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PURPOSE: To evaluate a small-caliber esophagus at barium esophagography with idiopathic eosinophilic esophagitis (IEE) and determine if there is a useful threshold diameter for suggesting this diagnosis. MATERIALS AND METHODS: The institutional review board approved this retrospective study and waived informed consent. This study was HIPAA compliant. A search of the radiology database (by using the search term small-caliber esophagus) revealed 10 patients with a small-caliber esophagus at barium esophagography who had IEE (defined as more than 20 eosinophils per high-power field in endoscopic biopsy specimens). Images were reviewed to characterize findings and determine the length of narrowing. Luminal diameters were measured at three levels for nine patients and nine control subjects, and mean diameter, range, and standard deviation were determined at each level. An analysis of variance test was performed to determine whether the difference between the range of mean thoracic esophageal diameters in patients with IEE versus that in control subjects was significant. RESULTS: All 10 patients had long-segment but variable-length narrowing of the thoracic esophagus (mean length, 15.4 cm) with tapered margins. The mean diameter at the aortic arch, carina, and one vertebral body above the gastroesophageal junction was 13.9, 14.3, and 15.1 mm, respectively, for patients with small-caliber esophagus versus 20.2, 30.3, and 28.7 mm for control subjects. The mean overall diameter was 14.7 mm for patients with small-caliber esophagus versus 26.3 mm for control subjects. In the nine patients in whom the luminal diameter was measured, the mean thoracic esophageal diameter was 20 mm or less; all nine control subjects had a mean thoracic esophageal diameter greater than 20 mm. The difference in the range of mean thoracic esophageal diameters between these two groups was highly significant (P < .0001), so 20 mm was a useful threshold diameter for suggesting this diagnosis. CONCLUSION: The small-caliber esophagus of IEE is characterized at barium esophagography by long-segment but variable-length narrowing of the thoracic esophagus, with a mean length of 15.4 cm, a diameter of 20 mm or less, smooth contours, and tapered margins.

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OBJECTIVE: The purposes of this study were to reassess the relation between a feline esophagus (transient transverse esophageal folds) and gastroesophageal reflux (GER) and to determine whether a feline esophagus is observed more often during swallowing or during reflux of barium. MATERIALS AND METHODS: A computerized search of double-contrast esophagrams was performed to generate four equal groups of 56 patients with marked, moderate, mild, and no GER. The imaging findings were reviewed to determine the frequency of a feline esophagus in these groups and whether this sign was detected during swallowing or reflux of barium. The presence of a feline esophagus also was correlated with the presence of a hiatal hernia, reflux esophagitis, a peptic stricture, and esophageal dysmotility. RESULTS: A feline esophagus was detected in 20 of 224 patients (9%). It was detected during reflux of barium in 17 patients (85%), swallowing of barium in two patients (10%), and both in one patient (5%). GER was present in all 20 patients with a feline esophagus and in 148 of the 204 patients (73%) without a feline esophagus (p = 0.0068). A significant relation also was found between a feline esophagus and the presence of a hiatal hernia (p = 0.0116) but not between a feline esophagus and the presence of reflux esophagitis, a peptic stricture, or esophageal dysmotility. CONCLUSION: All patients with a feline esophagus at barium esophagography had associated GER. These transverse folds were observed mainly during reflux of barium from the stomach rather than during swallowing of barium. When a feline esophagus is detected during barium studies, the patient is extremely likely to have GER whether or not GER is seen at fluoroscopy.

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Despite an array of sophisticated imaging techniques, the barium examination remains a valuable diagnostic test for evaluating structural abnormalities of the small bowel. Most patients can be examined with conventional small-bowel follow-through studies, in which periodic imaging of the entire small bowel is performed by using fluoroscopic guidance; however, some patients may benefit from enteroclysis, in which contrast agents are instilled into the small bowel via a catheter placed in the proximal jejunum for optimal distention and better depiction of individual small-bowel loops. This review for residents discusses the major diseases involving the mesenteric small bowel and presents a pattern approach for the wide spectrum of abnormalities found on barium studies, including polypoid lesions, cavitated lesions, annular lesions, outpouchings, separation of loops, abnormal folds, nodules without abnormal folds, and dilated small bowel.

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OBJECTIVE: The purpose of our study is to present a series of 14 patients with chronic diverticulitis on barium enema examinations and to correlate the radiographic findings with the clinical and pathologic findings in these patients. CONCLUSION: Chronic diverticulitis is a distinct pathologic entity characterized by the frequent development of chronic obstructive symptoms and abdominal pain rather than the classic clinical findings of acute sigmoid diverticulitis. Barium enema examinations usually reveal a relatively long segment of circumferential narrowing in the sigmoid colon with a spiculated contour and tapered margins, sometimes associated with retrograde obstruction. Our experience suggests that chronic diverticulitis can often be diagnosed on the basis of the characteristic clinical and radiographic findings in these patients.

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OBJECTIVE: The purpose of our study was to characterize the clinical and radiographic features of the hyperirritable stomach and to determine if it is associated with extraintestinal causes of nausea and vomiting in the absence of gastric outlet obstruction, gastroparesis, or intestinal obstruction or ileus. CONCLUSION: The hyperirritable stomach was characterized on barium studies in 15 patients by rapid emesis of ingested barium, a collapsed stomach with little or no retained debris or fluid, and normal emptying of residual barium into nondilated duodenum and proximal jejunum. Fourteen (93%) of these 15 patients had extraintestinal causes of nausea and vomiting, and 13 (93%) of 14 with clinical follow-up had marked improvement or resolution of symptoms after treatment. Radiologists therefore should evaluate the stomach and duodenum even after rapid emesis of ingested barium in patients with nausea and vomiting to differentiate a hyperirritable stomach from mechanical or functional gastrointestinal obstruction.

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OBJECTIVE: The purpose of this study was to assess the accuracy of retrograde ileostomy radiographic examination for detecting small-bowel abnormalities in patients with ileostomies. MATERIALS AND METHODS: Our database contained the records of 35 patients who had undergone retrograde ileostomy examinations from 1999-2005 and fulfilled our inclusion criteria. The images from the examinations were reviewed to determine the frequency and nature of small-bowel abnormalities, whether lateral views were obtained, and whether the catheter tip was withdrawn to the stoma. The accuracy of these examinations was determined by correlating clinical, radiographic, and surgical findings. RESULTS: Twenty-eight (80%) of the patients had small-bowel abnormalities: adhesions in 14 (40%), adynamic small-bowel ileus in four (11%), strictures in two (6%), Crohn's disease in two (6%), focal perforation in two (6%), fistulas (one enterocutaneous and one enterovaginal) in two (6%), metastasis in one (3%), and parastomal hernia in one (3%) of the patients. The other seven (20%) patients had normal findings. Abnormalities were detected on lateral but not frontal or oblique views in six (75%) of eight patients with distal ileal disease and in three (43%) of seven patients for whom views were obtained only after withdrawal of the catheter to the stoma. Retrograde ileostomy examination had a sensitivity of 96%, specificity of 86%, positive predictive value of 96%, and negative predictive value of 86%. CONCLUSION: Our experience suggested that retrograde ileostomy examination is an accurate technique for detecting symptomatic small-bowel abnormalities in patients with ileostomies, particularly in the distal-most portion of the ileum abutting the ileostomy stoma.

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Although a variety of diagnostic procedures are often performed on patients with pharyngeal or esophageal symptoms, barium esophagography is a noninvasive, inexpensive, and readily available test that can simultaneously evaluate swallowing function, esophageal motility, gastroesophageal reflux, and a host of structural abnormalities in the pharynx and esophagus. This article reviews the role of barium esophagography for assessing swallowing function, morphologic abnormalities of the pharynx (diverticula, webs, and carcinoma), esophageal motility disorders (achalasia and diffuse esophageal spasm), and morphologic abnormalities of the esophagus (reflux esophagitis, Barrett's esophagus, infectious esophagitis, drug-induced esophagitis, eosinophilic esophagitis, Schatzki's ring, and esophageal carcinoma).

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The double-contrast upper gastrointestinal series is a valuable diagnostic test for evaluating structural and functional abnormalities of the stomach. This article will review the normal radiographic anatomy of the stomach. The principles of analyzing double-contrast images will be discussed. A pattern approach for the diagnosis of gastric abnormalities will also be presented, focusing on abnormal mucosal patterns, depressed lesions, protruded lesions, thickened folds, and gastric narrowing.

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OBJECTIVE: The purpose of our investigation was to determine the frequency of secondary achalasia and other esophageal motility disorders revealed on barium studies after laparoscopic Nissen fundoplication and to present the clinical and radiographic findings in these patients. CONCLUSION: Esophageal dysmotility was found in nine (7%) of 138 patients after laparoscopic Nissen fundoplication, including secondary achalasia in three (33%), diffuse esophageal spasm (DES) in two (22%), and a nonspecific esophageal motility disorder in four (44%). Our findings suggest that patients who undergo laparoscopic Nissen fundoplication for gastroesophageal reflux disease are at risk for the development of esophageal motility disorders, including secondary achalasia and DES. Careful evaluation of esophageal motility on postoperative barium studies may help to identify esophageal dysmotility and to differentiate this finding from structural complications of the wrap as a cause of refractory symptoms in these patients.

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OBJECTIVE: The objectives of our study were to review our experience with a group of patients in whom contrast examinations after transhiatal esophagogastrectomy and gastric pull-through revealed intraluminal migration of a surgical drain and to describe the radiographic appearance and clinical relevance of this phenomenon. CONCLUSION: Our findings indicate that intraluminal migration of a surgical drain after transhiatal esophagogastrectomy is an infrequent but serious phenomenon that hinders or prevents healing of an anastomotic leak. Radiologists should be aware of this phenomenon and should be able to recognize the findings of an intraluminal drain on contrast examinations. When such drains are identified, we believe that they should be promptly withdrawn or removed to facilitate healing of anastomotic leaks.

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OBJECTIVE: The purpose of our study was to determine the utility of contrast enemas for detecting clinically relevant anastomotic strictures after total proctocolectomy and ileal pouch-anal anastomosis and to facilitate management by defining a critical anastomotic caliber at or below which obstruction is likely to develop after ileostomy closure. MATERIALS AND METHODS: Our radiology database revealed 42 patients with contrast enemas after total proctocolectomy and ileal pouch-anal anastomosis who fulfilled our exclusion criteria. The initial postoperative contrast enemas were reviewed blindly to determine the diameter of the ileoanal anastomosis. The diagnosis of a stricture was made only if the patient had signs of intestinal obstruction after ileostomy closure with confirmation on follow-up contrast enema or sigmoidoscopy and clinical improvement after anastomotic dilatation. The data were then correlated to determine if there was a critical anastomotic caliber at or below which such strictures were likely to develop. Using this threshold value, the sensitivity and specificity of routine contrast enemas for detecting clinically relevant anastomotic strictures were then determined. RESULTS: Six (14%) of the 42 patients who underwent total proctocolectomy and ileal pouch-anal anastomosis had strictures at the ileoanal anastomosis on contrast enemas. The mean diameter of the anastomosis was 5.8 mm in the six patients with anastomotic strictures versus 15 mm in the 36 patients without strictures (p = 0.0002). If an anastomotic diameter of 8 mm is defined as the critical caliber at or below which clinically relevant strictures are present, the sensitivity of contrast enemas for detecting strictures at the ileoanal anastomosis was 100% (six of six patients) and the specificity was 92% (33 of 36 patients). CONCLUSION: Routine contrast enema after total proctocolectomy and ileal pouch-anal anastomosis is a sensitive test for detecting clinically relevant strictures at the ileoanal anastomosis when an anastomotic diameter of 8 mm or less is used as the threshold value for diagnosing these strictures. Such patients may need dilatation procedures to decrease the risk of anastomotic obstruction after ileostomy closure.

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OBJECTIVE: The purpose of this study was to describe the clinical and radiographic findings in a series of patients with nonanastomotic strictures after colonic interposition. CONCLUSION: Nonanastomotic strictures usually appear on upper gastrointestinal tract radiography as relatively long segments of smooth, tapered narrowing involving the interposed colon, most likely resulting from chronic ischemia. Unlike strictures at the esophagocolic or cologastric anastomosis, these long nonanastomotic strictures generally have a poor response to endoscopic dilatation procedures and are more likely to necessitate surgical revision of the colonic interposition.

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OBJECTIVE: The purpose of this study was to compare the clinical and barium radiographic findings for 17 patients with large hiatal hernias and a floppy fundus with those for 61 patients with large hiatal hernias but no floppy fundus. CONCLUSIONS: Patients with large hiatal hernias can develop a floppy fundus, which has a characteristic appearance on barium studies because it droops below the most superior portion of the herniated gastric body. Distortion of the gastric anatomy in patients with this type of hernia can cause mechanical symptoms that usually resolve after surgical repair of the hernia. Radiologists should be aware of the barium radiographic findings associated with a floppy fundus and of the potential role of surgery in the treatment of patients with symptoms.

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OBJECTIVE: The purpose of this report is to assess the findings on esophagography in patients with esophageal stents for palliation of malignant tumors involving the esophagus. CONCLUSION: Radiologists should be familiar with findings of little importance (stent narrowing, flow of contrast medium around stent, stent kinks, and apparent esophageal narrowing below stent because of incompletely distended hiatal hernias) versus more important findings (polypoid defects above or below stent, narrowing within or below stent, delayed stent emptying, esophageal-airway fistulas, stent migration, and abutting of distal stent against greater curvature of stomach) on esophagography after stent placement to guide endoscopists regarding the need for stent revision.

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PURPOSE: To retrospectively determine the diagnostic yield of double-contrast barium enema examinations performed for colorectal cancer screening of neoplasms 1 cm or larger or advanced neoplastic lesions of any size in average-risk adults older than 50 years. MATERIALS AND METHODS: The Institutional Review Board at the affiliated Veterans Affairs Medical Center approved this HIPAA-compliant study protocol and did not require informed consent from patients. Computerized databases revealed 276 double-contrast barium enema examinations performed for colorectal cancer screening in average-risk adults older than 50 years. Radiographic and pathologic reports were reviewed to determine the number of patients who had polypoid lesions 1 cm or larger, polyps smaller than 1 cm, or advanced neoplastic lesions of any size. Forty-five (16.3%) of the 276 patients underwent follow-up sigmoidoscopy or colonoscopy. Medical, endoscopic, and pathologic records were reviewed and compared with radiographic findings. RESULTS: The results of double-contrast barium enema examination revealed 74 (26.8%) of 276 patients with 104 polypoid lesions in the colon, including 32 patients (11.6%) with 41 polypoid lesions 1 cm or larger, 15 patients (5.4%) with 19 polyps 6-9 mm, and 27 patients (9.8%) with 44 polyps 5 mm or smaller. Endoscopy was performed in 24 (75%) of 32 patients, the results of which confirmed 23 (72%) of 32 radiographically diagnosed lesions 1 cm or larger in 16 (67%) of 24 patients. In two of these individuals, the polyps were hyperplastic. The remaining 14 patients had a total of 21 neoplastic lesions 1 cm or larger, including 11 tubular adenomas, seven tubulovillous adenomas, one villous adenoma with marked dysplasia, and two cancers. The diagnostic yield of screening double-contrast barium enema examination was 5.1% (14 of 276 patients) for neoplastic lesions 1 cm or larger and 6.2% (17 of 276 patients) for advanced neoplastic lesions of any size. CONCLUSION: Double-contrast barium enema examinations performed in average-risk adults older than 50 years have a diagnostic yield of 5.1% for neoplastic lesions 1 cm or larger and 6.2% for advanced neoplastic lesions, regardless of size.

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Findings of anterior abdominal wall hernias at computed tomography and magnetic resonance imaging are well documented; however, little information is available about the depiction and characterization of such hernias in barium studies, primarily in small-bowel follow-through examinations. Such examinations are performed frequently, and radiologists should be familiar with the hernia features that may be observed. Anterior abdominal wall hernias are best recognized in profile on lateral spot images from a small-bowel follow-through study when one or more loops of bowel extend beyond the fascial planes of the anterior abdominal wall, with luminal narrowing at the entry or exit site of the hernia or at both sites. In some patients, the hernia also can be recognized indirectly on a frontal view because of the displacement and, often, extrinsic compression or deformity of herniated bowel loops. In such cases, additional views should be obtained with the patient in the lateral position to confirm the presence of the hernia with direct visualization of the herniated loops in profile. The reducibility of bowel from an anterior abdominal wall hernia also can be assessed with manual palpation of the abdominal wall while the patient is in the lateral position. Manual palpation performed during fluoroscopy helps determine whether the bowel loops can be returned to the proper location or are fixed in the hernia, an important observation because of the higher risk of obstruction or strangulation when the bowel is incarcerated. Fluoroscopy therefore is a useful technique for the detection and characterization of anterior abdominal wall hernias in barium studies.

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OBJECTIVE: To determine whether there is an association between abnormal primary peristalsis in the esophagus and gastroesophageal reflux (GER) on barium studies. METHODS: A computerized search of radiologic reports revealed 151 patients with esophageal dysmotility (characterized by intermittently decreased or absent peristalsis in the esophagus on upper gastrointestinal tract examinations) who fulfilled our study's entry criteria. These 151 patients were stratified into two groups depending on whether this dysmotility was associated with nonperistaltic contractions (NPCs): 92 patients had no NPCs (Dysmotility and No NPCs Group) and 59 had NPCs (Dysmotility and NPCs Group). An age-matched control group of 92 patients with normal motility was also generated from the radiologic reports. The reports were also reviewed for the presence and degree of GER and other complications of GER. The frequency and degree of GER were tabulated for each group, and the data were analyzed using a Pearson chi square test to determine if significant differences were present in the frequency and degree of GER or other findings among the groups. RESULTS: The frequency of GER was significantly higher in patients with abnormal peristalsis and no NPCs than in controls (p = 0.02). When GER was stratified based on the degree of reflux, the frequency of moderate-to-marked GER was significantly higher in patients with abnormal peristalsis and no NPCs than in patients with abnormal peristalsis and NPCs (p = 0.01) or in controls (p = 0.0031). The frequency of reflux esophagitis also was significantly higher in patients with abnormal peristalsis and no NPCs than in controls (p = 0.04). CONCLUSION: Our findings suggest that patients with esophageal dysmotility characterized by intermittently decreased or absent peristalsis without NPCs have a significantly higher frequency and degree of GER than patients with normal motility. The presence of this specific form of esophageal dysmotility on barium studies therefore should suggest underlying reflux disease.

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OBJECTIVE: Our objective was to determine the optimal radiographic projections for the detection of strictures at the gastrojejunal anastomosis after gastric bypass surgery. CONCLUSION: Steep oblique or lateral spot images routinely should be obtained during upper gastrointestinal radiographic studies after gastric bypass surgery to optimize detection of strictures at the gastrojejunal anastomosis.

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PURPOSE: To retrospectively assess the findings of idiopathic eosinophilic esophagitis (IEE) at barium studies and determine the frequency of the ringed esophagus in patients with this condition. MATERIALS AND METHODS: The institutional review board approved all aspects of this retrospective study and did not require informed consent from patients whose records were included in the study. The study was compliant with the Health Insurance Portability and Accountability Act. A review of the pathology and radiology databases at the authors' institution revealed 14 patients (11 men and three women; mean age, 41.3 years) with IEE (defined as more than 20 eosinophils per high-power field in biopsy specimens) who had undergone barium studies and endoscopy. The radiographs were reviewed for strictures, esophagitis, or other abnormalities. The endoscopic reports, clinical records, and laboratory data were also reviewed and compared with the radiographic findings. RESULTS: Seven of the 14 patients (50%) had a history of allergies, and two of nine patients with complete blood cell counts (22%) had peripheral eosinophilia. Thirteen patients (93%) had dysphagia, six (43%) had food impactions, and six (43%) had reflux symptoms. Ten patients (71%) had a total of 11 strictures at barium studies (two in the upper part of the esophagus, two in the middle part, three in the distal part, one in the middle and distal parts, and three at the gastroesophageal junction). The strictures had a mean length of 5.1 cm. In seven patients (50%), the strictures contained multiple fixed ringlike indentations that produced a ringed esophagus. The ringlike indentations appeared as multiple, fixed, closely spaced, concentric rings traversing the stricture. Four patients (28%) had esophagitis. Of 13 patients who underwent recumbent imaging, 10 (77%) had hiatal hernias and nine (69%) had reflux. Eight of the 10 patients (80%) with strictures underwent endoscopic dilation procedures, which resulted in only temporary relief of dysphagia. CONCLUSION: The findings suggest that most patients with IEE have esophageal strictures, often with distinctive ringlike indentations that produce a ringed esophagus.

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