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Pediatric lower esophageal disorders and diseases are rare (Figures 1 and 2). Further imaging of the remainder of the
in the pediatric population. The most common include hiatus stomach and the duodenum is usually performed, which will
hernia, achalasia, duplication cyst, esophageal varices, and not be assessed in this essay. The ALARA (As Low As
esophagitis. In all these disorders transabdominal sonography Reasonably Achievable) principle should always be applied,
and fluoroscopy are able to provide substantial diagnostic data, to keep radiation dose low [1].
including both morphologic and functional information of the
lower esophagus. The educational objective of this pictorial
essay is to review the technique of esophageal ultrasound and Esophageal Sonography Technique
fluoroscopy, as well as the imaging findings of the commonest
pediatric lower esophageal disorders. The evaluation of the distal esophagus should be per-
formed in quiet and calm infants after giving a weight-related
food amount (milk or chamomile) for filling the stomach
Esophageal Fluoroscopy Technique sufficiently. Children should be examined in the supine and
anterior oblique positions, and in some cases in the erect
Esophageal fluoroscopy is performed after adequate position. The examination should be performed with a
fasting of the child, with the use of contrast material, most curvilinear transducer of 5-8 MHz or a linear high frequency
commonly barium sulfate. The contrast media is delivered by transducer, using the left hepatic lobe as acoustic window
a baby bottle in infants and small children, or taken from a [2,3]. In longitudinal section, the esophagus is revealed as a
cup in older children. The examination begins with the child tubular structure consisted of 2 hypoechoic peripheral bands,
in the lateral projection, obtaining images from the naso- which represent the muscular layers and a central hyper-
pharynx to the esophagogastric junction as well as the echoic line, which represents the mucosa and collapsed
stomach fundus. Subsequently the child lies supine, to lumen. In cross-sectional images esophagus appears as a
examine the esophagus in the anteroposterior projection. The target with a hypoechoic peripheral ring, which represents its
anatomic course, the calibre, the mucosal surface of the muscular layer and a hyperechoic centre, the mucosa and
esophagus, and the position of the gastroesophageal junction collapsed lumen. Some ultrasound measurements should be
should be evaluated. In addition, esophageal peristalsis made when necessary, for precise evaluation of esophageal
should be assessed and possible reflux should be documented disorders. Abdominal esophageal length should be measured
at the end of a normal exhalation, from the point at which the
* Address for correspondence: Chrysoula Koumanidou, MD, PhD, Fthio- esophagus penetrates the diaphragm, to the base of the
tidos 13, Marousi, Athens, 15122, Greece. triangular pad of gastric folds at the anterior surface of
E-mail address: argyromazioti@hotmail.com (C. Koumanidou). the fundus of the stomach. The mean length normally ranges
0846-5371/$ - see front matter Ó 2017 Canadian Association of Radiologists. All rights reserved.
https://doi.org/10.1016/j.carj.2017.10.001
2 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8
Figure 3. Normal abdominal esophagus. Sonographic longitudinal scan in a 3-month-old girl using the left hepatic lobe as acoustic window. (A) The panel is
not annotated. (B) The normal triangular pad of gastric folds at the anterior surface of the fundus of the stomach is shown (sketch triangle). The esophageal
length is measured from the point at which the esophagus penetrates the diaphragm, to the base of the triangular pad (double arrow).
Duplication Cyst
Figure 4. Normal abdominal esophagus. Sonographic longitudinal scan in
Esophageal duplication cyst is a rare developmental the same 3-month-old girl. The gastroesophageal angle (angle of His) is
anomaly, with an estimated incidence of 1 in 8200 [10]. measured (curved line).
4 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8
Figure 18. Eosinophilic esophagitis. Transabdominal ultrasound in the same Figure 20. Reflux esophagitis. Barium meal in the same boy as in Figure 19.
girl as in Figure 17 demonstrates mild esophageal thickening. Wall thickness An eccentric stenosis at the level of abdominal esophagus is revealed (thick
(measured between calibres) is 0.41 cm. arrow). Further workup of the child revealed reflux esophagitis.
8 C. Koumanidou et al. / Canadian Association of Radiologists Journal xx (2017) 1e8
thickness. Another proposed reliable marker for the diag- upper gastrointestinal tract, esophageal fluoroscopy is one of
nosis of esophageal varices in children is the ratio of the the first imaging studies required. In addition, ultrasonogra-
portal vein to body surface [12]. It has been postulated that phy, having the advantages of being a low-cost and rapid im-
the correlation of a ratio of LO thickness to aortic diameter at aging method, with no patient discomfort, no radiation
the same level between 1.3-1.8 and a ratio of the portal vein exposure, and no need for patient hospitalization, is also able to
to body surface >12 mm or the presence of portal obstruc- contribute substantially to the diagnostic procedure, as it can
tion increases the diagnostic predictivity to 100% [12]. also provide both morphologic and functional information.
Esophageal fluoroscopy is able to detect varices as mul- This is why radiologists should be familiar with these imaging
tiple serpiginous filling defects, which interrupt the normal techniques as well as the imaging findings of these disorders, to
parallel course of the esophageal mucosal folds (Figure 15). guide the diagnostic process in a correct and quick manner. In
that way the need for performing more invasive studies (eg,
Esophagitis radionuclide scanning, endoscopy, esophageal manometry, pH
monitoring, endoscopic esophageal sonography) is carefully
Types of pediatric esophagitis include infectious, chemi- evaluated and is some cases may even be omitted or postponed.
cal (resulting from GERD or from the ingestion of corrosive
substances), radiation-induced, or eosinophilic esophagitis.
References
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Conclusions gastroesophageal reflux clinical practice guidelines: joint recom-
mendations of the North American Society for Pediatric Gastro-
enterology, Hepatology, and Nutrition (NASPGHAN) and the
Pediatric lower esophageal disorders and diseases are rare European Society for Pediatric Gastroenterology, Hepatology, and
in the pediatric population. Their clinical symptoms are vari- Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009;49:498e
able and diagnosis is often delayed. For the investigation of the 547.