A specific diagnosis of Barrett esophagus can be suggested if a proximal esophageal stricture, deep penetrating ulcer, or reticular mucosal surface pattern is seen on the esophagogram (as demonstrated in the image below).
Spot radiograph from double-contrast esophagography shows a smooth stricture in the midesophagus. Multiple ulcerations in the region of the stricture are seen. Note the reticular mucosal appearance extending down from the inferior aspect of the stricture.
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Although esophageal ulceration in Barrettesophagus can occur anywhere along the columnar epithelium, classically it involves the most proximal portion at or near the squamocolumnar junction, well above the cardia and even as high as the aortic arch. Unlike the shallow ulcerations that usually are caused by reflux esophagitis in the squamous epithelium, a Barrett ulcer tends to be deep, penetrating, and identical to a peptic gastric ulcer. Stricture formation usually accompanies the ulceration. At times, no ulceration is evident, and only a smooth, tapered stricture is present.
The stricture forms at the squamocolumnar junction. The Barrett stricture tends to be short and tight, typically causing eccentric narrowing of the lumen in contrast to the smooth, symmetric, and circumferential luminal narrowing in peptic strictures. A specific sign of Barrett esophagus is the ascending or migrating stricture, in which progressive upward migration of both the squamocolumnar junction and the level of the stricture is depicted on serial esophagograms.
A delicate reticular pattern extending inferiorly for a variable distance from the level of a stricture has been described as a radiologic sign of Barrett metaplasia. However, this appearance is nonspecific, and it has been observed in other conditions such as candidiasis, viral esophagitis, superficial spreading carcinoma, and areae gastricae in a small hiatal hernia.
A sliding hiatal hernia with gastroesophageal reflux (GER) commonly is seen in patients with Barrett esophagus. However, in most patients, a variable length of normal-appearing esophagus separates the Barrett ulcer from the hiatal hernia. This finding is in contrast to that of reflux esophagitis, in which the distal esophagus is abnormal down to the level of the hernia.
Another radiologic sign that raises the possibility of Barrett esophagus is a focal defect in the esophageal contour at least 4 cm proximal to the esophagogastric junction. The contour defect is believed to be an early stage of a midesophageal stricture, a classic feature of Barrett esophagus.
Esophageal contour defects caused by Barrett esophagus simulate normal variations in the caliber of the esophagus. Optimal distention of the esophageal lumen and varying obliquity may be necessary to confirm the presence of restricted distensibility and to identify fixed transverse folds. Subtle contour defects can be observed more readily on double-contrast images because fixation of the esophageal wall may be more conspicuous than on images obtained with a single-contrast technique.
Radiographic findings in short-segment Barrett esophagus are less specific. In one study, 70% of patients with short-segment Barrett esophagus had reflux esophagitis, peptic scarring or strictures, or both on double-contrast esophagograms, and 30% had only hiatal hernias or GER as radiographic findings. [26]
Findings of Barrett esophagus on a double-contrast esophagogram must be confirmed with esophagogastroduodenoscopy (EGD) and biopsy.
The fine reticular pattern inferior to the stricture in some patients with Barrett esophagus also may be observed when the areae gastricae, which is the normal appearance of the gastric mucosa on a double-contrast image, is visualized within a small hiatal hernia.
