evidence of esopha- FIG 14.
geal varices in a patient with cirrhosis. B, repeat examination Normal double-contrast examination of the esophagus.
showing serpiginous esophageal varices following parenteral ad-
ministration of 30 mg of propantheline bromide.
contrast examination of the lower esophagus.3Zm”4
employed during double-contrast radiography of The double-contrast technique is effective in
the stomach and duodenum.“‘-“” The most consis- showing various types of esophagitis and neo-
tent results are achieved by having the patient plasms, particularly small lesions (Figs 2, 8, 16, and
swallow barium as rapidly as possible. Many pa- 17). With proper distention, extrinsic effects as well
tients swallow a great deal of air with the barium as local esophageal narrowing due to stricture or
suspension, or gas from the stomach refluxes into carcinoma are also well shown. Conversely, small
the esophagus and promotes distention. However, hiatal hernias, lower esophageal mucosal rings,
the double-contrast effect is transitory, and filming some peptic strictures, and esophageal varices are
must be closely timed. poorly shown (see Figs 1, 4, and 15). Indeed, the
The principal advantage of the double-contrast double-contrast method performed with the pa-
technique is that it enables one to examine the tient upright fails to detect most hiatal hernias and
distended esophagus and its mucosal surface si- mucosal rings shown by the full-column examina-
multaneously. Consequently, this method com- tion.“, l1
bines desirable features of both the full-dolumn
and mucosal relief techniques. However, optimal
MOTION RECORDING TECHNIQUES
double-contrast films are not always obtained
since the distention is transient and filming must Fluoroscopic observation is an integral part of
be critically timed (Figs 4 and 15). This inconsis- the radiographic evaluation of the esophagus, the
tency is a particular problem in the lower esoph- data being recorded mentally by the radiologist.
agus and the esophagogastric region where up- An experienced fluoroscopist seldom needs a per-
right double-contrast films may fail to allow manent motion recording of the examination un-
evaluation of the area adequately in about one less transient or subtle abnormalities are seen.
third of individuals.“‘, “j3’ If necessary, additional However, motion recording techniques greatly aid
techniques with the patient prone or esophageal in evaluating oropharyngeal swallowing disorders
intubation may be used to improve double- and the pharyngoesophageal junction.35-38 The
14 Curr Probl Diap Radial, January/February 1988
FIG 15.
FIG 16.
A, full-column vrew demonstratrng 17.mm mucosal ring In patrent
A, mucosal irregularity and ulceration of lower esophagus wrth hia-
wrth dysphagra. B, upright double-contrast examrnation rn same
tal hernia. Reflux esophagrtrs shown endoscopically with ulceration
patrent failed to show the ring. (From Ott DJ, Chen YM, Wu WC, et
at esophagogastric functron B, double-contrast view in severe en-
al: Radiographic and endoscopic sensitivity in detecting lower
doscopically demonstrated esophagitis shows surface irregularity.
esophageal mucosal ring. AJR 1986; 147:261L265 Used by per-
erosions (arrows), and mild narrowing with wall thickness (arrow-
mrssion.)
heads). (From Ott DJ: Banum esophagram, in Castell DO, Wu WC.
Ott DJ (eds) Gastroesophageai Reflux Dsease. Mount KISCO, NY.
rapidity of events occurring in these areas makes
Futura Publishing Co, 1985. Used by permission )
static filming of transient abnormalities difficult.
Observations, such as poor bolus transport from
the oral cavity, minimal penetration of barium into ever, most of the devices available record only two
the nasopharynx or laryngeal vestibule, poor epi- to six images per second, which is an inadequate
glottic-laryngeal motion, and cricophar-yngeal rate for optimal evaluation of the oropharynx.
muscle dysfunction are optimally evaluated with Rapid-sequence spot-filming generally exposes at
motion recording methods. rates lower than spot-film cameras and is subject
Permanent motion recording techniques include to the same disadvantages in evaluating the oro-
videotape recording, cinerecording, spot-film cam- pharynx. Computerized digital storage devices are
eras, and rapid-sequence filming.” Videotape film- now being made available and will be of additional
ing is currently the most convenient form of mo- value for rapid sequence filming.
tion recording because the initial cost is low and
immediate viewing of the videotape is possible.
RECOMMENDED EXAMINATIONS
Cinerecording is advantageous because it provides
a good quality permanent record, and the films are As is apparent from the discussion above, nu-
easily stored. Important disadvantages, however, merous techniques are available for examining the
include a higher radiation dose, the need to de- esophagus. In practice, however, an examination
velop the film before viewing, and the need for a routine must be adopted that is thorough, expe-
separate projector. ditious, and effective. This must include the use of
Spot-film cameras record the output of the im- a combination of techniques and is best described
age amplifier on loo-mm or 10.5mm film.3s-41 Ra- as a multiphasic examination of the esophagus.
diation exposure is low, and multiple images can Depending on the patient’s symptoms and the ini-
be recorded without changing film cassettes. How- tial findings on the survey examination, additional
Curr Probl Diagn Nadiol, January/February 1988 15
 TABLE 1.
Recommended Radiographic Examinations of
the Esophagus

I. Esophagogram as a separate examination

A. Ompharynx and cervical esophagus
1. Patient upright in frontal position
2. Videotaping of swallow(s)
3. Spot-film taken after swallow
4. Sequence repeated in lateral position
B. Thoracic esophagus and EGR
1. Double-contrast examination
a. Patient upright turned left
b. Ingests gas producing agent
c. Drinks barium rapidly
d. Multiple spot-films taken
2. Full-column examination
a. Patient placed prune oblique
b. Bolster may be used
c. Single swallows for peristalsis
d. Rapid swallowing for distention
3. Mucosal relief examination
a. Barium-coated collapsed esophagus
b. Spot-film(s) exposed
II. Esophagogram during UGI examination
A. Ompharyngeal evaluation omitted
B. Thoracic esophagus/EGR as above
III. Supplemental examining techniques
A. Iced barium method
1. Four ounces crushed ice
2. Add to dense barium and shake
3. Do full-column technique
B. Solid bolus methods
FIG 17. 1. Barium tablets
A, patient on lmmunosuppressants with dysphagia due to diffuse
a. Usual 12.5.mm tablet
Candida esophagitis. B, diffuse esophagitis In another patient from
b. Use tap water
herpetlc infection.
2. Marshmallows
a. Half regular marshmallow
techniques or maneuvers can be added when nec- h. Dilute barium suspension
essary. c. Do full-column technique
The barium esophagogram can be performed as 3. Other materials
a separate examination or as part of the upper gas- (1. Miscellaneous techniques
1. Esophageal intubatioo
trointestinal series. The esophagus is often evalu-
a. Small bore tube
ated alone when the presenting symptoms are lo- b. Double-contrast exam
calized to the oropharynx or chest. The barium 2. Pharmacologic aids
esophagogram includes evaluation of the orophar- a. Glucagon (food impaction1
ynx, esophagus, and esophagogastric region (EGR) h. Anticholinergics lvaricesi
(Table 1). Two cups of dense barium suspension
(250% w/v) are used, and six to eight spot-expo-
sures are made on two to three total films. The the technical quality and thoroughness of the
examination takes only a few minutes to perform study performed and on the specific types of
with a radiation dose of 1 to 2 rads, depending esophageal disorders that need to be detected. A
primarily on the amount of fluoroscopic time multiphasic examination of the esophagus is
used. When performed as part of the UGI series, needed to evaluate thoroughly for functional and
evaluation of the oropharynx is usually omitted structural abnormalities. The quality of the exami-
with a consequent reduction in the number of nation must be closely controlled to ensure that
films used and in the radiation exposure lsee Ta- optimal films are obtained for each technique
ble 1). used. For example, failure to achieve maximal dis-
tention of the esophagogastric region may result in
RADIOLOGIC EFFICACY overlooking an esophageal stricture or mucosal
ring (see Figs 1, 3, and 4).
The effectiveness of the radiologic examination The types of disorders that can cause esopha-
in evaluating patients with dysphagia depends on geal dysphagia can be divided into three general
16 Cur-r Probl Diagn Radial, January/February 1988
categories: (1) extrinsic structural lesions; (21 intrin-
sic structural lesions; and (3) esophageal motor
disorders (Table 21.’ The more common causes of
esophageal dysphagia will be emphasized, and the
efficacy of the radiologic examination will be com-
pared to that of other investigations when appro-
priate.

ZXTRINSZC STRUCTURAL LESIONS

Extrinsic structural lesions are easily detected
on films of the fully distended esophagus if the ab-
normality encroaches on the esophageal lumen.
Upper esophageal dysphagia may develop second-
ary to cervical spondylosis.42’43 Although degener-
ative changes of the cervical spine are common in
older patients, dysphagia is infrequent and occurs
predominantly in those with more severe disease
(Fig 18). Other causes of upper esophageal dys-
phagia, such as oropharyngeal dysmotility, must
be excluded before attributing the dysphagia to
cervical spondylosis, particularly in the elderly. If FIG 18.
necessary, surgical correction may be performed Lateral full-column (A) and mucosal relief views (B) of pharyngo-
to relieve symptoms. esophageal region in patient with cervical dysphagia caused by
Masses that occur in the neck or mediastinum marked spondylosis.

resulting from a variety of causes may encroach on

the esophagus and cause dysphagia. In the neck, Symptomatic compression of the esophagus by
thyroid enlargement from benign or malignant dis- the thoracic aorta or by aberrant vessels can also
ease can compress and displace the cervical occur. Dysphagia lusoria results from a sympto-
esophagus, often causing displacement of the tra- matic impression on the upper thoracic esopha-
chea as well. Neoplastic or inflammatory disease of gus from an aberrant right subclavian artery.-”
the mediastinum and enlargement of the heart, es- The aberrant vessel usually passes behind the
pecially the left atrium, are additional causes of esophagus, producing an oblique defect coursing
esophageal dysfunction from contiguous involve- upward and to the right. Most patients with this
ment. anomaly, however, do not have dysphagia. Dys-
phagia aortica is a term used to describe sympto-
matic compression of the lower esophagus by a
TABLE 2. tortuous descending thoracic aorta.4749 Although
Causes of Esophageal Dysphagia displacement and compression of the distal
I. Extrinsic structural lesions esophagus by an atherosclerotic aorta is frequently
A. Cervical spondylosis seen in the elderly, most patients will not have sig-
IS. Neck masses nificant dysphagia (Fig 19). In older individuals
I. ‘Thyroid enlargement cardiac enlargement and kyphosis of the thoracic
2. Other masses spine are occasionally associated with aortic tor-
C. Mediastinal disease
tuosity and may aggravate the symptoms of dys-
D. Vascular compression
II. Intrinsic structural lesions
phagia.
A. Diverticular disease
R. Rings and webs
C. Esophageal neoplasms
INTRINSIC STRUCTURAL LESIONS
1. Leiomyomas
Diverticula of the esophagus are acquired abnor-
2. Carcinomas
malities usually caused by pulsion mechanisms,
D. Esophagi&
1. Medication-related such as esophageal dysmotility.8’5a-52 Most diver-
2. Infectious origin ticula occur in the middle and distal thirds of the
3. Reflux esophagitis esophagus and are rare in more proximal sites. A
4. Peptic stricture Zenker’s diverticulum originates just above the cri-
III. Esophageal motor disorders copharyngeal muscle and is most appropriately
A. Primary motor disorders
classified as a hypopharyngeal abnormality.53’54 Al-
R. Secondary motor disorders
though most esophageal diverticula are not symp-
Curr Probl Diagn Radical, January/February 1988 17
FIG 19.
Elderly patient with dysphagia showing acute angulation of the FIG 20.
lower esophagus due to uncoiling of the aorta. (From Gelfand DW, A, small esophageal diverticula with tertiary contractions. Primary
Ott DJ: Anatomy and technique In evaluating the esophagus. peristalsis was intermittently poor fluoroscopically. B, epiphrenlc
Semin Roentgen01 1981; 16:168-182 Used by permiwon.) diverticulum with large hiatal hernia Nonspecific esophageal mo-
tor disorder present fluoroscopically and manometrically.
tomatic, dysphagia may be caused by underlying
esophageal dysmotility or complications resulting tubulovestibular junction. The term esophageal
from a diverticulum.‘, 50-52,55,56 ring should be limited to narrowings in the esoph-
Large esophageal diverticula may be observed agogastric region occurring predominantly at the
on plain chest films as soft tissue masses often upper and lower borders of the esophageal vesti-
with an air-fluid level. Smaller diverticula may be bule. Esophageal rings are most commonly classi-
transient in their appearance and form during or fied as muscular or mucosal rings.
shortly after a peristaltic contraction. Motion re- Esophageal webs occur most commonly in the
cording techniques may be necessary to demon- cervical region; rarely, they may involve the tho-
strate these smaller, transitory outpouchings. racic esophagus or be multiple.58m”5 Cervical esoph-
Since small esophageal diverticula rarely produce ageal webs arise from the anterior wall, often ex-
symptoms, fluoroscopic assessment of esophageal tending laterally and occasionally around the cir-
motility is important to evaluate for an associated cumference. Most webs appear as thin smoodl
esophageal motor disorder (Fig 20). Esophageal structures and must be distinguished from the
manometry is of further assistance in identifying posterior indentation of the cricopharyngeal mus-
and characterizing an accompanying esophageal cle or the normal anteriorly located, postcricoid
motor abnormality. impression (Fig 21).66,67 Cervical webs are best
Ring-like constrictions have been described at demonstrated with motion recording techniques.
locations throughout the length of the esophagus They have been reported in 1% to 5% of asympto-
and may be a cause of dysphagia. The two most matic individuals5’, 61 and in up to 15% of patients
common terms used for these constrictions are with dysphagia.60 The relationship between esoph-
web and ring. Their interchangeable use has often ageal webs and iron deficiency anemia, the so-
led to confusion in distinguishing these various called Plummer-Vinson syndrome, remains con-
strLlctures.57 The term esophageal web should be troversial.
reserved for constrictions totally covered by squa- The muscular ring occurs at the upper border of
mous epithelium and located above the level of the the esophageal vestibule and is totally covered by
18 Cur-r Probl Diagn Hadiol, January/February 1988
 squamous epithelium (Fig 22) .57,68J6g Radiographi-
tally, the muscular ring appears as a broad,
smooth narrowing at the tubulovestibular junc-
tion. The caliber of the ring varies during the ex-
amination. On maximal distention of the esopha-
gus, the ring may disappear completely (Fig 23).
Muscular rings rarely cause dysphagia, and can be
seen most often in patients with hiatal hernia, gas-
troesophageal reflux, and possibly esophageal mo-
tor disorders. The relationship between the mus-
cular ring and these other abnormalities is
uncertain.
The lower esophageal mucosal ring, or “Schatzki
ring,” marks the lower border of the esophageal
vestibule. Most pathologic reports have described
the presence of squamous epithelium covering the
upper surface of the ring and columnar epithelium
on its undersurface.57,68-72 The mucosal ring ap-
pears as a thin, transverse structure encircling the
esophagogastric junction (Fig 24). The margins of
the ring are smooth and symmetric, and its maxi-
mal internal diameter is fixed and reproducible
when the esophagogastric region is adequately
distended above the caliber of the ring.
The lower esophageal mucosal ring is an impor-
tant cause of episodic dysphagia, particularly
when solid food is ingested. The presence of dys-
phagia is related to the inner caliber of this mu-
cosal ring.57, 72 A wide, patent mucosal ring more
than 20 mm in diameter is rarely symptomatic.
Conversely, rings that are less than 13 mm in di-
FIG 21. ameter nearly always cause dysphagia. Rings 13 to
Thin cervical esophageal web (closed arrow) ansing anteriorly be- 20 mm in diameter may be symptomatic depend-
low a broader postcricord rmpressron (open arrows). ing, in part, on the eating habits of the patient. Im-
paction of a food bolus at the ring may also occm
and is often associated with severe chest pain.73
Radiologic demonstration of the mucosal ring

ESOPHAGUS

TUBULOVESTIBULAR JUNCTION

DIAPHRAGM
CARDIAC I NCISURA

VESTIBULE

HIATAL MARGIN

ASTRIC SLING FIBERS

M EM BRANE

FIG 22.
Diagram of lower esophageal anatomy wtth simplificatron of terminology Esophageal vestibule is defined by tubulovestibular junction
superiorly and upper margin of gastric sling fibers inferiorly. When present, mucosal ring occurs at lower level of esophageal vestibule.
(Modified from Zboralske FF, Frredland GW: Drseases of the esophagus-present concepts West J Med 1970; 112:33-51.)

(:urr Probl Diagn Radial, January/February 1988 19

FIG 23. FIG 24.
A, esophageal vestibule (V) is demarcated superiorly by muscular A, widely patent mucosal ring projects 3 cm above pinch-cock
ring (arrows) at tubulovesfibular junction and inferiorly by mucosal effect of the diaphragmatic hiatus (arrowheads). B, double-con-
rrng (arrowheads) at esophagogastnc junction. B, moments later, trast view of esophagogastric region in another patient. Smooth,
muscular narrowing disappears while mucosal ring remains static symmetric mucosal ring. Arrows = tubulovestibular junction; V =
in appearance (From Ott DJ, Gelfand DW, Wu WC, et al: Esopha- vestibule; HH = hiatal hernia. (From Ott DJ, Gelfand DW, Wu WC,
gogastric region and its rings. AJR 1984; 142:281-287. Used by et al: Esophagogastric region and its rings AdR 1984; 142281L
permrssion.) 287. Used by permission.)

requires distention of the esophagogastric region agent (or both) to force the impacted material into
above or beyond the caliber of the ring (see Figs 1, the stomach.74-78
3, and 5). The full-column technique performed Radiographic examination appears to be more
with the patient in the prone or prone oblique po- sensitive than endoscopy in demonstrating lower
sition best demonstrates mucosal rings.‘0”2’57 The esophageal mucosal rings. In one report, the ra-
prone position, especially if an abdominal bolster diographic detection rate for mucosal rings was
is used, promotes orad displacement of the esoph- 95% as against 58% for endoscopy.l’ Endoscopic
agogastric junction, thus facilitating the demon- detection, however, was significantly related to
stration of abnormalities of the esophagogastric re- ring diameter, with a detection rate of 82% of rings
gion. On the other hand, the double-contrast I3 mm or less, 54% of 14- to lS-mm rings, and 25%
method performed with the patient upright will of rings 20 mm or greater. Dysphagia was present
not detect most mucosal rings.*oJ l2 In one series,l’ in approximately half of the patients with mucosal
only 17% of mucosal rings were seen by the dou- rings undetected by endoscopy. Endoscopic sen-
ble-contrast examination; it failed to demonstrate sitivity also depended on the size of the fiberoptic
four symptomatic rings that were less than 13 mm instruments used; narrower endoscopes (less than
in diameter (see Figs 1 and 15). Occasionally, use 10 mm in diameter) enabled diagnosis of only 47%
of a solid bolus will enable identification of a mu- of rings as opposed to 76% with larger instruments
cosal ring not seen initially on full-column exami- (Fig 26).
nation with fluid barium (Figs 6 and 25). Food im- A wide variety of neoplasms and tumor-like le-
paction above a mucosal ring may be treated sions may occur in the esophagus and cause dys-
conservatively, using either glucagon to relax the phagia. Esophageal carcinoma and leiomyoma are
lower esophageal sphincter or a gas-producing the most important. Although they are the most
20 Cur-r Probl Diagn Radio& January/February 1988
 FIG 26.
FIG 25.
A, 13.mm mucosal ring (arrows) in patient with dysphagia not seen
A, patient with intermittent dysphagia with a normal initial barium
with large caliber (13-mm) endoscope (arrowheads = muscular
esophagogram and endoscopy. B, repeat esophagogram 2 days
ring; !I = vestibule; HH = hratal hernra) B, 15.mm mucosal ring
later showed a 12.mm mucosal ring. Production of a hiatal hernra
In patient with dysphagia not detected with small caliber (g-mm)
facilitated by the use of a marshmallow (not shown) permitted dis-
endoscope (From Ott DJ, Chen YM, Wu WC, et al: Radiographic
tention of the esophagogastric region beyond the caliber of the
and endoscopic sensitivity in detecting lower esophageal mucosal
ring. (From Ott DJ, Gelfand DW, Wu WC, et aI, Esophagogastric
ring AS? 1986; 147:261-265. Used by permission.)
region and its rungs. AN 1984; 142:281-287. Used by permis-
sion.!

common benign tumors of the esophagus, leio- lower esophagus.87-Y” Increasing evidence suggests
myomas are rare.7g-sz Many patients are asympto- that Barrett’s epithelium predisposes to adenocar-
matic, and discovery of the neoplasm is incidental cinema of the esophagus and esophagogastric
(Fig 27). Leiomyomas generally occur as solitary le- junction.g0-g3 Squamous cell carcinomas demon-
sions most commonly located in the lower two strate a spectrum of morphological patterns and
thirds of the esophagus and are usually 2 to 6 cm vary in size from small, eccentric lesions to large,
in size. They are invariably intramural, rarely ulcer- bulky tumors.‘, “I 3o
ate, and typically present as a smooth, eccentric Radiologic detection of the esophageal carci-
filling defect. Larger leiomyomas show an adjacent noma depends on the size of the lesion and the
mass effect, which may be apparent on plain chest techniques used. Large circumferential or poly-
films .81-83 Larger lesions are easily demonstrated poid lesions are easily demonstrated regardless of
radiographically; however, detection of small leio- the technique employed (see Fig 81. However, small
myomas requires proper distention of the esoph- sessile lesions less than I.5 to 2.0 cm in size may
agus, particularly on double-contrast examina- not be seen in a limited radiographic examination
tion.84 Multiple leiomyomas are even rarer and (see Fig 2).g4-g8Use of multiple techniques will pro-
may cause considerable distortion of the esopha- vide the best possible demonstration of even the
geal lumen.85’ 86 smallest esophageal neoplasms and will detect vir-
Squamous cell carcinoma and adenocarcinoma tually all symptomatic esophageal carcinomas.
are the most common primary esophageal malig- That use of multiple techniques detects all such
nancies. Adenocarcinoma accounts for only 10% of carcinomas has been shown in three reports of 408
these malignancies and arises primarily on the patients with dysphagia who had endoscopy. No
Cur-r Probl Diagn Radio& January/February 1988 21
 cations have been implicated as a cause of esoph-
agitis~lOs-l10 The most common drugs reported to
induce esophagitis have been emepronium, tetra-
cycline, and slow-releasing potassium chloride.
Slow clearance of the medication from the esoph-
agus or abnormal esophageal motility may contrib-
ute to prolonged contact between the ingested
material and the esophageal mucosa. The mid-
esophagus at the level of the aortic arch is the
usual site of involvement. Superficial erosions and
ulcerations are the most common endoscopic
findings and may be demonstrated radiographi-
tally. Focal esophageal narrowing, often caused by
spasm or edema, may also be present.
Infectious esophagitis can be produced by a
wide variety of viral, bacterial, or fungal agents.
Can&da albicans and herpes simplex virus are
most often responsible for the esophagitis that
usually presents as an opportunistic infection, al-
though herpetic esophagitis has occurred in oth-
erwise healthy individuals.“” I” Radiologic fea-
tures of Candida esophagitis vary according to the
severity and length of the esophageal involve-
ment.113-‘17 Fine ulceration and a cobblestone pat-
tern are early findings best appreciated on mu-
cosal views. Abnormal motility, severe ulceration,
pseudomembrane formation, and rarely, stricture
are later features (see Figs 9 and 17). The radio-
FIG 27. graphic appearance of herpetic esophagitis is often
A, 1.5~cm leiomyoma (arrow) found incidentally in a patient without indistinguishable from that caused by Candida al-
esophageal symptoms. B, large (6.5 x 7.5-cm) leiomyoma with bicans.118-‘2’ Although discrete ulceration may be
adjacent mass effect In patient with dysphagia seen early in herpetic infection, histologic exami-
nation is needed for a specific diagnosis. The re-
esophageal carcinomas went undetected radio- ported radiographic sensitivity in detecting infec-
graphically.“gm’“’ Also, the multiphasic examination tious esophagitis using a multiphasic examination
will allow the best evaluation of the oropharynx has been 80% to 92% .122,123
and esophagus and enable detection of synchron- Reflux esophagitis is a common clinical prob-
ous carcinomas.102m’04 lem. The patient usually presents with heartburn,
Esophagitis results from numerous causes, although dysphagia occurs with more severe dis-
many of which may produce dysphagia or odyno- ease, especially if complicated by peptic stricture.
phagia (Table 3). In recent years, there has been an The more common structural abnormalities that
increased awareness that a wide variety of medi- may be seen radiographically in reflux esophagitis
include mucosal contour irregularity, longitudinal
fold thickening, erosions and ulceration, wall
TABLE 3. thickening, and segmental narrowing, particularly
Causes of Esophagitis from stricture formation (see Figs 4, 10, 12,
Common causes 16). “, 238124-12g Pseudodiverticula (Fig 28) and in-
Infectious forms flammatory polyps or esophagogastric fistulization
Keflux esophagitis are rarer observations.130-‘34 Barrett’s epithelium is
Caustic injury considered a complication of gastroesophageal re-
Radiation injury
flux disease and is radiographically suggested
Rare causes
Medicatiowrelated
when focal esophagitis or stricture is separated
Crohn’s disease from an accompanying hiatal hernia by an inter-
Mucocutaneous disease vening segment of normal esophagus (Figs 28 and
Ulcerative colitis 29). 135-141
Behcet’s disease The radiologic detection of reflux esophagitis
Thermal injury depends on the endoscopic grade of disease and
Traumatic causes
the thoroughness of the barium examination. Var-

22 Curr Probl Diagn Radial, January/February 1988

FIG 28. FIG 29.
A, peptic stricture associated with multiple smooth outpouchings Full-column (A) and double-contrast (B) views in Barrett’s esoph-
representing pseudodiverticula demonstrated endoscopically. agus showing a midesophageal stricture. (From Ott DJ: Barium
(From Ott DJ: Barium esophagram, in Caste11 DO, Wu WC, Ott DJ esophagram, in Caste11 DO, Wu WC, Ott DJ (eds): Gastroesopha-
(eds): Gastroesophageal Reflux Disease. Mount Kisco, NY, Futura geal Reflux &ease, Mount Kisco, NY, Futura Publishing Co,
Publishing Co, 1985. Used by permission ) B, large hiatal hernia 1985. Used by permlssion).
with peptic stricture (arrows) well above the level of the esopha-
gogastnc IunctIon (arrowhead) in a patient with Barrett’s esopha-
gus Pseudodiverticula and active esophagltls endoscopically diographic sensitivities reported for individual
techniques for all endoscopic grades of esophagitis
have been 43% to 80% but have risen to 65% to
ious endoscopic grading systems have been de- 88% when a combination of techniques is
scribed for classifying the severity of reflux esoph- used. 11,125-12gIn one report, sensitivities for the
agitis ‘I, 23S124-12g Mild esophagitis is diagnosed three individual examining techniques were (11
when erythema, friability, and streaky exudation 43%) mucosal relief technique; (2) 53%) full-column
are seen. Radiographic detection is generally poor technique; and (3) 45%, double-contrast method,
in mild esophagitis, especially if only erythema
and friability are present on endoscopy. The pres-
ence of erosions and ulcerations is the endoscopic
indication of moderate esophagitis in which re- TABLE 4.
ported radiographic sensitivities have been 71% to Comparison of Reports on Radiographic Detection of
Reflux Esophagitis According to Severity of Disease
93% (Table 4). Severe esophagitis is manifested en-
doscopically by marked ulceration or, most com- Radiographic SensitiviF %

monly, stricture formation, with radiographic sen- Authors Mild Moderate Severe Overall’
sitivities reported to be 95% to 100%. The
combined sensitivities for diagnosing moderate Ott et al.“” 22 83 95 60
Koehler el al.“’ ot 80 100 72
and severe esophagitis radiographically have aver-
Creteor et al.“” 53 93 100 88
aged 90% to 96% in most series.““25-“X Ott et al.” 26 79 100 6.5
A multiphasic examination using a combination Derksen et al.“” 50 71 100 62
of radiographic techniques is needed for the most ‘Using a combination of techniques
effective detection of reflux esophagitis. Overall ra- tPatients with only evhema endoscwpirnll~

Curr Probl Diagn Radial, .lanuary/Febru~y 1988 23

with an overall sensitivity of 65%.‘l The mucosal ESOPHAGEAL MOTOR DISORDERS
relief and double-contrast techniques were most
When a structural abnormality of the esophagus
useful in detecting mild and moderate disease,
is not shown radiographically in a patient with
whereas the full-column technique best detected
dysphagia, esophageal manometry, rather than en-
peptic stricture.
doscopy, may better explain the symptoms be-
Of all forms of reflux esophagitis, the radio-
cause esophageal motor dysfunction is more likely
graphic examination most effectively detects pep-
to occur.’ In several comparisons between radiol-
tic stricture. Although endoscopy has been gener-
ogy and endoscopy in patients with dysphagia,
ally considered more accurate than radiologic
those having normal endoscopy had a high preva-
techniques for diagnosing peptic stricture, re-
lence of esophageal motor abnormality.gS1ol Motor
ported sensitivities have been 95% to 100% in re-
disorders of the esophagus may involve either the
cent radiographic studies .ll, 125-13oP14’ In several
oropharynx or the esophageal body. Occasionally,
comparative investigations, endoscopic and radio-
both areas are affected simultaneously, particularly
logic detection rates were both excellent, both
95% s130.141 Endoscopic and radiographic in neurologic diseases. The following discussion
sensitivity
will be limited to primary esophageal motility dis-
depended on the diameter of the strictures with
orders that may cause dysphagia and will empha-
detection of all those under 10 mm and 88% to
size their radiologic evaluation and the effective-
90% detection of broader strictures. With the in-
ness of the radiographic examination (Table 5).
creasing use of smaller caliber endoscopes, how-
Radiographic evaluation of esophageal motor
ever, a carefully-performed barium esophagogram
function includes examination of the esophageal
may prove more sensitive than endoscopy in di-
body and both the upper and lower esophageal
agnosing peptic strictures (Fig 30).
sphincters. Although motion recording techniques
may be used and are necessary in the assessment
of oropharyngeal function, fluoroscopic observa-
tion is usually adequate to evaluate motor function
in the esophageal body. Single swallows of barium
are observed with the patient in the prone oblique
position because multiple swallows taken before
completion of a primary peristaltic sequence in-
hibit the propagating wave and may be mistaken

TABLE 5.
Classification of Esophageal Motor Disorders

I. Primary motor disorders

A. Achalasia and variants
B. Dill&e esophageal spasm
C. Nonspecific esophageal motor disorder
D. Nutcracker esophagus
E. Presbyesophagus?
F. Intestinal pseudo-obstruction
II. Secondary motor disorders
A. Collagen vascular disease
B. Chemical or physical agents
1. Reflux esophagitis
2. Caustic esophagitis
3. Radiation therapy
c. Infectious causes
D. Diabetes mellitus
E. Alcoholism
F. Endocrine disease
G. Neuromuscular disorders
1. Cerebmvascular disease
FIG 30. 2. Demyelinating disorders
A, smooth eccentric peptic stricture (arrows) measuring 15 mm in 3. Chorea-related disorders
caliber. Normal endoscopy using large caliber (13-mm) endo- 4. Myasthenia gravis
scope. (From Ott DJ, Chen YM, Wu WC, et al: Endoscopic sensi- 5. Muscular dystrophies
tivity in the detection of esophagal strictures. J C/in Gastroenterol 6. Other rarer causes
1985; 7:121-125. Used by permission.) B, 12.mm peptic stricture
H. Miscellaneous causes
not detected endoscopically by a small-caliber endoscope.

24 Curr Probl Diagn Radio& January/February 1988

for peristaltic disruption6* Rapid, repetitive swal- preted as disruption of primary peristalsis.14z, 143
lows maximally distend the esophagus for struc- Esophageal motor disorders are usually classi-
tural evaluation. fied as primary or secondary (see Table ~‘).l~l~ In
A normal primary peristaltic sequence is seen as primary motor disorders, the esophagus is either
an aboral contraction wave that obliterates the the only or the predominant organ involved. Set-
esophageal lumen, progressively stripping the bar- ondary motor disorders result from a wide variety
ium bolus from the esophagus (Fig 31). The lumen- of systemic diseases or physical or chemical injury
obliterating wave imparts an inverted V-configura- to the esophagus. The classification of esophageal
tion to the top of the barium column (Figs 32,A motor disorders, especially the primary types, is
and 33,A). The peristaltic wave normally strips all still evolving. New disorders have been added in
of the barium from the esophagus, especially in recent years, and others have been reclassified. Be-
younger patients. Occasionally, some proximal es- cause of these changes, classifications have occa-
cape or retrograde flow of barium at the level of sionally conflicted. Moreover, some types of
the aortic arch occurs because of the lower-ampli- esophageal motor dysfunction are not easily la-
tude pressure trough normally present at the belled.
striated-smooth muscle transition of the esopha- Achalasia is characterized by aperistalsis in the
gus (Figs 32,B and 33,B). Proximal escape becomes esophageal body and dysfunction of the lower
more frequent with aging and may be misinter- esophageal sphincter. Radiographically, primary

mm WS
‘-‘g +
150
120
Pharynx 90
60
30
Upper __--__-----_--_----_____ 0
sphmcter
90

Esophageal
body

Lower
sphincter

FIG 31.
Manometric representation of normal esophageal peristalsis from multiple recording sites in the esophagus including the upper and
lower esophageal sphincters After a wet swallow (WS), upper sphincter relaxation occurs almost immediately followed by prolonged
lower sphincter relaxation within several seconds. Primary peristaltic contraction wave is seen as an aborally progressing pressure peak
(From Dodds WJ: Normal motor physiology and motility disorders, in Margulis AR, Burhenne HJ (eds): Alimentary Tract Radiology, ed
3 St Louis, CV Mosby Co, 1983, vol 1. Used by permission.)

Cur-r Probl Diagn Radial, January/February 1988 25

 A B
NORMAL PROXIMAL
ESOPHAGEAL PERISTALSIS ESOPHAGEAL ESCAPE

PEJ

AA

EGJ
EGJ c_ c- -e
Time
Time

FIG 32.
A, schematic representation of normal primary peristalsis with lumen-obliterating contraction wave stripping all of the banum from the
esophagus. PEJ = pharyngoesophageal junction; AA = aortic arch: EGd = esophagogastric junction. 6, Normal primary perist; slsis
with proximal escape because contraction wave fails to obliterate the esophageal lumen completely at the level of the aortic arch. 1‘Jote
that the peristaltic sequence continues aborally.

FIG 33.
A, radrographic appearance of complete stripping of barium bolus (arrows) requiring about 6 to 8 seconds normally. B, proximal esc rape
of barium. Peristaltrc contraction wave (arrows) progresses normally but does not quite obliterate esophageal lumen. (From Dodds WJ:
Normal motor physiology and motility disorders, in Margulis AR, Burhenne HJ (eds): Alimentary Tract Radiology, ed 3. St Louis, cv
Mosby Co, 1983, vol 1. Used by permission.)

Curr Probl Diagn Radiol, January/February 1988

peristalsis is absent on all swallows observed, and
the lower end of the esophagus shows a smooth
“beak-like” tapering that reflects failure of the bar-
ium bolus to distend the tonically-contracted
sphincter (Fig 34) .88*47-*4g Repetitive, nonperistaltic
contractions may occasionally be seen. Depending
on the duration and severity of disease, the esoph-
agus may show marked dilatation, with retention
of food, secretions, and barium during the radio-
graphic examination.
Achalasia must be distinguished from other
causes of lower esophageal narrowing and dys-
function, particularly intrinsic and extrinsic neo-
plasms, peptic stricture, and complicated sclero-
derma. Carcinoma of the esophagogastric region
must be excluded, especially in older patients.‘5G152
Although most of these malignancies demonstrate
mucosal irregularity or mass effect, carcinoma of
the gastric cardia or extrinsic neoplasms involving
the esophagogastric region may cause smooth ta-
pering with associated peristaltic abnormalities
that simulate achalasia (Fig 35). Peptic stricture is
rarely associated with ape&&is. Also, hiatal her-
nia is seen in most patients with stricture but is FIG 35.
Smooth narrowing of esophagogastric junction simulating achala-
uncommon in achalasia (Fig 36,A). Scleroderma sia. Pathologically, scirrhous carcinoma of proximal stomach with
typically shows a patulous esophagogastric region esoohaaeal infiltration.
but may be complicated by peptic stricture and
may mimic achalasia (Fig 36,B).
Diffuse esophageal spasm is an uncommon pri-
mary esophageal-motor disorder diagnosed mano-
metrically in patients with dysphagia or chest
pain. Patients show intermittently normal peristal-
sis with simultaneous contractions and usually
have normal lower esophageal sphincter function.
Radiographically, peristalsis is intermittently dis-
rupted in the smooth muscle portion of the
esophagus where nonperistaltic contractions re-
piace the disrupted primary wave.8J147-14g Sponta-
neous, obliterating contractions may compartmen-
talize the esophageal lumen, causing the typical
“corkscrew” or “rosary-bead” appearance (Fig 37).
In diffuse esophageal spasm, the esophageal mus-
culature is frequently thickened, and the wall may
measure as much as z cm or more (normal, less
than 4 to 5 mm).8,153
Nonspecific esophageal motor disorder (NEMDI
is a catchall term recently used to describe symp-
tomatic patients with motility disturbances that
defy specific classification.145’ I46 Although NEMD
has been a commonly used diagnosis, its natural
history and clinical significance are not folly un-
derstood. Manometric abnormalities include inter-
mittent absence of peristalsis, low amplitude peri-
stalsis, occasional repetitive contractions, or in-
complete lower esophageal sphincter relaxation.
FIG 34. Radiographically, patients may show primary peri-
Esophageal dilatation and aperistalsis shown fluoroscopically. staltic disturbance and tertiary contractions that
Smooth tapering at lower end of esophagus represents the dys- suggest an esophageal motor disorder (Fig 38).
functional lower esophageal sphincter. However, only minor abnormalities are often seen
Curr Probl Diagn Radiol, January/February 1988 27
FIG 36. FIG 37.
A, peptic stricture with hiatal hernia (HH), which is present in most A, diffuse esophageal spasm with intermittent disruption of primary
patients with reflux disease but rare in achalasia. (From Chen YM, peristalsis associated with focally obliterative simultaneous con-
Ott DJ, Gelfand DW: Multiphasic examination of the esophagogas- traction. B, typical “corkscrew” or “rosary-bead” appearance in
tric region for strictures, rings, and hiatal hernias: Evaluation of the diffuse esophageal spasm. Clinical and manometric correlation is
individual techniques. Gastrointest Radio/ 198.5; lo:31 1-316. Used needed since this appearance may be nonspecific, especially in
by permission,) B, complicated scleroderma with hiatal hernia the elderly.
(HH) and peptic stricture. Aperistalsis of the esophagus shown
fluoroscopically. sphincter dysfunction. Radiographic abnormalities
reflected the manometric changes. However, many
on manometry, and the radiographic examination patients studied in earlier reports of this entity
is normal. had neurologic disorders or diabetes mellitus,
Nutcracker esophagus is a newly-described which may have produced esophageal dysmotility.
esophageal motor disorder seen in some patients Recent manometric investigations in healthy el-
with chest pain or dysphagia.153-155 Manometri- derly individuals have shown relatively minor
tally, primary peristalsis is intact, but distal peri- changes in esophageal function associated with
staltic contractions of abnormally high amplitude aging.‘“, 143 Since many of the manometric criteria
and prolonged duration are present. In most pa- of presbyesophagus are similar to those used for
tients with nutcracker esophagus, the radiographic NEMD, the latter has become the preferred term.
examination is normal, although nonspecific ter- The efficacy of radiology in evaluating normal
tiary contractions of uncertain significance may be and abnormal esophageal motor function depends
present. Nutcracker esophagus is, therefore, a on the quality of the examination performed, the
manometric diagnosis primarily made in the ap- experience of the examiner, and the types of motor
propriate clinical setting. disorders being evaluated. The properly performed
Presbyesophagus has been a controversial entity radiographic examination can accurately evaluate
in recent years. As described originally, presby- for the presence of normal esophageal peristalsis
esophagus referred to esophageal motor dysfunc- with reported specificities of 91% and 95%.‘58-160
tion associated with aging.1568’57 The major mano- Multiple single ~swallows must be observed with
metric criteria included decreased incidence of the patient prone to determine the actual inci-
normal peristalsis, increased frequency of tertiary dence of primary peristalsis.
contractions, and occasional lower esophageal Radiographic detection of esophageal motor dis-
28 Curr Probl Diagn Hadiol, January/February 1988
 TABLE 6.
Radiology vs. Endoscopy in Esophageal Dysphagia
Evaluation Radiology* Endoscopy

Motor Disorden
Achalasia ++++ +++
Diffuse spasm ++
NEMD + I //
Structural Disorders
Diverticular disease ++++ +++
Mucosal ring ++++ + +**
Infectious esophagitis ii+ ++++
Reflex esophagitis + +* +++s
Peptic stricture ++++ ++++
Carcinoma ++++ ++++
‘+poor sensitivity iGO%J; + + fair sensitivity 1>50%1;
+ + + good sensitivity 1>75%1; + + + + excellent sensitiv-
ity (>9OWJ.
** + + +, if rings less than 14 mm in caliber.
+ + + + in more severe grades of reflux esophagitis.
5 + + + +, if combined with mucosal biopsy
11~ not applicable.

tial screening of patients with dysphagia (Table 6).

Endoscopy is more expensive, generally requires
sedation, and is associated with a small but defi-
nite risk to the patient. Also, the endoscopic ex-
amination yields a poor evaluation of esophageal
motor function and may fail to detect mucosal
rings and peptic strictures, especially if smaller
FIG 38. caliber instruments are used. The chief limitations
A, 89-year-old man with dysphagia but no chest pain. Diffuse of the radiographic examination are poor detec-
“curling” of the esophagus is seen. Nonspecific esophageal motor tion of mild cases of esophagitis and variable sen-
disorder diagnosed manometrically. B, elderly man without esoph-
sitivity and specificity in diagnosing esophageal
ageal symptoms showing simultaneous tertiary contractions.
motor disorders.

orders is also dependent on the type of disorder

being evaluated. In one radiographic-manometric REFERENCES
correlation performed in 172 patients with dys-
1. Caste11 DO: Dysphagia. Gastroenterology 1979; 76:1015.
phagia, an esophageal motor disorder was diag- 2. Ott DJ, Gelfand DW, Wu WC, et al: Radiological evalu-
nosed manometrically in 66 patients.16’ Individual ation of dysphagia. JAMA 1986; 2562718.
radiographic sensitivities were 95% for achalasia, 3. Edwards DAW: Discriminative information in the di-
71% for diffuse esophageal spasm, and 46% for agnosis of dysphagia. J R Co11 Physicians Land 1975;
NEMD. Nutcracker esophagus was not specifically 9:257.
diagnosed on barium examination. The overall ra- 4. Edwards DAW: History and symptoms of esophageal
dysphagia, in Vantrappen G, Hellemans J teds): Dis-
diographic sensitivity was 56%, but it was in- eases of the Esophagus. New York, Springer-Verlag,
creased to 89% by excluding patients with NEMD 1974.
and nutcracker esophagus. Radiographic detection 5. Jones B, Ravich WJ, Donner MW, et al: Pharyngoesoph-
of secondary esophageal motor disorders is usu- ageal interrelationships: Observations and working
ally based on demonstration ‘of nonspecific find- concepts. Gastrointest Radio1 1985; 1022.5.
ings combined with clinical correlation for poten- 6. Gelfand DW, Ott DJ: Anatomy and technique in eval-
tial diseases that may cause esophageal motor uating the esophagus. Semin Roentgen01 1981; 16:168.
Ott DJ: Radiologic evaluation of the esophagus, in Cas-
dysfunction (see Table 51. tell DO, Johnson LF teds): Esophageal Function in
Health and Disease. New York, Elsevier North-Holland,
Inc, 1983.
SUMMARY Dodds WJ: Esophagus and esophagogastric region -
radiology, in Margulis AR, Burhenne HJ feds): Alimen-
In patients with dysphagia, the radiographic ex- tary Tract Radiology 3rd ed. St Louis, CV Mosby Co,
amination evaluates both structural and functional 1983, vol 1.
abnormalities of the esophagus. Radiologic exami- Hiipscher DN: Technique of examination of the
nation is more appropriate than endoscopy for ini- esophagus. Diagn lmag C/in Med 1986; 5.5:241.

Curr Probl Diagn Radiol, January/February 1988 29

 10. Chen YM, Ott DJ, Gelfand DW, et al: Multiphasic ex- contrast examination of the esophagus. AJR 1984;
amination of the esophagogastric region for strictures, 142293.
rings and hiatal hernia: Evaluation of individual tech- 34. Halpert RD, Dubin L, Feczko PJ, et al: Air contrast tube
niques. Gastrointest Radio1 1985; 10:311. esophagram: Technique and clinical examples-tech-
11. Ott DJ, Chen YM, Gelfand DW, et al: Analysis of a mul- nical note. J Can Assoc Radio1 1984; 3558.
tiphasic radiographic examination for detecting reflux 35. Dormer MW, Siegel CI: The evaluation of pharyngeal
esophagitis. Gastrointest Radio1 1986; 11:l. neuromuscular disorders by cinefluorography. AJR
12. Ott DJ, Chen YM, Wu WC, et al: Radiographic and en- 1965; 94299.
doscopic sensitivity in detecting lower esophageal 36. Jones B, Kramer SS, Donner MW: Dynamic imaging of
mucosal ring. AJJ? 1986; 147261. the pharynx. Gastrointest Radio1 1985; 10213.
13. Winship DH, Viegas de Andrade SR, Zboralske FF: In- 37. Ekberg 0, Nylander G: Cineradiography of the pharyn-
fluence of bolus temperature on human esophageal geal stage of deglutition in 250 patients with dys-
motor function. .I Clin Invest 1970; 49243. phagia. BF J Radio1 1982; 55258.
14. Ott DJ, Kelly RJ, Gelfand DW: Radiographic effects of 38. Curtis DJ, Cruess DF, Dachman AH: Normal erect
cold barium suspensions on esophageal motility. Ra- swallowing-normal swallowing and incidence of
diology 1981; 140:830. variations. Invest Radio1 1985; 20:717.
15. Ott DJ, Gelfand DW, Munitz HA, et al: Cold barium 39. Hynes DM, Edmonds EW, Krametz KR, et al: Radio-
suspensions in the clinical evaluation of the esopha- graphic, photofluorographic, and television imaging
gus. Gastrointest Radio1 1984; 9:193. systems: An evaluation. Radiology 1979; 133:751.
16. Wolf BS: Use of a half-inch barium tablet to detect 40. Hynes DM, Edmonds EW, Krametz KR, et al: Multi-
minimal esophageal strictures. J Mt Sinai Hasp 1961; image camera in spot radiography at fluoroscopic ex-
28:SO. aminations. Radiology 1980; 136.213.
17. Kelly JE Jr: The marshmallow as an aid to radiologic 41. Soini I, Kiuru A, M;ikell PJ, et al: Double-contrast ex-
examination of the esophagus. N Engl J Med 1961; amination of the stomach: 160-mm fluorography vs.
265:1306. full-size radiography. Radiology 1983; 148:627.
18. Davies HA, Evans KT, Butler F, et al: Diagnostic value 42. Lambert JR, Tepperman PS, Jimenez J, et al: Cervical
of “bread-barium” swallow in patients with esopha- spine disease and dysphagia. Am J Gastroenterol 1981;
geal symptoms. Dig Dis Sci 1983; 28:1094. 76:35.
19. Danielson KS, Hunter TB: Barium capsules. AJR 1985; 43. Mann NS, Brewer H, Sheth B: Upper esophageal dys-
144:414. phagia due to marked cetvical lordosis. J Clin Gas-
20. Somers S, Stevenson GW, Thompson G: Comparison of troenterol 1984; 6:57.
endoscopy and barium swallow with marshmallow in 44. Palmer ED: Dysphagia lusoria: Clinical aspects in the
dysphagia. J Can Assoc Radio1 1986; 37:73. adult. Ann Intern Med 1955; 42:1173.
21. Dodds WJ, McGlaughlin PS, Goldberg HI, et al: Esoph- 45. Dantas RO, de Godoy RA, Meneghelli UG, et al: Dys-
ageal roentgenography using tantalum paste. Radiol- phagia lusoria and segmental aperistalsis in the upper
ogy 1972; 102:204. third of the esophagus. J Clin Gastroenterol 1985;
22. Miller RE, Chernish SM, Brunelle RL: A comparative 7:522.
double-blind study of esophageal barium pastes. Gas- 46. Proto AV, Cuthbert NW, Raider L: Aberrant right sub-
trointest Radio1 1977; 2:163. clavian artery: Further observations. AJR 1987; 148:253.
23. Ott DJ, Gelfand DW, Wu WC: Reflux esophagitis: Ra- 47. Birnholz JC, Ferrucci JT Jr, Wyman SM: Roentgen fea-
diographic and endoscopic correlation. Radiology tures of dysphagia aortica. Radiology 1974; 111:93.
1979; 130583. 48. Beachley MC, Siconolii EP, Madoff HR, et al: Dysphagia
24. Dalinka MK, Smith EH, Wolfe RD, et al: Pharmacologi- aortica. Dig Dis Sci 1980; 25:807.
cally enhanced visualization of esophageal varices by 49. Mittal RK, Siskind BN, Hongo M, et al: Dysphagia aor-
Pro-Banthine. Radiology 1972; 102:281. tica-clinical, radiological, and manometric findings.
25. Liu C: Enhanced visualization of esophageal varices by Dig Dis Sci 1986; 31:379.
Buscopan. AJR 1974; 121:232. 50. Kaye MD: Oesophageal motor dysfunction in patients
26. Cockerill EM, Miller RE, Chernish SM, et al: Optimal with diverticula of the mid-thoracic oesophagus.
visualization of esophageal varices. AJR 1976; 126:512. Thora,x 1974; 29:666.
27. Waldram R, Nunnerley H, Davis M, et al: Detection and 51. Bruggeman LL, Seaman WB: Epiphrenic diverticula-
grading of oesophageal varices by fibre-optic endos- an analysis of 80 cases. AJR 1973; 119:266.
copy and barium swallow with and without Busco- 52. Debas HT, Payne WS, Cameron AJ, et al: Physiopathol-
pan. Clin Radio1 1977; 28:137. ogy of lower esophageal diverticulum and its implica-
28. Skucas J, Schrank WW: The routine air-contrast ex- tions for treatment. Surg Gynecol Obstet 1980; 151:593.
amination of the esophagus. Radiology 1975; 115:482. 53. Yarbrough DR III, Cunningham ER, Holmes HB: Phar-
29. Laufer I: Double Contrast Gastrointestinal Radiology yngoesophageal diverticula. South MedJ 1980; 73:1251.
Philadelphia, WI3 Saunders Co, 1979. 54. Knuff TE, Benjamin SB, Caste11 DO: Pharyngoesopha-
30. Gelfand DW: Gastrointestinal Radiology New York, geal (Zenker’s) diverticulum: A reappraisal. Gastroen-
Churchill Livingstone Inc, 1984. terology 1982; 82:734.
31. Balfe DM, Koehler RE, Weyman PJ, et al: Routine air- 55. Balthazar EJ: Esophagobronchial fistula secondary to
contrast esophagography during upper gastrointes- ruptured traction diverticulum. Gastrointest Radio1
tinal examinations. Radiology 1981; 139:739. 1977; 2:llS.
32. Cassel DM, Anderson MF, Zboralske FF: Double-con- 56. Saldana JA, Cone RO, Hopens TA, et al: Carcinoma
trast esophagrams-the prone technique. Radiology arising in an epiphrenic esophageal diverticulum.
1981; 139:737. Gastrointest Radio1 1982; 7:15.
33. Levine MS, Kressel HY, Laufer I, et al: The tube esoph- 57. Ott DJ, Gelfand DW, Wu WC, et al: Esophagogastric
agram: A technique for obtaining a detailed double- region and its rings. AJR 1984; 142:281.

30 Cum Probl Diap Radial, JanuarylFebruary 198X

 58. Clements JL Jr, Cox GW, Torres WE, et al: Cervical a mediastinal mass. J Can Assoc Radio1 1981; 32:12y.
esophageal webs-a roentgen-anatomic correlation. 84. Montesi A, Pesaresi A, Graziani L, et al: Small benigtl
AJR 1974; 121:221. tumors of the esophagus: Radiological diagnosis wit11
59. Nosher JL, Campbell WL, Seaman WB: The clinical sig- double-contrast examination. Gastrointest Radio1 1983
nificance of cervical esophageal and hypopharyngeal 8207.
webs. Radiology 1975; 117:45. 85. Shaffer HA Jr: Multiple leiomyomas of the esophagus
60. Ekberg 0: Cervical esophageal webs in patients with Radiology 1976; 118:29.
dysphagia. Clin Radio1 1981; 32:633. 86. Godard JE, McCranie D: Multiple leiomyomas of the
61. Ekberg 0, Nylander G: Webs and web-like formations esophagus. AJR 1973; 117:259.
in the pharynx and cervical esophagus. Diagn Imaging 87. Norton GA, Postlethwait RW, Thompson WM: Esoph-
1983; 52:lO. ageal carcinoma: A survey of populations at risk. South
62. Han SY, Mihas AA: Circumferential web of the upper Med J 1980; 7325.
esophagus. Gastrointest Radio1 1978; 3:7. 88. Giuli R, Gignoux M: Treatment of carcinoma of the
63. Longstreth GF, Wolochow DA, Tu RT: Double congen- esophagus. Ann Surg 1980; 192:44.
ital midesophageal webs in adults. Dig Dis Sci 1979; 89. Galandiuk S, Hermann RE, Gassman JJ, et al: Cancer
24:162. of the esophagus-the Cleveland Clinic experience.
64. Shiflett DW, Gilliam JH, Wu WC, et al: Multiple esoph- Ann Surg 1986; 203:lOl.
ageal webs. Gastroenterology 1979; 77:556. 90. Wang HH, Antonioli DA, Goldman H: Comparative fea-
65. Munitz HA, Ott DJ, Rocamora LR, et al: Multiple webs tures of esophageal and gastric adenocarcinomas: Re-
of the esophagus. South Med J 1983; 76:405. cent changes in type and frequency. Hum Path01 1986;
66. Pitman RG, Fraser GM: The post-cricoid impression on 17:482.
the oesophagus. Clin Radio1 1965; 16:34. 91. Agha FP: Barrett carcinoma of the esophagus: Clinical
67. Friedland GW, Filly R: The postcricoid impression and radiographic analysis of 34 cases. AJR 1985;
masquerading as an esophageal tumor. Am J Dig Dis 145:41.
1975; 20287. 92. Saubier EC, Gouillat C, Samaniego C, et al: Adenocar-
68. Goyal RK, Glancy JJ, Spiro HM: Lower esophageal ring. cinema in columnar-lined Barrett’s esophagus. Am J
N Engl J Med 1970; 282:1298 and 1355. Surg 198.5; 150:365.
69. Friendland GW: Historical review of the changing con- 93. Rogers EL, Goldkind SF, Iseri OA, et al: Adenocarci-
cepts of lower esophageal anatomy: 430 B.C.-1977. AJR noma of the lower esophagus - A disease primarily of
1978; 131:373. white men with Barrett’s esophagus. J Clin Gastroen-
70. Schatzki R, Gary JE: Dysphagia due to a diaphragm- terol 1986; 8:613.
like localized narrowing in the lower esophagus 94. Levine MS, Dillon EC, Saul SH, et al: Early esophageal
(“lower esophageal ring”). AJR 1953; 70:911. cancer. AJR 1986; 146:507.
71. Schatzki R, Gary JE: The lower esophageal mucosal 95. Moss AA, Koehler RE, Margulis AR: Initial accuracy of
ring. AJR 1956; 75:246. esophagograms in detection of small esophageal car-
72. Schatzki R: The lower esophageal ring: Long term fol- cinoma. AJR 1976; 127:909.
low-up of symptomatic and asymptomatic rings. AJR 96. Koehler RE, Moss AA, Margulis AR: Early radiographic
1963; 90:805. manifestations of carcinoma of the esophagus. Radiol-
73. Norton RA, King GD: “Steakhouse syndrome:” The ogy 1976; 119~1.
symptomatic lower esophageal ring. Lahey Clin Found 97. Itai Y, Kogure T, Okuyama Y, et al: Superficial esopha-
Bull 1963; 13:55. geal carcinoma. Radiology 1978; 126:597.
74. Ghahremani GG, Heck LL, Williams JR: A pharmaco- 98. Zornoza J, Lindell MM Jr: Radiologic evaluation of
logic aid in the radiographic diagnosis of obstructive small esophageal carcinoma. Gastrointest Radio1 1980;
esophageal lesions. Radiology 1972; 103:289. 5:107.
75. Ferrucci JT Jr, Long JA Jr: Radiologic treatment of 99. DiPalma JA, Prechter GC, Brady CE III: X-ray-negative
esophageal food impaction using intravenous gluca- dysphagia: Is endoscopy necessary? J Clin Gastroen-
gon. Radiology 1977; 12525. terol 1984; 6:409.
76. Mohammed SH, Hegediis V: Dislodgement of im- 100. Ott DJ, Wu WC, Gelfand DW: Efficacy of radiology 01
pacted oesophageal foreign bodies with carbonated the esophagus for evaluation of dysphagia. Gastroin-
beverages. Clin Radio1 1986; 37:589. test Radio1 1981; 6:109.
77. Rice BT, Spiegel PK, Dombrowski PJ: Acute esophageal 101. Halpert RD, Feczko PJ, Spickler EM, et al: Radiological
food impaction treated by gas-forming agents. Radiol- assessment of dysphagia with endoscopic correlation.
ogy 1983; 146:299. Radiology 1985; 157:599.
78. Smith JC, Janower ML, Geiger AH: Use of glucagon and 102. Thompson WM, Oddson TA, Kelvin F, et al: Synchro-
gas-forming agents in acute esophageal food impac- nous and metachronous squamous cell carcinomas of
tion. Radiology 1986; 159:567. the head, neck and esophagus. Gastrointest Radio1
79. Faivre J, Bory R, Moulinier B: Benign tumors of oesoph- 1978; 3:123.
agus: Value of endoscopy. Endoscopy 1978; 10:264. 103. Shons AR, McQuarrie DG: Multiple primary epidel,-
80. Davies PM: Smooth muscle tumours of the upper gas- moid carcinomas of the upper aerodigestive tract.
trointestinal tract. Clin Radio1 1978; 29:407. Arch Surg 1985; 120:1007.
81. Hare WSC, Ketheranathan V: Leiomyoma of the eosoph- 104. Goldstein HM, Zornoza J: Association of squamous
agus. Australas Radio1 1980; 24:273. cell carcinoma of the head and neck with cancer of
82. Bruneton JN, Drouilland J, Roux P, et al: Leiomyoma the esophagus. AJR 1978; 131:791.
and leiomyosarcoma of the digestive tract-a report of 105. Teplick JG, Teplick SK, Ominsky SH, et al: Esophagitis
45 cases and review of the literature. Eur J Radio1 1981; caused by oral medication. Radiology 1980; 134:23.
1291. 106. Mason SJ, O’Meara TF: Drug-induced esophagitis. .I
83. Cohen AM, Cunat JS: Giant esophageal leiomyoma as Clin Gastroenterol 1981: 3:115.

Curr Probl Diagn Radial, January/February 1988 31

107. Winckler K: Tetracycline ulcers of the oesophagus. En- Ilammatory esophagogastric polyp and fold. Radiology
doscopy, histology and roentgenology in two cases, 1978; 128589.
and review of the literature. Endoscopy 1981; 13225. 132. Rabin MS, Bremner CG, Botta JR: The reflux gastro-
108. Creteur V, Laufer I, Kressel HY, et al: Drug-induced esophageal polyp. Am J Gastroenterol 1980; 73:451.
esophagitis detected by double-contrast radiography. 133. Staples DC, Knodell RG, Johnson LF: Inflammatory
Radiology 1983; 147:365. pseudotumor of the esophagus: A complication of
109. Amendola MA, Spera TD: Doxycycline-induced esoph- gastroesophageal reflux. Gastrointest Endosc 1978;
agitis. JAMA 1985; 253:1009. 241175.
110. Agha FP, Wilson JAP, Nostrand ‘IT: Medication- 134. Raymond JI, Khan AH, Cain LR, et al: Multiple esoph-
induced esophagitis. Gastrointest Radio1 1986; 11:7. agogastric fistulas resulting from reflux esophagitis.
111. Springer DJ, DaCosta LR, Beck IT: A syndrome of acute Am J Gastroenterol 1980; 73:430.
self-limiting ulcerative esophagitis in young adults 135. Halpert RD, Feczko PJ, Chason DP: Barrett’s esopha-
probably due to herpes simplex virus. Dig Dis Sci 1979; gus: Radiological and clinical considerations. J Can
24:535. Assoc Radio1 1984; 35:120.
112. DeGaeta L, Levine MS, Guglielmi GE, et al: Herpes 136. Robbins AH, Vincent ME, Saini M, et al: Revised radio-
esophagitis in an otherwise healthy patient. AJR 1985; logic concepts of the Barrett esophagus. Gastrointest
144:1205. Radio1 1978; 3:377.
113. Goldberg HI, Dodds WJ: Cobblestone esophagus due 137. Levine MS, Kressel HY, Caroline DF, et al: Barrett
to monilial infection. AJR 1968; 104:608. esophagus: Reticular pattern of the mucosa. Radiology
114. Lewicki AM, Moore JP: Esophageal moniliasis-a re- 1983; 147:663.
view of common and less frequent characteristics. AJR 138. Chen YM, Gelfand DW, Ott DJ, et al: Barrett esophagus
1975; 125:218. as an extension of severe esophagitis: Analysis of
115. Athey PA, Goldstein HM, Dodd GD: Radiologic spec- radiologic signs in 29 cases. AJR 1985; 145:275.
trum of opportunistic infections of the upper gas- 139. Agha FP: Radiologic diagnosis of Barrett’s esophagus:
trointestinal tract. AJR 1977; 129:419. Critical analysis of 65 cases. Gastrointest Radio1 1986;
116. Ott DJ, Gelfand DW: Esophageal stricture secondary to 11:123.
candidiasis. Gastrointest Radio1 1978; 2:323. 140. Chernin MM, Amberg JR, Kogan FJ, et al: Efficacy of
117. Agha FP: Candidiasis-induced esophageal strictures. radiologic studies in the detection of Barrett’s esoph-
Gastrointest Radio1 1984; 9:283. agus. AJR 1986; 147257.
118. Skucas J, Schrank WW, Meyers PC, et al: Herpes 141. Ott DJ, Chen YM, Wu WC, et al: Endoscopic sensitivity
esophagitis: A case studied by air-contrast esopha- in the detection of esophageal strictures. J Clin Gas-
gography. AJR 1977; 128:497. troenterol 1985; 7:121.
119. Meyers C, Durkin MG, Love L: Radiographic findings 142. Hollis JB, Caste11 DO: Esophageal function in elderly
in herpetic esophagitis. Radiology 1976; 119:21. men. Ann Intern Med 1974; 80:371.
120. Shortsleeve MJ, Gauvin GP, Gardner RC, et al: Herpetic 143. Khan TA, Shragge BW, Crispin JS, et al: Esophageal
esophagitis. Radiology 1981; 141:611. motility in the elderly. Dig Dis Sci 1977; 22:1049.
121. Levine MS, Laufer I, Kressel HY, et al: Herpes esopha- 144. Cohen S: Motor disorders of the esophagus. N Engl J
gitis. AJR 1981; 136:863. Med 1979; 301:184.
122. Levine MS, Macones AJ Jr, Laufer I: Candida esopha- 145. Blackwell JN, Caste11 DO: Motility disorders of the
gitis: Accuracy of radiographic diagnosis. Radiology lower esophagus. Surv Dig Dis 1983; 1:157.
1985; 154:581. 146. Katz PO, Caste11 DO: Review: Esophageal motility dis-
123. Vahey TN, Maglinte DDT, Chernish SM: State-of-the-art orders. Am J Med Sci 1985; 290:61.
barium examination in opportunistic esophagitis. Dig 147. Caste11 DO: Achalasia and diffuse esophageal spasm.
Dk Sci 1986; 31:1192. Arch Intern Med 1976; 136:571.
124. Ott DJ, Dodds WJ, Wu WC, et al: Current status of ra- 148. Margulis AR, Koehler RE: Radiologic diagnosis of dis-
diology in evaluating for gastroesophageal reflux dis- ordered esophageal motility. Radio1 Clin North Am
ease. J C/in Gastroenterol 1982; 4:365. 1976; 14:429.
125. Ott DJ, Wu WC, Gelfand DW: Reflux esophagitis revis- 149. Stewart ET: Radiographic evaluation of the esophagus
ited: Prospective analysis of radiologic accuracy. Gas- and its motor disorders, Med Clin North Am 1981;
trointest Radial 1981; 6:l. 6.5:1173.
126. Ott DJ: Barium Esophagram, in Caste11 DO, Wu WC, 150. Lawson TL, Dodds WJ: Infiltrating carcinoma simulat-
Ott DJ teds): Gastroesophageal Reflu)c Disease. Mount ing achalasia. Gastrointest Radio1 1976; 1:245.
Kisco, NY, Futura Publishing Co, Inc, 1985. 151. Ott DJ, Gelfand DW, Wu WC, et al: Secondary achalasia
127. Koehler RE, Weyman PJ, Oakley HF: Single- and dou- in esophagogastric carcinoma: Re-emphasis of a diffi-
ble-contrast techniques in esophagitis. AJR 1980; cult differential problem. Rev Interam Radio/ 1979;
135:15. 4:135.
128. Creteur V, Thoeni RF, Federle MP, et al: The role of 152. Feczko PJ, Halpert RD: Achalasia secondary to nongas-
single and double-contrast radiography in the diag- tmintestinal malignancies. Gastrointest Radio1 1985;
nosis of reflux esophagitis. Radiology 1983; 147:71. 10:273.
129. Derksen OS, Booy AP, van de Borne H, et al: Value of 153. Ott DJ, Richter JE, Wu WC, et al: Radiologic and mano-
radiology in the diagnosis of reflux esophagitis. Diagn metric correlation in “nutcracker esophagus”. AJR
lmag Clin Med 1985; 54257. 1986; 147:692.
130. Ott DJ, Gelfand DW, Lane TG, et al: Radiologic detec- 154. Benjamin SB, Gerhardt DC, Castell DO: High ampli-
tion and spectrum of appearances of peptic esopha- tude, peristaltic esophageal contractions associated
geal strictures. J Clin Gastroenterol 1982; 4:ll. with chest pain and/or dysphagia. Gastroenterology
131. Bleshman MH, Banner MP, Johnson RC, et al: The in- 1979; 77:478.

32 Cur-r Probl Diagn Radio& January/February 1988

1.55. Chobanian SJ, Curtis DJ, Benjamin SB, et al: Radiology 158. Dodds WJ, Hogan WJ, Reid DP, et al: A comparison
of the nutcracker esophagus. J Clin Gastroenterol between primary esophageal peristalsis following wet
1986; 8:230. and dry swallows. J Appl Physiol 1973; 35:851.
156. Soergel KH, Zboralske FF, Amberg JR: Presbyesopha- 1.59. Dodds. WJ: Current concepts of esophageal motor
gus: Esophageal motility in nonagenarians. J Clin In- function: Clinical implications for radiolam. AJR 1977;
vest 1964; 43:1472. 128:549.
157. Zboralske FF, Amberg JR, Soergel KH: Presbyesopha- 160. Ott DJ, Richter JE, Chen YM, et al: Esophageal radiog-
gus: Cineradiographic manifestations. Radiologv 1964; raphy and manometty: Correlation of the esophagus
82:463. in 172 patients with dysphagia. AJR 1987; 149:307.

Curr Probl Diagn Radial, January/February 1988 33