Roentgenologic study of the lower esophagus and the esophagogastric junction.

Abstract

At times the detection of early organic lesions and physiological disturbances involving the lower end of the esophagus still offers some difficulty. Part of this difficulty lies in the lack of accurate knowledge of the anatomy and physiology of this region. The roentgenologist must await clarification from the anatomists and physiologists who, up to now, cannot fully agree as to the relative importance of the various structures participating in the closing mechanism at the esophagogastric junction. A great contribution, however, can be found in Lerche's book on The Esophagus and Pharynx in Action (1). This, coupled with a simple oil-contrast technic (2) which improves the visualization of the mucosal pattern of the lower esophagus, has made the present study possible. The use of mineral oil as a double-contrast medium for mucosal pattern visualization was first reported by Gianturco (3) in his studies on the stomach. In order to verify Lerche's concepts and to give the oil-contrast technic a more extensive trial as a screening process in detecting abnormalities of the lower esophageal region, a survey was initiated in the Department of Radiology at Bellevue Hospital Center. Five hundred unselected ward and outpatients were used. Technic: After fluoroscopy, and before the taking of conventional gastrointestinal films, the patient was given 2 heaping tea-spoonfuls of thick barium cream, followed immediately by 2 ounces of extra heavy mineral oil. In about one-third of the patients a polygraph (four exposures) of the lower esophagus was obtained before the conventional film study, and in the remaining two-thirds the polygraph was taken after the films. The polygraphs, obtained with the patient prone, with the xiphoid process on the center of the film, included two views in the posteroanterior position, in deep inspiration and expiration respectively, and two views in the right anterior oblique, also in deep inspiration and expiration (Fig. 1). The chief advantage of this technic is that a single administration of thick barium and mineral oil suffices for a prolonged examination of the esophagus. The polygraphs taken after the conventional films gave a better mucosal pattern than those taken before. The rate of retention of the medium, however, varies considerably and is probably an individual factor dependent on the amount of secretion present. Normal polygraphs were studied for anatomical and physiological variations. Positive cases were checked with the conventional films and the findings were compared. A clinical summary of the gastrointestinal symptoms and findings was obtained from the patient's chart and analyzed. The results appear later. Lerche has demonstrated the anatomical presence of an inferior esophageal sphincter and has described a gastroesophageal segment of expulsion, the component structures of which are diagrammatically shown in Figure 2. Our roentgenologic study seems to confirm his findings.