David W. Gelfand

Modified barium swallow: clinical and radiographic correlation and relation to feeding recommendations

Clinical and videofluoroscopic evaluation of swallowing were correlated to determine their agreement and relationship to feeding recommendations. We reviewed a total of 148 patients with swallowing difficulties, of which 93 (45 women, 48 men; mean age 62 years) were evaluated by both clinical and radiographic examinations. A variety of materials were used for clinical bedside evaluation of oral and pharyngeal function. Radiographic examination was done with variable viscosity materials and videotape recording of the oral cavity and pharynx. The severity of oral and pharyngeal abnormalities was graded and findings of the examinations were compared. The combined results of both evaluations generated an index of swallowing difficulty which was correlated to the type of diet used if oral feeding was recommended or to a nonoral route of nutrition. In the assessment of oral and pharyngeal dysfunction, clinical evaluation and radiographic examination correlated closely in 94% of patients; however, the status of pharyngeal function was not determined in 61 (66%) of the 93 patients by clinical examination alone. The combined swallowing index was calculated in 89 patients and its severity correlated significantly with the type of feeding recommended; 64 patients were placed on one of three types of diets and 25 had enteral feedings. In conclusion, combined clinical and radiographic examinations correlated well, but clinical evaluation alone was limited by failure to evaluate the pharynx in many patients. The swallowing severity correlated well with final feeding recommendations.

Reflux Esophagitis: Radiographic and Endoscopic Correlation

Although the value of endoscopy in reflux esophagitis is accepted, the role of radiology has not been well defined. The radiographic and endoscopic findings in 75 patients were correlated. A grading system was employed to stage the severity of involvement. Thirty-five appeared normal on endoscopy and 40 had esophagitis of differing stages of severity. The results indicate that radiography is insensitive in mild degrees of inflammation but that its sensitivity and accuracy improves in more severe grades of esophagitis.

Predictive relationship of hiatal hernia to reflux esophagitis

The relationship between hiatal hernia and reflux esophagitis was compared in 93 patients who underwent both radiographic and endoscopic examination of the esophagus. In 46 patients with a normal esophagus shown endoscopically, hiatal hernia was present in 59%, while 94% of 47 patients with reflux esophagitis had hiatal hernia. The positive and negative predictive values for hiatal hernia in diagnosing or excluding esophagitis were 62% and 86%, respectively. Extrapolation of these data and review of the literature suggest that much of the confusion concerning the relationship between hiatal hernia and reflux esophagitis is based on reports of populations with considerable variation in the prevalence of esophagitis and in which the radiographie criteria for diagnosing hiatal hernia have not been uniformly applied.

Multiphasic examination of the esophagogastric region for strictures, rings, and hiatal hernia: evaluation of the individual techniques

Three hundred multiphasic examinations of the lower esophagus and esophagogastric region were assessed to determine the individual sensitivities of the full-column, mucosal relief, and double contrast techniques in the detection of common structural abnormalities, such as hiatal hernia, lower esophageal rings, and peptic strictures. In 159 patients, there were 211 structural abnormalities including 153 hiatal hernias, 35 mucosal rings, 20 peptic strictures, and 3 esophageal diverticula. The overall sensitivity of the full-column technique in detecting these abnormalities was 100% compared to 52% and 34% for the mucosal relief and double-contrast techniques, respectively. We conclude that the prone full-column technique must be incorporated into any examination of the esophagogastric region if these common abnormalities are to be demonstrated reliably.

Reflux esophagitis revisited: Prospective analysis of radiologic accuracy

A prospective radiologic-endoscopic study of the esophagogastric region in 266 patients, including 206 normals and 60 with esophagitis, is reported. The endoscopic classification grading severity of esophagitis was grade 1 — normal; grades 2, 3, and 4 — mild, moderate, and severe esophagitis, respectively. Radiology detected 22% of patients with mild esophagitis, 83% with moderate esophagitis, and 95% with severe esophagitis. Although hiatal hernia was present in 40% of normals and 89% with esophagitis, absence of radiographic hiatal hernia excluded esophagitis with 95% accuracy. The implications of this study regarding the role of radiology in evaluating patients with suspected reflux esophagitis are discussed.

Complications of gastrointestinal radiologic procedures: I. Complications of routine fluoroscopic studies.

B a r i u m s tudies o f t he g a s t r o i n t e s t i n a l t r ac t a re the c o n t r a s t e x a m i n a t i o n s m o s t f r e q u e n t l y p e r f o r m e d by rad io log i s t s . T h e ine r t n a t u r e o f b a r i u m sul fa te a n d its e m p l o y m e n t as a s u s p e n s i o n o f i n s o l u b l e par t i cles a lso m a k e the r o u t i n e e x a m i n a t i o n o f t he gast r o i n t e s t i n a l t r a c t t he safest o f r a d i o l o g i c c o n t r a s t exa m i n a t i o n s . A l t h o u g h c o m p l i c a t i o n s o f these s tudies a re r e p o r t e d , as will be r ev i ewed , t h e y a re v e r y l o w in f r e q u e n c y c o n s i d e r i n g the vas t n u m b e r s o f e x a m i n a t i o n s p e r f o r m e d , m o r e t h a n 16 m i l l i o n in 1971 [1].

Complications of gastrointestinal radiologic procedures: II. Complications related to biliary tract studies

Since production of the first cholecystogram by Graham and Cole in 1924 [1], a number of compounds have been developed for oral cholecystography (OCG). In 1952, following observations on a series of aryl triiodo alkanoic acid derivatives, Hoppe and Archer introduced iopanoic acid (Telepaque| [2]. The triiodinated aromatic ring of this compound became the general structure for all modern OCG agents (Fig. 1). Telepaque remains the most widely used gallbladder contrast medium, and over 40 million

Radiographic evaluation of esophagus immediately after pneumatic dilatation for achalasia.

Forty-one (98%) of 42 patients with achalasia of the esophagus had pneumatic dilatation performed successfully using the Brown-McHardy dilator. One to four dilatations (mean, 1.9) were done on each patient with inflation pressures of 8–15 psi (mean, 11.1 psi). Immediately after the procedure, all patients were examined radiographically by injection of contrast material into the lower esophagus through a nasoesophageal tube. Two immediate and two delayed perforations occurred. Six intramural hematomas were noted, five of which resolved spontaneously. The luminal diameter at the esophagogastric junction increased from a mean of 4.2 mm before dilatation to 7.5 mm following treatment. Four patients with previous Heller myotomy were dilated without complications. Perforation was more common in patients with a minimal change in the esophagogastric diameter. Thirty-five patients (85%) improved symptomatically within several days following pneumatic dilatation. Excluding patients with perforation, the postdilatation appearance of the lower esophagus poorly correlated with clinical response.

Cowden's disease: A case report and literature review

Cowdens disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 51-year-old man with hyperplastic polyposis of the entire alimentary tract as the most prominent feature of this disease. We also present a review of 85 cases of this entity as reported in the English medical literature, and summarize the pertinent findings.

Radiologic Detection and Spectrum of Appearances of Peptic Esophageal Strictures

We compared radiology and endoscopy in 80 patients with peptic esophageal stricture, with special attention to radiographic sensitivity for stricture caliber. Each stricture was classified by length into three types: 1) short (6–25 mm in length); 2) annular (under 6 mm in length); and 3) long (over 25 mm in length). Overall, radiology detected 95% of all strictures, including 90% of those over 1 cm in caliber. Morphologically, 75% of all strictures were short; 14% annular, and 11% long. Radiographically, smooth-stricture margins reliably excluded active esophagitis, while irregularity correlated well with its presence. Properly performed, barium esophagram can accurately detect esophageal strictures with a sensitivity approximating that of endoscopy.