eMedicine Specialties > Radiology > Gastrointestinal
Gastroesophageal Reflux: Imaging
Updated: Mar 6, 2008
Radiography
Findings
Plain radiography
Plain radiographic findings are not useful in evaluating patients for GERD, but they are helpful in evaluating pulmonary status and basic anatomy. Chest images may demonstrate a large hiatal hernia, but small hernias can be missed easily.
In patients with pulmonary symptoms, an infiltrate due to aspiration pneumonia may be seen. The standard radiologic workup of a patient with reflux disease does not require chest radiography.
Upper GI series
Upper GI contrast-enhanced studies are the initial radiologic procedure of choice in the workup of the patient in whom GERD is suggested.
The primary use of an upper GI in suspected reflux is to evaluate anatomy and not detect reflux as sensitivity is limited in patients with known esophagitis and normal controls can have visualized reflux. Drinking 15-30 mL of iced water can improve the sensitivity and specificity for reflux.
Barium esophagograms or swallows are helpful for identifying structural abnormalities of the esophagus and esophageal hiatus, which include esophageal rings, strictures and ulcers, and hiatal hernias.
Various techniques are used, and each has relative strengths and weaknesses in the ability to detect specific abnormalities or disease processes.
A typical barium esophagram is performed in multiple steps or phases. A high-density barium suspension is administered, and double-contrast views are used for images taken with the patient in the upright position. Prone-positioned images are typically obtained with single contrast and a lower-density barium suspension. Mucosal relief images can be made to complement these techniques.
Esophageal inflammatory and neoplastic diseases are better detected with double-contrast techniques. Conversely, single-contrast techniques are more sensitive for structural defects such as hiatal hernias and strictures or esophageal rings (Levine, 2005).
The presence of Barrett esophagus occasionally is detected as a reticular mucosal pattern. As may be expected, the more advanced the esophageal disease, the more sensitive is barium swallow at detecting it.
Early esophagitis is not well demonstrated and decreases the overall sensitivity of barium swallows, especially compared to tests such as 24-hour pH monitoring. This is why many clinicians reserve barium swallow for the evaluation of patients with GERD and symptoms that include dysphagia.
Barium swallow is not sensitive in the detection of actual reflux, except in the occasional patient who has a wide-open LES and free reflux.
Barium swallow is a very important study in the investigation and detection of postoperative complications following fundoplication. Recurrent hiatal hernia, disruption or slippage of the fundoplication, and other structural abnormalities can be identified (Mattioli, 2004).
Late postoperative dysphagia can be investigated by a combination of manometry and esophageal fluoroscopic examination. Increases in esophagogastric transit time of liquid barium and solid boluses correlate positively with the presence of postoperative dysphagia (Scheffer, 2005).
Degree of Confidence
The degree of confidence offered by plain films for the diagnosis of GERD is low. A suggested diagnosis of GERD must always be confirmed by other more sensitive and specific tests.
False Positives/Negatives
No well-described normal variants of GERD are seen on plain radiographs.
Computed Tomography
Findings
CT scanning, similar to chest radiography, is not a part of the standard radiologic workup of patients with GERD. CT scans can provide information regarding the anatomy (ie, presence and size of a hiatal hernia) but do not provide information regarding the presence or absence of reflux. CT does not need to be performed in most of patients with reflux disease.
Degree of Confidence
CT scanning offers excellent anatomic detail and is sensitive for the detection of a hiatal hernia; however, it cannot help make a diagnosis of GERD.
False Positives/Negatives
No well-described normal variants of GERD can be detected by using CT scans.
Magnetic Resonance Imaging
Findings
Currently, MRI has no role in the evaluation or diagnosis of GERD in patients with reflux disease.
Degree of Confidence
No role exists for MRI in the workup of this disease process.
False Positives/Negatives
No variants of GERD have been found on MRIs.
Ultrasonography
Findings
Ultrasonography is not used in the diagnosis of GERD.
False Positives/Negatives
There are no normal ultrasonographic variants of GERD.
Nuclear Imaging
Findings
Gastric-emptying studies may be worthwhile in the evaluation of patients in whom delayed gastric emptying is believed to contribute to the manifestation of GERD symptoms.
Gastroesophageal reflux scintigraphy can be performed with acidified orange juice labeled with technetium-99m sulfur colloid. Compared with fluoroscopy, this allows for a longer time of evaluation, a decreased radiation dose, and the ability to semiquantitate the amount of reflux. However, gastroesophageal reflux scintigraphy has little role in the adult patient due to limited sensitivity and the availability of other methods of evaluation.
Gastroesophageal reflux scintigraphy is much more commonly used in infants and children due to the noninvasive nature of the study and relatively low radiation dose. In infants and children the study is often performed with labeled milk. In addition to evaluating the degree of reflux, pulmonary aspiration can be detected by imaging over the lungs.
Degree of Confidence
Scintigraphic studies are neither sensitive nor specific for the diagnosis of GERD. The results should always be confirmed with another study, preferably upper GI endoscopy or 24-hour pH monitoring.
False Positives/Negatives
No normal scintigraphic variants for GERD have been described.
Angiography
Findings
Angiography has no role in the diagnosis of GERD.
More on Gastroesophageal Reflux |
| Overview: Gastroesophageal Reflux |
 Imaging: Gastroesophageal Reflux |
| Follow-up: Gastroesophageal Reflux |
| Multimedia: Gastroesophageal Reflux |
| References |
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Further Reading
Keywords
hiatal hernia, heartburn, reflux regurgitation, GERD, gastric reflux, gastroesophageal reflux disease, acid reflux, bile reflux, esophageal clearance, pyrosis, esophagitis, esophageal strictures, Barrett esophagus, dysphagia
