Gastroesophageal Reflux Imaging
- Author: Michael AJ Sawyer, MD; Chief Editor: Eugene C Lin, MD more...
Excessive retrograde movement of acid-containing gastric secretions or bile and acid-containing secretions from the duodenum and stomach into the esophagus is the etiologic effector of gastroesophageal reflux disease (GERD). Reflux of these secretions to some degree into the esophagus is prevalent in the United States. A study by Richter and a Gallup Organization National Survey estimated that 25-40% of healthy adult Americans experience symptomatic GERD, most commonly manifested clinically by pyrosis (heartburn), at least once a month. Furthermore, approximately 7-10% of the adult population in the United States experiences such symptoms on a daily basis. (See the images below.)[2, 3]
In most of these people, endogenous defense mechanisms either limit the amount of noxious material that is introduced into the esophagus or rapidly clear the material from the esophagus so that symptoms and esophageal mucosal irritation are minimized. Examples of the defense mechanisms include actions of the lower esophageal sphincter (LES) and normal esophageal motility.
When the defense mechanisms are defective or become overwhelmed so that the esophagus is bathed in acid or bile and acid-containing fluid for prolonged periods, GERD can be said to exist. Patients typically have numerous daily episodes of symptomatic reflux, including pyrosis, water brash or sour taste in the mouth, nighttime coughing or aspiration, pneumonia or pneumonitis, bronchospasm, and laryngitis and voice changes including hoarseness. In addition, objective evidence of esophageal damage can be seen on esophagogastroduodenoscopy.
Among imaging studies, barium esophagogram findings can demonstrate anatomy and possible complications of reflux disease (strictures). Reflux and inadequate gastric emptying may also be demonstrated.
Nuclear medicine gastric emptying studies are sensitive in evaluating for incomplete gastric emptying.
Presently, no role exists for computed tomography (CT) scanning, magnetic resonance imaging (MRI), or ultrasonography in the routine evaluation of patients with reflux disease.
Esophageal inflammation demonstrated by 18F-fluorodeoxyglucose (FDG) PET/CT has been shown to correlate with endoscopic findings and symptomatology of GERD.
Limitations of techniques
A conclusive diagnosis of reflux disease cannot be made by using barium esophagography. This technique is not sensitive for the detection of motility disorders. Nuclear medicine gastric-emptying study does not help in assessing anatomy and cannot help in the diagnosis of reflux disease.
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. (See the image below.)
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 to 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. (Barium esophagograms are presented below.)
Various techniques are used, and each has relative strengths and weaknesses in the ability to detect specific abnormalities or disease processes.
A typical barium esophagogram 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.
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.[8, 9, 10]
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.
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.
No well-described, normal variants of GERD can be detected by using CT scans.
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. No well-described, normal variants of GERD can be detected by using CT scans.
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 (99m Tc) 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.
No normal scintigraphic variants for GERD have been described.
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.
Fock KM, Poh CH. Gastroesophageal reflux disease. J Gastroenterol. 2010 Jun 29. [Medline].
Gallup Organization. Heartburn Across America: A Gallup Organization National Survey. Princeton, NJ: Gallup Org. 1988.
Richter JE. Surgery for reflux disease: reflections of a gastroenterologist. N Engl J Med. 1992 Mar 19. 326(12):825-7. [Medline].
Bello B, Zoccali M, Gullo R, Allaix ME, Herbella FA, Gasparaitis A, et al. Gastroesophageal reflux disease and antireflux surgery-what is the proper preoperative work-up?. J Gastrointest Surg. 2013 Jan. 17(1):14-20; discussion p. 20. [Medline].
Erdogan Z, Silov G, Ozdal A, Turhal O. Enterogastroesophageal reflux detected on 99m-technetium sestamibi cardiac imaging as a cause of chest pain. Indian J Nucl Med. 2013 Jan. 28(1):45-8. [Medline]. [Full Text].
Wu YW, Tseng PH, Lee YC, Wang SY, Chiu HM, Tu CH, et al. Association of esophageal inflammation, obesity and gastroesophageal reflux disease: from FDG PET/CT perspective. PLoS One. 2014. 9 (3):e92001. [Medline].
Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology. 2005 Nov. 237(2):414-27. [Medline].
Mattioli S, Lugaresi ML, Di Simone MP, et al. The surgical treatment of the intrathoracic migration of the gastro-oesophageal junction and of short oesophagus in gastro-oesophageal reflux disease. Eur J Cardiothorac Surg. 2004 Jun. 25(6):1079-88. [Medline].
Shan CX, Zhang W, Zheng XM, Jiang DZ, Liu S, Qiu M. Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease. World J Gastroenterol. 2010 Jun 28. 16(24):3063-71. [Medline]. [Full Text].
Borie F, Glaise A, Pianta E, Veyrac M, Millat B. Long-term quality-of-life assessment of gastrointestinal symptoms before and after laparoscopic Nissen fundoplication. Gastroenterol Clin Biol. 2010 May 28. [Medline].
Scheffer RC, Samsom M, Haverkamp A, et al. Impaired bolus transit across the esophagogastric junction in postfundoplication dysphagia. Am J Gastroenterol. 2005 Aug. 100(8):1677-84. [Medline].