1. GI Barium Cases 1-25

2. Case directory 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

3. Case 1

4. Intramural pseudodiverticula
Case directory
Intramural pseudodiverticula
Case findings:
Multiple contrast-filled cavities, only 1 or 2 millimeter in diameter in the esophageal mucosa
Dilated excretory ducts of deep mucous glands in esophagus
Secondary to esophagitis: pseudodiverticula vanish when the esophagitis is treated (MC Candida)
Dilated submucosal glands and ducts, which are similar to Rokitansky-Aschoff sinuses of GB
DDX:
Moniliasis
Glycogen acanthosis

5. Case 2

6. Esophageal varices Etiology: portal venous hypertension Classification
Case directory
Esophageal varices
Etiology: portal venous hypertension
Classification
Uphill varices: mid to distal esophagus, portal hypertension
Downhill varices: upper or mid esophagus, SVC obstruction
DDX:
Varicoid carcinoma: superficial spreading carcinoma, with thickened nodular tortuous longitudinal folds
Has a rigid, fixed, nodular folds that do NOT change configuration (unlike varices)
Esophagitis with thickened esophageal folds
Lymphoma
Squamous cell carcinoma

7. Case 3

8. Pharyngeal pouch Case findings:
Contrast-filled cavity at the posterior wall of the esophagus
Arises between the superior and the middle pharyngeal constrictors (congenitally weak point of the pharyngeal wall)
Esophageal diverticula:
Pulsion diverticula: contain no muscle in their wall so they tend to stay filled with barium after the rest of the esophagus empties
Traction diverticula: contain muscle in their walls so they tend to empty with the rest of esophagus

9. Esophageal diverticulum
Pharyngo-esophageal (Zenker):
Herniation of mucosa and submucosa through oblique and transverse muscle bundles of the cricopharyngeal muscle (pseudodiverticulum)
Increased intraluminal pressures and tic formation in midline of Killian dehiscence at level of C5-C6
MC posterior
Traction diverticulum (interbronchial diverticulum):
Response to pull from fibrous adhesions following lymph node infection (MC TB)
MC right anterior esophageal wall
Distal (epiphrenic diverticulum):
Pulsion, associated with hiatal hernia
MC right
Related to long-standing peptic esophagitis and strictures

10. Esophageal diverticulum
Killian-Jamieson diverticulum:
Lateral to the insertion of the longitudinal tendon of the esophagus on the cricoid cartilage
Diverticula are in the mid esophagus can congenital or traction:
Traction types develop by traction from contiguous mediastinal inflammation and adenopathy such as from TB or histoplasmosis
Other causes of mid and lower diverticula:
Iatrogenic
Ehlers-Danlos syndrome
Motility disorders such as achalasia and esophageal spasm

11. Zenker’s diverticulum

12. Epiphrenic diverticulum
Large diverticulum (arrows) arising from the posterior wall of the distal esophagus

13. Traction diverticulum
Case directory
Traction diverticulum
Traction diverticulum identified by black arrow
MC located in the mid-esophagus
Result from scarring and retraction of the esophageal wall due to granulomatous disease in adjacent subcarinal or hilar lymph nodes
Presence of calcification in subcarinal (white arrows), hilar, or paratracheal lymph nodes  TB

14. Case 4

15. Paraesophageal hernia
Case findings:
Gastroesophageal junction in normal position
Parts of the stomach slip through the esophageal hiatus
Hiatal hernia:
Sliding: MC (80%), GEJ slides superior into the chest through the esophageal hiatus
Paraesophageal: GEJ remains in its normal position, but parts of the stomach and peritoneum slip through the esophageal hiatus

16. Paraesophageal hernia

17. Case directory
Sliding hiatal hernia

18. Case 5

19. Gastric carcinoma Case findings:
Filling defect in the gastric body
Location: MC pylorus > lesser curve, GEJ, greater curvature
Types:
Polypoid
Ulcerating
Infiltrating or schirrous: linitis plastica
DDX: metastatic breast carcinoma
Superficial spreading: confined to mucosa and submucosa
Predisposing factors:
H. pylori, adenomatous polyps, pernicious anemia, atrophic gastritis

20. DDX gastric mass Malignant: Benign: Others:
Carcinoma, lymphoma, leiomyosarcoma, metastases
Benign:
Leiomyoma, lipoma, neurofibroma
Polyps:
Hyperplastic
Adenomatous
Hamartomatous
Others:
Bezoar, Nissen fundoplication, ectopic pancreas

21. Gastric polyps Hyperplastic (MC)
Case directory
Gastric polyps
Hyperplastic (MC)
Adenomatous: increased risk of malignancy
Familial adenomatous polyposis (FAP)
Gardner’s syndrome
Turcot syndrome: associated with CNS tumors (e.g., gliomas)
Hamartomatous:
Peutz-Jeghers syndrome
Cowden syndrome
Inflammatory:
Cronkhite-Canada syndrome

22. Case 6

23. Duodenal diverticulum
Case findings:
Large duodenal diverticulum with some small diverticula at the top
MC located near the ampulla

24. Duodenal diverticulum

25. Intraluminal duodenal diverticulum (2 cases)
Case directory
Intraluminal duodenal diverticulum (2 cases)

26. Case 7

27. Celiac disease (sprue)
Case findings:
Proximal small bowel dilatation
Smudging and dilution of barium in LUQ
Moulage sign: produced by barium reaching such diluted, fluid-filled, hypotonic segments
Normal sized, but widely spaced, sparser folds in jejunum
Associated with transient intussusception
Risk of intestinal lymphoma
Features:
Small bowel dilatation
Moulage pattern: barium pooling
Flocculation: excessive mucus prevents an adequate coating of the mucosa by the barium (barium flocculates in the presence of mucus)
Jejunization of the ileum: increased number of folds in the ileum, with reversal of the normal jejuno-ileal fold pattern

28. Celiac disease (sprue)
Jejunization of the ileum

29. Celiac disease (sprue)
Flocculation

30. Celiac disease (sprue)
Case directory
Celiac disease (sprue)
Lymphoma arising in celiac disease as thick, slightly undulating folds (arrows) and smooth nodules (arrowheads)

31. Case 8

32. Crohn’s Case findings: Features:
Deep and superficial linear ulcerations and small bowel wall thickening near the terminal ileum
Fistula track
Features:
Deep and superficial linear ulcerations
Cobblestoning
Bowel wall thickening, strictures, skip lesions
Pseudopolyposis, fistula

33. Crohn’s
DDX:
Yersinia colitis: fold thickening (early finding), aphthoid ulcers, coarsened mucosal surface and inflammatory nodules (indistinguishable from early Crohn’s)
Deeper ulceration and marked luminal narrowing is unlikely
Heals to a lymphoid hyperplasia pattern, resolves completely
Ileitis: due to Shigella, Salmonella, Campylobacter
Self-limited and will not reach a stenotic stage
Tuberculosis: identical to Crohn’s

34. Crohn’s
Cobblestoning: deep and superficial linear ulcerations in descending colon

35. Crohn’s
Numerous barium-filled linear clefts are seen as straight, longitudinal and transaxial lines (arrows)
Cobblestones: between the fissures are residual islands of less inflamed mucosa

36. Crohn’s
Confined to the mucosa and submucosa with thickened and curved folds
Long mesenteric border ulcer is seen as a thin barium-filled line (arrows)

37. Case directory
Crohn’s
Area of ulceration merging with marked narrowing (arrowhead) of the terminal ileum
Small ulcers are also seen in the ascending colon (arrow)

38. Case 9

39. Ulcerative colitis Case findings:
Case directory
Ulcerative colitis
Case findings:
Loss of haustra and mucosal distortion

40. Case 10

41. Diverticulitis Case findings:
Irregular bowel wall thickening, with narrowing of the sigmoid lumen
Mucosal pattern preserved (implies a benign process)

42. Case directory
Diverticulitis

43. Case 11

44. Moniliasis Case findings: DDX:
Diffuse nodular and plaque like mucosal defects
Plaque like defects are longitudinally oriented
Sharply defined plaques
DDX:
Glycogen acanthosis
Reflux esophagitis: ill-defined plaques

45. Case directory
Moniliasis
With progression, esophagus may have a grossly irregular or shaggy contour (shaggy esophagus)
Shaggy contour due to multiple plaques, pseudomembranes, and ulcers

46. Case 12

47. Herpes esophagitis
Multiple small discrete superficial ulcerations: appears as a small barium collection with a surrounding halo of lucency due to edema
No fold thickening, normal esophageal contour
Ulcers may be clustered, MC in mid-esophagus (relative sparing of distal esophagus)

48. Herpes esophagitis

49. Herpes esophagitis
Discrete ulcers surrounded by radiolucent halos of edematous mucosa
Normal intervening mucosa

50. Case directory
Herpes esophagitis

51. Case 13

52. Glycogen acanthosis Degenerative condition, MC seen in elderly
Case directory
Glycogen acanthosis
Degenerative condition, MC seen in elderly
Asymptomatic
No risk of malignant degeneration
Features: multiple small, rounded nodules or plaques in the mid or distal esophagus
DDX:
Candida esophagitis (moniliasis): well-defined plaques
Reflux esophagitis: nodular mucosa (ill-defined plaques)

53. Case 14

54. Barrett’s esophagus Case findings:
Reticular pattern is distal esophagus, adjacent to a stricture in the mid esophagus
Adenocarcinoma arising in Barrett’s esophagus may appear as a flat slightly elevated nodular lesion or as a sessile polyp

55. Case directory
Barrett’s esophagus
Plaque-like tumor: area of nodular mucosa in distal esophagus (arrows) above a hiatal hernia
Edge of plaque-like lesion is seen en face as a white line (arrowhead)

56. Case 15

57. CMV esophagitis Case findings:
Case directory
CMV esophagitis
Case findings:
Giant flat ulcer (> 3 cm) on the posterior wall of the distal esophagus with a thin, radiolucent rim of edema
May also present with multiple small ulcers indistinguishable from Herpes esophagitis
DDX giant flat ulcer:
HIV esophagitis
CMV esophagitis

58. Case 16

59. Esophageal leiomyoma Case findings: DDX submucosal lesion:
Case directory
Esophageal leiomyoma
Case findings:
Upper and lower borders of the lesion form slightly obtuse angles (in profile) with the adjacent esophageal wall (submucosal lesion)
DDX submucosal lesion:
MC leiomyoma
LC fibroma, neurofibroma, lipoma, hemangioma, granular cell tumor, squamous papilloma
DDX multiple submucosal lesion:
Granular cell tumor
Neurofibromatosis
Lymphoma

60. Case 17

61. Esophageal carcinoma Case findings: MC squamous cell Types:
Iinfiltrating esophageal cancers cause irregular narrowing and obstruction of the lumen with nodularity and/or ulceration of the mucosa
MC squamous cell
Types:
Infiltrating
Polypoid
Ulcerative
Varicoid: superficial spreading

62. Esophageal carcinoma
Polypoid: lobulated or fungating intraluminal masses, often containing areas of ulceration
Polypoid edge of the tumor is etched in white by barium
Central ulcer protrudes from the expected luminal contour

63. Esophageal carcinoma
Advanced infiltrating carcinoma of the mid-esophagus

64. Varicoid esophageal carcinoma
Case directory
Varicoid esophageal carcinoma
Focal nodularity in the mid-esophagus due to tiny, coalescent nodules and plaques
DDX:
Moniliasis: localized plaque formation, the plaques tend to have discrete, well-defined borders with normal intervening mucosa

65. Case 18

66. Achalasia Case findings: Primary achalasia:
Dilated, aperistaltic esophagus that tapers abruptly to a narrowed, fixed lumen
Tapering is concentric and the lumen contour is absolutely smooth
Primary achalasia:
Result of degeneration of the myenteric plexus innervating the lower esophageal sphincter
Failure of relaxation and lack of coordinating peristalsis (aperistalsis)
Secondary achalasia (pseudoachalasia):
Most carcinomas that cause achalasia are adenocarcinoma arising either in the stomach or in distal esophagus in a Barrett's esophagus
Chagas' disease (trypanosomiasis)

67. Achalasia (secondary)
Case directory
Achalasia (secondary)
Secondary achalasia due to metastasis to GEJ from adenocarcinoma of the mid esophagus
Smooth, tapered narrowing (black arrow) of the distal esophagus just above GEJ
Ulcerated mass (white arrows) in mid esophagus

68. Case 19

69. Annular pancreas Case findings:
Case directory
Annular pancreas
Case findings:
Circumferential narrowing of the 2nd portion of duodenum
Mucosal pattern is preserved

70. Case 20

71. Erosive gastritis Case findings:
Multiple erosions present in the antrum of the stomach, seen as small barium-filled ulcer craters with a radiolucent halo (edema) around them
Incomplete linear and serpiginous erosions in the distal stomach (erosive gastritis)
Etiology:
NSAID, H. Pylori, alcohol, Crohn’s

72. Atrophic gastritis Associated with gastric atrophy
Case directory
Atrophic gastritis
Associated with gastric atrophy
Atony is common in elderly
Stomach has a tubular appearance
Lack of normal gastric mucosal folds
Areae gastricae may be smaller and irregular in the gastric fundus and body
Case findings:
Smooth, non-distensible antrum
No peristalsis seen on fluoroscopy

73. Case 21

74. Benign gastric ulcer
Large ulcer crater (arrowhead) on greater curvature
Multiple folds (arrows) radiating to the edge of ulcer crater
Folds taper gradually to the edge of the crater
Crater itself extends beyond the outlines of the gastric lumen

75. Benign gastric ulcer
Supine position: fundus posterior and contains barium
Large ring shadow (arrow) etched-in-white appearance in the gastric antrum (anterior non-dependent wall)

76. Benign gastric ulcer Prone position
Large collection of barium (arrow) in the same area of the gastric antrum (anterior dependent portion)

77. Benign gastric ulcer Case directory
Ulcer crater protrudes beyond the contour of the stomach
Ulcer is central in the mound (of inflammation and edema) that is smooth and symmetrical
Hampton's line: mucosa is more resistant to ulceration than the fat in the lamina propria and submucosa
Ulcer often spreads laterally in the soft submucosal fat, undermining the mucosa
Undermined mucosa is seen when a gastric ulcer is demonstrated in profile (seen as a thin Hampton's line crossing the ulcer crater)
Folds radiating towards the ulcer crater are smooth and taper towards the crater's edge
No masses associated with the ulcer
Mucosa surrounding the ulcer is not nodular

78. Case 22

79. Ectopic gastric mucosa
Case directory
Ectopic gastric mucosa
Case findings:
Multiple 1-3 mm, polygonally-shaped radiolucent filling defects in the duodenal cap

80. Case 23

81. Crohn’s of the duodenum
Case directory
Crohn’s of the duodenum
Large polygonal nodules covering the mucosal surface of the duodenal cap
2nd part of the duodenum shows mucosal irregularity
Focal eccentric narrowing of the lumen (arrowheads)
Two aphthoid ulcers (arrows) in the proximal 2nd part of the duodenum

82. Case 24

83. Gastric volvulus Mesenteroaxial (this case): Organoaxial:
Stomach has rotated about the gastrohepatic ligament (lesser omentum)
Organoaxial:
Stomach flips superiorly parallel to the longitudinal axis of the organ
Greater curvature lies superior to the lesser curvature

84. Oganoaxial gastric volvulus

85. Case directory
Gastric volvulus
Organoaxial volvulus of the stomach

86. Case 25

87. Case directory
Erosive duodenitis
Multiple aphthoid-like small ulcers in the duodenal cap  tiny barium collections surrounded by radiolucent halos of edema
Erosions are seen both en face (arrows) and in profile (arrowhead)