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Barium
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ANSWERS
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Spot 5. Paraesophageal
Hernia
In a true paraesophageal
hernia, the esophagogastric junction is
below the esophageal hiatus of the diaphragm.
More commonly, the esophageal hiatus of the diaphragm is
extremely wide, allowing superior axial migration of the gastric
cardia (a routine axial hiatal hernia) and a portion of mid
stomach going back through the esophageal hiatus of the
diaphragm alongside the gastric cardia. This situation is often
described as a form of gastric volvulus.
In our case presented here, there is a rent in the left
hemidiaphragm just lateral to the esophageal hiatus of the
diaphragm This diaphragmatic rent allows a small portion of
gastric fundus to herniate into the chest. Because there was no
history of even remote trauma, this hernia could not be
described as a traumatic hernia
Some surgeons and radiologists would describe this as a
paraesophageal hernia. It is better to describe the anatomic
location of the herniation and what portion of stomach is above
the diaphragm.
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Spot 7. Achlasia
Primary peristalsis is absent. Some patients exhibit
shallow nonperistaltic contractions; a few patients have
relatively higher amplitude nonperistaltic contractions
so-called vigorous achalasia.
The distal esophagus has a short, smooth, beaklike
tapered arrowing that eventually opens to a variable
degree; this reflects the lower esophageal sphincter
dysfunction. The esophagus is variably dilated.
In early achalasia, esophageal dilation may be subtle. In
these patients, diagnosis depends on evaluation of
peristalsis and lower esophageal sphincter opening.
With longer duration of disease, the esophagus dilates.
With end-stage disease, the esophagus is massively
dilated and tortuous, assuming a sigmoid shape in
some patients.
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Spot 8. Pseudo-Achlasia
Pseudoachalasia typically results from
submucosal infiltration of the distal
esophagus and cardia by cancer.
Pseudoachalasia can be differentiated
from achalasia by clinical findings and
by asymmetry, abrupt transitions,
mucosal nodularity, and associated
mass and ulceration in the former.
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Spot 9. Varices
Varices are manifested on barium studies as smooth, thick,
undulating, scalloped folds that change size with various
degrees of esophageal distention, peristalsis, or respiration.
Enlarged folds in Reflux esophagitis are not smooth, but have
a slightly irregular contour.
Submucosal spread of squamous cell carcinoma may produce
thick undulating folds; however, the surface of the folds is
often nodular,mand the tumorous folds do not change size or
shape with various degrees of luminal distention.
Dysphagia is more frequent in patients with varicoid
carcinoma than in patients with varices.
Lymphoma infiltrating the esophagus can mimic varices, but is
usually midesophageal and does not change size or shape
with various degrees of luminal distention. Lymphoma
infiltrating the esophageal mucosa is exceedingly rare
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Reflux
esophagitis
Reflux esophagitis is typified by tiny, ill-defined elevations of the