Fluoroscopy Barium Swallow
Indication:
- High or low dysphagia.
- Gastro-esophageal reflux disease (GERD/GERD)
- Assessment of a hiatus hernia.
- Generalized epigastric pain.
- Globus pharyngeus.
- Persistent vomiting.
- Assessment of fistula.
- Inability to pass the endoscope during UGIE
Patient
Preparation:
Barium
Swsllow এক্স-রে করতে তেমন কোন প্রস্তুতির প্রয়োজন হয় না। শুধুমাত্র খালিপেটে থাকলে এই পরীক্ষা সম্পুর্ন করা যায়। রোগীর কানে ও গলায় Metalic/গহনা থাকলে তা খুলে নিতে হবে।
Preparation of Barium Sulphate:
বাজারে বিভিন্ন Brand এর Barium Sulphate পাওয়া যায়। ১০০ গ্রাম Barium Sulphate এর সাথে প্রয়োজন মতো পানি দিয়ে pest এর মতো করে, গ্লাস এ গুলিয়ে নিই।
Technique/Procedure:
- Machine এর Foot Stand এ রোগীকে এ দাঁড় করাই।এবার গ্লাসে রক্ষিত গোলানো Barium Sulphate এর তৈরী pest থেকে ১ চামুচ নিয়ে রোগীর মুখে দেই এবং গিলতে বলি। এবার Fluoroscopic screen এ রোগীকে গলধঃকরন লক্ষ করি।
- Barium Sulphate ঠিক মতো নিচের দিকে নামলে রোগীকে আরও ১ চামুচ মুখে দেই এবং গিলতে নিষেধ করি। এবার রোগীকে A/P Position করে TV Monitor এ লক্ষ করি এবং Barium Sulphate গিলতে বলি। আবার গলধঃকরন লক্ষ করি । গলধঃকরন ঠিক থাকলে বড় সাইজের Cassette এর মাধ্যমে Mouth Cavity থেকে esophagus এর অর্ধেক অংশের ছবি নিই।
- আবার রোগীকে Barium Sulphate মুখে দিয়ে গিলতে বলি এবং TV Monitor বা Fluoroscopic screen এ রোগীর গলধঃকরন লক্ষ করি। আবার একই Position এ বাকি অর্ধেক অংশের আরেকটি (A/P Position এর) ছবি নিই।
- A/P Position এর ছবি ঠিকমতো হলে, রোগীকে আস্তে আস্তে ঘুরিয়ে Oblique Position করি। ১ চামুচ Barium Mixture রোগীর মুখে দিয়ে গিলতে বলি এবং Mouth Cavity থেকে esophagus এর অর্ধেক অংশের ছবি নিই।
- আবার রোগীকে ১ চামুচ Barium Sulphate মুখে দিয়ে গিলতে বলি এবং Monitor বা Fluoroscopic screen এ রোগীর গলধঃকরন লক্ষ করি। একই Position এ বাকি অর্ধেক অংশের আরেকটি Oblique Position এর ছবি নিই।
- Oblique Position এর ছবি ঠিকমতো হলে, রোগীকে lateral Position করি। ১ চামুচ Barium Mixture রোগীর মুখে দিয়ে গিলতে বলি এবং Mouth Cavity হতে esophagus এর অর্ধেক অংশ পর্যন্ত ছবি নিই।
- আবার রোগীকে ১ চামুচ Barium Mixture রগীর মুখে দিয়ে গিলতে বলি এবং screen এ রোগীর গলধঃকরন লক্ষ করি। একই Position এ বাকি অর্ধেক অংশের (আরেকটি lateral Position এর) ছবি নিই।
- এখানে উল্লেখ্য esophagus এর কোন নির্দিষ্ট জায়গায় সমস্যা দেখা গেলে, কখনও কখনও Spot Film নেওয়ার প্রয়োজন হতে পারে।
Anatomy oesophagus
The oesophagus is a fibromuscular tube, approximately 25cm in length, that transports food from the pharynx to the stomach.
It originates at the inferior border of the cricoid
cartilage (C6) and extends to the cardiac orifice of the stomach
(T11).
In this article we shall examine the anatomy of the oesophagus –
its structure, vascular supply and clinical correlations.
Fig 1.0 – The oesophagus
Anatomical Course
The oesophagus begins in the neck, at the level of
C6. Here, it is continuous superiorly with the laryngeal part of the pharynx (the
laryngopharynx).
It descends downward into the superior
mediastinum of the thorax, positioned between the trachea and
the vertebral bodies of T1 to T4. It then enters the abdomen
via the oesophageal hiatus (an opening in the right crus of the
diaphragm) at T10.
The abdominal portion of the oesophagus is approximately
1.25cm long – it terminates by joining the cardiac orifice of the stomach at
level of T11.
Anatomical Structure
The oesophagus shares a similar structure with many of the
organs in the alimentary tract:
Adventitia – outer layer of connective tissue.
Note: The very distal and intraperitoneal portion of the
oesophagus has an outer covering of serosa, instead of adventitia.
Muscle layer – external layer of longitudinal muscle
and inner layer of circular muscle. The external layer is composed of different
muscle types in each third:
Superior third – voluntary striated muscle
Middle third – voluntary striated and smooth muscle
Inferior third – smooth muscle
Submucosa
Mucosa – non-keratinised stratified squamous epithelium
(contiguous with columnar epithelium of the stomach).
Food is transported through the oesophagus by peristalsis –
rhythmic contractions of the muscles which propagate down the oesophagus.
Hardening of these muscular layers can interfere with peristalsis and cause
difficulty in swallowing (dysphagia).
Fig 2 – The layers of the oesophagus. The muscle layer is
further divided into an outer longitudinal layer and inner circular layer.
Oesophageal Sphincters
There are two sphincters present in the oesophagus, known as
the upper and lower oesophageal sphincters. They act to prevent the entry of
air and the reflux of gastric contents respectively.
Upper Oesophageal Sphincter
The upper sphincter is an anatomical, striated muscle
sphincter at the junction between the pharynx and oesophagus. It is produced by
the cricopharyngeus muscle. Normally, it is constricted to prevent
the entrance of air into the oesophagus.
Lower Oesophageal Sphincter
The lower oesophageal sphincter is located at the gastro-oesophageal
junction (between the stomach and
oesophagus). The gastro-oesophageal junction is situated to the left of
the T11 vertebra, and is marked by the change from oesophageal to gastric
mucosa.
The sphincter is classified as a physiological (or
functional) sphincter, as it does not have any specific sphincteric muscle.
Instead, the sphincter is maintained by four factors:
Oesophagus enters the stomach at an acute angle.
Walls of the intra-abdominal section of the oesophagus
are compressed when there is a positive intra-abdominal pressure.
Prominent mucosal folds at the gastro-oesophageal
junction aid in occluding the lumen.
Right crus of the diaphragm has a “pinch-cock” effect.
During oesophageal peristalsis, the sphincter is relaxed to
allow food to enter the stomach. Otherwise at rest, the function of this
sphincter is to prevent the reflux of acidic gastric contents into the
oesophagus.
Anatomical Relations
The anatomical relations of the oesophagus give rise to
four physiological constrictions in its lumen – it is these areas
where food/foreign objects are most likely to become impacted. They can be
remembered using the acronym ‘ABCD‘:
Arch of aorta
Bronchus (left main stem)
Cricoid cartilage
Diaphragmatic hiatus
The table below lists the anatomical relations of
the oesophagus:
|
Anterior |
Posterior |
Right |
Left |
|
|
Cervical and thoracic |
Trachea Left recurrent laryngeal nerve Pericardium |
Thoracic vertebral bodies Thoracic duct Azygous veins Descending aorta |
Pleura Terminal part of azygous vein |
Subclavian artery Aortic arch Thoracic duct Pleura |
|
Abdominal |
Left vagus nerve Posterior surface of the heart |
Right vagus nerve Left crus of the diaphragm |
Vasculature
In respect to its arterial and venous supply, the oesophagus
can be divided into its thoracic and abdominal components.
Thoracic
The thoracic part of the oesophagus receives its arterial
supply from the branches of the thoracic aorta and the inferior
thyroid artery (a branch of the thyrocervical
trunk).
Venous drainage into the systemic circulation occurs via
branches of the azygous veins and the inferior thyroid vein.
Abdominal
The abdominal oesophagus is supplied by the left
gastric artery (a branch of the coeliac trunk) and left inferior phrenic
artery. This part of the oesophagus has a mixed venous drainage via two routes:
To the portal circulation via left gastric vein
To the systemic circulation via the azygous vein.
These two routes form a porto-systemic anastomosis, a
connection between the portal and systemic venous systems.
Fig 3 – Posterior view of the oesophagus. Some of the
thoracic vasculature is noted.
Innervation
The oesophagus is innervated by the oesophageal plexus,
which is formed by a combination of the parasympathetic vagal trunks and
sympathetic fibres from the cervical and thoracic sympathetic
trunks.
Two different types of nerve fibre run in the vagal trunks.
The upper oesophageal sphincter and upper striated muscle is supplied by fibres
originating from the nucleus ambiguus. Fibres supplying the lower
oesophageal sphincter and smooth muscle of the lower oesophagus arise from
the dorsal motor nucleus.
Lymphatics
The lymphatic drainage of the oesophagus is
divided into thirds:
Superior third – deep cervical lymph nodes.
Middle third – superior and posterior mediastinal
nodes.
Lower third – left gastric and celiac nodes.
Clinical Relevance: Disorders of the Oesophagus
Barrett’s Oesophagus
Barrett’s
oesophagus refers to the metaplasia (reversible change from
one differentiated cell type to another) of lower oesophageal squamous
epithelium to gastric columnar epithelium. It is usually caused by chronic acid
exposure as a result of a malfunctioning lower oesophageal sphincter. The acid irritates
the oesophageal epithelium, leading to a metaplastic change.
The most common symptom is a long-term burning sensation of
indigestion.
It can be detected via endoscopy of the
oesophagus. Patients who are found to have it will be monitored for any
cancerous changes.
Oesophageal Carcinoma
Around 2% of malignancies in the UK are oesophageal
carcinomas. The clinical features of this carcinoma are:
Dysphagia – difficulty swallowing. It becomes progressively
worse over time as the tumour increases in size, restricting the passage of
food.
Weight loss
There are two major types of oesophageal
carcinomas: squamous cell carcinoma and adenocarcinoma.
Squamous cell carcinoma – the most common subtype of
oesophagus cancer. It can occur at any level of the oesophagus.
Adenocarcinoma – only occurs in the inferior third
of the oesophagus and is associated with Barrett’s oesophagus. It usually
originates in the metaplastic epithelium of Barrett’s oesophagus.
Fig 4 – Endoscopic view of oesophageal varices
Oesophageal Varices
The abdominal oesophagus drains into both the systemic and portal circulation,
forming an anastomosis between the two.
Oesophageal varices are abnormally dilated sub-mucosal
veins (in the wall of the oesophagus) that lie within this anastomosis.
They are usually produced when the pressure in the portal system increases
beyond normal, a state known as portal hypertension. Portal
hypertension most commonly occurs secondary to chronic liver disease, such as
cirrhosis or an obstruction in the portal vein.
The varices are predisposed to bleeding, with most patients
presenting with haematemesis (vomiting of blood). Alcoholics are at a
high risk of developing oesophageal varices.
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