Pooling Of Barium Research Articles

Successful management of megaoesophagus associated with hypothyroidism in a dog: A case report

A seven-year-old male Dachshund was presented with a history of chronic regurgitation and weight loss for two months. On clinical examination, dry and rough hair coat with alopecia on nose bridge and rat tail appearance were observed. Elevated rectal temperature and increased respiratory rate were noticed. Auscultation of lung field revealed mild crackles. Leucocytosis and mild anaemia were evident on complete blood count. Hypercholesterolaemia, hypertriglyceridaemia and elevation of Lactate dehydrogenase (LDH) and Alkaline phosphatase (ALP) were observed in serum biochemistry. The total T4 (TT4) value was low and canine-specific thyroid stimulating hormone (cTSH) was elevated. Megaoesophagus was confirmed by plain radiography. Barium contrast radiograph revealed generalised dilatation with pooling of barium in the oesophagus. The animal was treated with levothyroxine sodium at 0.02 mg/kg BW PO BID and bethanechol at 10 mg PO TID. Supportive therapy included antibiotics, antacids and antiemetics. Elevated feeding was advised. The animal had no episodes of regurgitation even after one month Keywords: Megaoesophagus, hypothyroidism, bethanechol, elevated feeding

S2004 A Hard Pill to Swallow: Oropharyngeal Dysphagia Secondary to Antipsychotics

INTRODUCTION: Dysphagia can be anatomically categorized as either oropharyngeal or esophageal based on where and when the patient endorses difficulty swallowing and oropharyngeal dysphagia secondary to antipsychotic medications is often overlooked. Antipsychotics, especially the first generation, have been classically associated with extrapyramidal symptoms such as dystonia, akathisia, tremors and tardive dyskinesia. Dysphagia is an uncommon side effect of antipsychotics which can lead to choking, asphyxiation, or even aspiration pneumonia. Antipsychotic medications block the D2 receptors in the nigrostriatal pathway which are also hypothesized to regulate motor neurons responsible for complex muscle movements such as swallowing. Here, we present a case of severe dysphagia leading to failure to thrive in an adult after initiation of a first-generation antipsychotic. CASE DESCRIPTION/METHODS: A 69-year-old male with a history of schizoaffective disorder who presented with a one-month history of difficulty swallowing. Three days before this symptom, he was started on Haloperidol for his schizoaffective disorder. He complained of difficulty in initiating a swallow, pointing towards his neck region, which was soon followed by coughing and choking with both solid and liquid food. He stopped eating and drinking due to the overwhelming fear of choking leading to significant weight loss and cachexia. His physical examination was significant for temporal wasting, bradykinesia, cogwheel rigidity and diffuse hyperreflexia. Labs were unremarkable. A barium swallow revealed a difficulty in initiation of swallow, aspiration of thin barium with no spontaneous cough and poor pharyngeal constriction. CT soft tissue/neck revealed no evidence of extrinsic compression and MRI brain was done to rule out a stroke. An upper endoscopy was not performed as the barium swallow provided sufficient information to clinch the diagnosis. The patient’s antipsychotics were discontinued, and his nutritional status had to be optimized with NG tube feedings. After two weeks, the patient was transitioned to a liquid diet and discharged from the hospital. DISCUSSION: Antipsychotic-related oropharyngeal dysphagia is an uncommon side effect; however, it has been reported in case reports. It is important to identify this side effect, especially in elderly patients or patients with pre-existing anatomical or functional changes as it can lead to complications such as asphyxiation and aspiration pneumonia contributing to mortality.Figure 1.: Barium swallow study showing heavy pooling of barium in vallecula and pyriform sinuses.Figure 2.: Barium swallow revealing poor pharyngeal constriction leading to aspiration of thin barium without coughing.

Pooling of barium at mucosotomy site after peroral endoscopic myotomy on Barium Swallow Study

Peroral endoscopic myotomy (POEM) is a minimally invasive, incisionless alternative to Heller myotomy for treatment of Achalasia. It is still an evolving procedure done only at expert centers. We report an interesting post-procedure radiological finding that might be helpful in managing patients undergoing this procedure. A 24-year-old woman with advanced Achalasia underwent POEM performed in the standard method after which she was kept nil per oral on intravenous antibiotics. Barium swallow study done on the next day showed free passage of barium into stomach with no leak but there was pooling of a small amount of barium in the submucosal space at the upper end of the mucosotomy site without passage down the tunnel into the mediastinum. X-ray showed intact endoscopic clips at the mucosotomy site. Patient was afebrile and only had the expected post-procedure mild chest discomfort. She was continued nil per oral for an additional day and Barium swallow study was repeated which did not show any further pooling of barium at the mucosotomy site and the barium had passed freely into the stomach without a leak. Pooling of a small amount of barium at the mucosotomy site was likely due to the passage of barium into the submucosal space between the clips as they might not have created watertight closure of mucosotomy. This finding is usually of no clinical consequence if barium does not leak out through the tunnel into the mediastinum. Starting myotomy at least 2–3 cm distal to mucosotomy site such that the submucosal space closes off by mucosal flap above the myotomy site and meticulous, watertight closure of mucosotomy site may prevent such occurrence.

Pooling of Barium at Mucosotomy Site After Peroral Endoscopic Myotomy For Achalasia

Introduction: A 24-year-old woman with achalasia underwent Peroral endoscopic myotomy (POEM). POEM was performed in standard steps including vertical mucosotomy on the anterior wall in the mid esophagus, creation of submucosal tunnel by submucosal dissection, selective myotomy of circular muscle starting 3cm distal to mucosotomy site extending 4cm into the cardia and closure of mucosotomy using endoscopic clips. The mucosotomy was about 2 cm long and 8 endoscopic clips (Wilson Cook, NC, USA) were used to close the mucosotomy site. Patient was kept nil per oral along with intravenous antibiotics and a barium swallow study was performed next day. It showed free passage of barium into stomach without a leak, however, there was pooling of small amount of barium in the submucosal space at upper end of the mucosotomy site adjacent to endoclips, without passage down the tunnel (figure 1). Patient was afebrile with normal white count except for mild chest discomfort as expected post-procedure. Patient was continued nil per oral for an additional day and a barium swallow study was repeated. It did not show any further pooling of barium at the mucosotomy site and it passed freely into the stomach without a leak (figure 2). Clear liquid diet was started and she was discharged home. Pooling of small amount of barium at the mucosotomy site was likely due to passage of barium into submucosal space between the clips as they might not have caused water tight closure of mucosotomy. However, this finding is usually of no clinical consequence especially if barium does not leak out through the tunnel into the mediastinum. Meticulous and water tight closure of mucosotomy site might have prevented this. It is also important to start myotomy at least 2-3 centimeters distal to mucosotomy site such that the submucosal space closes off above the myotomy site and acts as a safety cushion.Figure 1Figure 2

A Case of Cascade Stomach

Purpose: We present a 47-year-old female with history of Grave's disease, history of longstanding dysphagia in the setting upper esophageal Killian Jaimeson diverticulum that later underwent open neck surgical procedure (diverticulopexy), who developed new persistent symptoms of severe dysphagia. Upon further investigation of dysphagia, via upper gastrointestinal series, patient was incidentally found to have findings consistent with cascade stomach. Upper gastrointestinal series under fluoroscopy showed aerophagia with significant swallowed air in the esophagus, stomach, and duodenum, with slight delay in barium transit but no obstruction or stricture. The stomach was found to be rotated in its long axis with initial pooling of barium in the retroflexed gastric fundus followed by slight delayed emptying in to the body. Findings were consistent with cascade stomach. Cascade stomach is diagnosed from the characteristic appearance of the stomach on barium studies. The cascade stomach consists of a biloculation of the gastric cavity into a ventral and dorsal recess and is a rare cause of upper abdominal symptoms. The causes of gastric cascade described in the literature are manifold, some of which include reflux symptoms, dyspepsia symptoms, or epigastralgia symptoms. This disorder is often difficult to diagnose or is not recognized, therefore, its true incidence is currently not known. We summarize and highlight a case of cascade stomach incidentally found in a patient who was being evaluated for dysphagia.Figure

Mechanical Advancement of an Esophageal Bezoar Following Prolonged Nasogastric Tube Feeding

Purpose: Enteral feeding via nasogastric tube (NGT) is a common practice, however, bezoar formation from this source has only been reported a handful of times in the literature. The cases previously reported were commonly associated with anatomic abnormalities, neurologic disorders, or motility disorders. We report a case of esophageal bezoar (EB) from long standing NGT feeding. Methods: A 45 year old with only a known history of COPD was brought to our hospital for management of respiratory distress requiring intubation and ventilation. The patient required prolonged NGT feeding for approximately 8 weeks. The NGT became malpositioned and the tip was found to be located in the fundus of the stomach and could not be repositioned. A barium swallow demonstrated pooling of barium at the epiglottis. Results: At endoscopy, a large cast of semi-solid white material was encountered just distal to the upper esophageal sphinchter and extended down to the gastroesophageal junction, otherwise the remainder of the examination was normal to the duodenum. The EB was successfully advanced into the empty stomach with pressure from the endoscope. Recommendations were made to provide gastric lavage with bicarbonate and to begin treatment with pancreatic enzyme. Unfortunately, the patient died several days later from unrelated reasons and before a repeat EGD could be performed. Conclusion: NGT feeding should be limited to a short course. Supine positioning during NGT feeding should be avoided. EB are a rare cause of abormal barium imaging. As casein containing feeds are capable of forming concretions at a low pH, acid suppression medications should be considered in long term NGT feeds.Figure: Bezoar in the esophagusFigure: Bezoar advanced to the stomach

The usefulness of the water swallowing test and videofluorography in swallowing rehabilitation in patients with cerebrovascular disease

It has been suggested that videofluorography (VF) is useful in the diagnosis of aspiration. The aim of this study was to investigate the usefulness of the water swallowing test and VF in swallowing rehabilitation in patients with cerebrovascular disease. Fifteen patients (mean age 72.9 +/- 2.3 years) were examined. The swallowing abnormality was assessed by the water swallowing test and VF. Patients with abnormal swallowing function on the water swallowing test (Group A, n = 4) showed aspiration and silent aspiration into the trachea on VF. However, patients suspected of dysphagia on the water swallowing test (Group B, n = 11) could swallow, demonstrating the disappearance of silent aspiration, with pooling of barium in the piriform sinus on VF. All patients in Group A could not ingest any food by mouth and received percutaneous endoscopic gastrostomy or intermittent oro-esophageal tube feeding. The swallowing function in Group B improved after swallowing rehabilitation. All patients in Group B could ingest food by mouth. These findings suggest that the water swallowing test is useful for quantitative assessment of swallowing disorder and for deciding on therapy of swallowing function.

Double-contrast barium enema examination technique.

This review article presents the principles for performing a safe, comfortable, and accurate double-contrast barium enema examination. The procedure is a flexible examination in which the fluoroscopist interacts with the patient, the controls of the fluoroscope, and the image on the television monitor. During a double-contrast examination, images of the colon are created by manipulating the patient, the barium pool, and the amount of air insufflated into the rectum. Fluoroscopy is essential for guiding the radiologist to obtain spot images with adequate technical factors. The fluoroscopist analyzes the luminal contour, the barium-coated mucosal surface en face, and the barium pool to detect abnormalities in the colon. With careful technique, a high-quality examination can be performed in most patients.

TWO CASES OF PRIMARY SMALL BOWEL CANCER SHOWING EXTRALUMINAL GROWTH

Two cases of primary small bowel cancer showing extraluminal growth are repoted. Case 1 was a 61-year-old woman, who presented with abdominal pain. X-ray examination of the small bowel showed a diverticular like pooling of contrast material in the jejunum. CT showed air within the tumor. Angiography revealed encasement of the jejunal artry. Case 2 was a 72-year-old man, who presented with general fatigue. X-ray examination of the small bowel showed irregular pooling of barium with ileal stenosis. The CT and angiographic findings were similar to those in case 1. Surgical treatment consisted of resection of the tumor with the invaded adjacent organs in both cases. Histologically, both tumors showed moderately-differentiated adenocarcinoma. Carcinoma with extraluminal growth should be kept in mind when an extraluminally-growing malignant tumor of the small bowel is differentially diagnosed.

Colonoscopically detected colorectal cancer missed on barium enema

The radiographs and clinical records of 26 patients with colorectal cancer missed on barium enema, and subsequently detected at colonoscopy, were reviewed to determine the cause of radiological error. Twenty (77%) of the patients were female. In 24 of 26 patients, anemia and/or rectal bleeding was a presenting feature. Fourteen of the 26 (54%) missed cancers were in the sigmoid colon, 10 (38%) in the ascending colon or hepatic flexure, and two (8%) in the rectum. Tumor size ranged from 20-100 mm. Fifteen were polyps, and 11 annular cancers. Fourteen (54%) were Dukes C or D tumors. Twenty-eight barium enemas in 23 patients were available for review: 86% were double-contrast studies. In 18 (76%), the cancer could be seen in retrospect and, in over half, the tumor was obvious. The dominant perceptive error was due to missing the lesion in the barium pool. Other major errors were missing the lesion en face or in overlapping loops. As most cancers were missed because of observer perceptive error, by both experienced and inexperienced radiologists, the authors recommend double reporting of all barium enemas.

Tetanus: An Uncommon Cause of Dysphagia

A 53-year-old woman was examined at our medical center because of progressive dysphagia of 14 days' duration and a severe inability to open her mouth and swallow saliva. A barium esophagogram showed no obstruction, but pooling of barium in the hypopharynx suggested a neuromuscular disorder. The clinical diagnosis of tetanus was confirmed by electromyography. With appropriate therapy, the patient recovered during a period of 6 weeks. This case illustrates both an uncommon cause of dysphagia and an uncommon initial manifestation of tetanus.

Radiologic recognition of colonic diverticula simulating polyps.

The differentiation of colonic polyps and diverticula on the double-contrast barium enema is generally straightforward, using current diagnostic criteria. However, diverticula may be misinterpreted on the double-contrast barium enema as polyps when they appear uncommonly as filling defects within the barium pool. As a result of such erroneous interpretation, the patient may subsequently undergo costly and inconvenient repeat barium enema or colonoscopy. Carefully studied scout films, oblique views, compression spot images, and postevacuation films generally can differentiate these diverticula from polyps. The usual reason that a diverticulum assumes the appearance of a polyp is that it contains impacted stool.

Colorectal carcinoma missed on double contrast barium enema study: a problem in perception.

A total of 31 cases of primary colorectal carcinoma missed on double contrast barium enema studies over a 5 year period (1976-1980) were collected from six institutions, and the causes of error reviewed. The errors were purely perceptive in 52%, due to a combination of perceptive and technical factors in 32%, and interpretative in 6%. The most common perceptive mistakes were failure to recognize a filling defect in the barium pool and failure to detect the tumor en face in double contrast study. Five cases were only detected at the time of the study as a result of double reading. Ten percent of the lesions could not be seen in retrospect, and therefore can be attributed to failure of the technique itself. At four of the institutions, the double contrast barium enema study missed 11 (6%) of 197 primary colorectal carcinomas. The lesion was invisible in retrospect in only two (1%) of these 197 studies, indicating that the double contrast examination is potentially highly sensitive for detecting colorectal carcinoma. The mainly perceptive nature of the errors indicates the need for more careful viewing of double contrast barium enemas. Familiarity with the different appearances of colorectal carcinoma on double contrast study, together with double-reading by the same or different observers, should reduce the incidence of missed lesions.

DOUBLE CONTRAST GASTROGRAPHY IN THE NORMAL DOG

Double contrast gastrography affords more accurate detection of gastric lesions because it allows direct evaluation of mucosal pattern contours. The technic involves the induction of gastric hypomotility with intravenous glucagon, gastric intubation for the introduction of air and high‐density barium directly into the stomach, and positional manipulation for maximal air‐barium interface demonstration. Some dogs require sedation. Although fluoroscopic observation is an asset in isolating gastric anatomic abnormalities, this study may be performed using conventional radiographic equipment without fluoroscopic guidance. Double contrast gastrography is used to demonstrate the stomach mucosal surface by coating it with high‐density barium and having the mucosa contrast with the air‐filled gastric lumen. There are three elements to each double contrast image: the dependent surface, the nondependent surface, and the barium pool. The barium pool is manipulated to coat the mucosal surface and fill depressions of the dependent surface. Protrusions of the dependent surface appear as radiolucencies in the barium pool. Depressions and protrusions of the nondependent surface are outlined by barium. Double contrast gastrography is indicated in dogs where clinical signs suggest anatomic changes in the gastric mucosal surface, e.g., neoplasms, ulcers, or polyps. Concurrent gastrointestinal motility evaluation is precluded by sedation and the glucagon‐induced gastric hypomotility.

Radiologic Diagnosis of Aspiration

Aspiration is frequently encountered in clinical medicine. In order to properly appreciate it, an adequate radiographic visualization of the pharynx during the second stage of swallowing is required. This is demonstrated best on the lateral view. In some cases, however, routine conventional procedures are often found inadequate because of the rapid sequence of events in the region during deglutition. For this reason, it may be helpful to use cinefluorographic analysis in obtaining a detailed information of the mechanisms involved in this phenomenon.This phenomenon results from multiple causes, but it is possible to classify them into two main groups, local structural lesions and neurogenic diseases. In these lesions, which block mechanically the adequate closure of the laryngeal aperture or inhibit functionally the normal closing actions of the aspiration barrier, some of barium are aspirated. Aspiration may also occur if there is prolonged stasis and pooling of barium in the pharynx, because barium may overflow the aditus.It should be pointed out that this phenomenon is frequently accompanied with other radiographic abnormalities. They consist of: (1) hesitancy in initiating a swallow; (2) asymmetrical deglutition; (3) pharyngeal laxity; (4) pharyngeal stasis; (5) return of barium from the oropharynx to the oral cavity; (6) nasal regurgitation; (7) abnormalities of the upper esophageal sphincter relaxation. When this sign is found along with these functional disorders of deglutition, and if neurogenic disorders can be excluded, development of local structural lesions involving the pharynx, larynx and cervical esophagus is strongly suspected.

Dystrophia myotonica--a radiological survey.

Nineteen cases of dystrophia myotonica have been surveyed radiologically. The post-mortem findings in one case and in the infant child of another are presented. Abnormalities were found in the gastro-intestinal tract of 13 out of 18 cases investigated. The commonest changes were in the oesophagus, which showed poor peristalsis and well-marked dilatation, with pooling of barium in the pharynx. Two cases had a barium enema examination. In one of these the colon was atonic with a deficient haustral pattern throughout the bowel. Basal atelectasis with elevation of the diaphragm was present in nine cases. The skull radiographs of 11 patients showed some or all the following features: hyperostosis; thick posterior clinoid processes; ossification of the diaphragma sella; poor mandibular angle; large frontal sinuses.

Case records of the Massachusetts General Hospital. Case 50-1961.

Presentation of Case A sixty-year-old woman entered the hospital because of epigastric pain. Four months previously she experienced the onset of constant, aching epigastric pain that was associated with heartburn and eructation and relieved by food or alkali. There were no tarry stools, nausea or vomiting. Seven weeks before entry a stool specimen gave a ++++ guaiac test, and the hemoglobin was 9.5 gm. per 100 ml. An upper gastrointestinal series at that time demonstrated moderate deformity of the duodenal cap and convergence of the mucosal folds, with a small pooling of barium. With a bland diet and antacids she . . .