How valuable is cineradiography with examination by solid and liquid contrast ?
L. Engelholm, J. De Toeuf, J. Jeanmart (Brussels)
Diffuse esophageal spasm is characterised by chest pain and/or dysphagia in patients exhibiting repetitive nonpropulsive contractions of high amplitude . The nonpropulsive contractions should follow at least 30 p. cent of swallows [5, 16]. The abnormal responses to swallowing are interspersed between normal contraction waves .
Manometrically, swallowing excites a normal peristaltic wave in the upper third of the esophagus. From the middle third of the esophagus onward, the peristaltic wave is transformed into one or more stationary contractions, often of high amplitude and prolonged duration . Interrupted peristalsis and segmental contractions are both anomalies of motility observed in diffuse spasm .
In the majority of patients with diffuse spasm, the function of the LES is normal.
However, about a third of the patients have abnormal sphincter function with raised resting pressures or imperfect relaxation of the sphincter on swallowing .
Radiology must begin with a complete investigation of the esophagus to exclude other diseases  and then study the disorders of motility.
In diffuse spasm, the radiological examination may prove normal or it may show non specific findings such as interruption of primary peristalsis and tertiary contraction waves. The radiologic diagnosis of diffuse esophageal spasm rests on the demonstration of normal peristalsis interspersed with periods of abnormal, nonpropulsive motor activity. Most of the nonpropulsive contractions are simultaneous contractions. The nonpropulsive contractions may also comprise nontransmitted, interrupted or retrograde waves.
When multiple nonpropulsive contractions are observed, various terms have been used to describe the radiologic appearances. The segment resembles a pile of plates or a string of beads or a corkscrew, depending on whether the orientation of the contractions is perpendicular or oblique in relation to the esophageal axis .
Previous authors have given excellent descriptions of the major forms of diffuse esophageal spasm [2, 16]. Primary peristalsis transports the barium bolus as far as the aortic arch and comes to a halt below this level. Then the bolus accumulates in the lower part of the esophagus and gradually distends its lumen. When a critical point of distension is reached, the esophagus suddenly goes into spasm and shows the characteristic appearance of alternating narrow and dilated zones. The barium is then regurgitated into the upper esophagus. Secondary peristalsis reconveys the content of the upper third towards the lower part of the esophagus and the cycle is repeated . The phenomenon is transient, the esophagus resuming its uniform caliber and smooth straight outlines after relaxation of the contractions .
However, the tertiary activity responsible for the classical appearances has been seen in only 24 p. cent of the 17 patients .
The work of Chen et al.  allows assessment of the statistical value of the various radiologic signs compared to manometry. They correlated the radiologic appearances with the manometric findings in 17 patients: primary peristalsis was absent or incomplete in 13 patients (76 %) and tertiary activity was seen in 12 (71 %).
The tertiary contraction waves, which are a radiologic description for nonperistaltic esophageal contraction waves, may be classified as moderate or severe. The severe forms, with obliteration of the esophageal lumen, are always observed in abnormal primary peristalsis, whereas the moderate forms are not specific to motor disorders of the esophagus since they can be observed in 36 p. cent of normal swallows .
Moderate to severe tertiary activity is seen in 71 p. cent of patients and, conversely, was absent in 29 p. cent, thus drawing attention to the importance of detecting primary peristalsis.
The role of cineradiography
The radiologic studies may demonstrate nonpropulsive contractions, interruption of primary esophageal peristalsis (figure I), spasms (figure 2), spontaneous and repetitive contractions, tertiary contractions (figure 3), aperistalsis or disordered function of the LES due to spasm imperfect relaxation or gaping.
Figure 1. Digitalized images, acquisition 2 images/sec. Secondary contraction wave well shown in the 2 lower films.
Figure 2. Patient with thoracic pain, OAG view, acquisition 2 images/sec. Appearance of tertiary contraction waves of severe type. Stasis in the lower part of the esophagus. Reascent of barium in the esophagus.
Figure 3. Digitalized images, acquisition 2 images/sec.
1 Distension of esophagus
2 Acquisition 1.5 sec later
3 Acquisition 3 sec after image I. Appearance of small tertiary contraction waves
4 Acquisition 3.5 sec later. Dyskinetic contractions and tertiary contraction waves.
In diffuse spasm of the esophagus, radiology can be carried out by conventional examination [8, 16], by an examination combining double contrast, a study of the mucosal relief and a study with a column full of barium , or by dynamic studies. These may use recording on film [4, 20, 21, 24] and can be secondarily projected in a monitor allowing analysis of the video-fluoroscopic findings. A dynamic study can also be made by cinematography, ampli-photos with a 105 mm camera, or digitalized rapid-sequence images.
The routine use of cineradiography or film recording is probably unnecessary for the diagnosis of disorders of esophageal motility , although certain types of dynamic recordings may be used for demonstration purposes or for research in patients with significant motor disorders [ 15].
However, the recording of the dynamic phenomena has the advantage, if the rhythm of the image-taking is adequate, of fixing transient phenomena and allowing more detailed analysis, which may prove necessary and repetitive.
Importance of the solid meal
The use of solid meals for study of disorders of esophageal motility is based on the idea that a solid meal conforms more closely than a liquid meal to what actually happens in a patient exhibiting dysphagia .
It has been used in radiology and in scintigraphy to follow the fate and passage of tablets [1,6, 11, 17], in scintigraphy to study the transit time or retention of the solid meal [11, 12, 13, 28] and to follow the progress of an achalasia [12, 14].
Mellow , using manometry, has shown that certain abnormal peristaltic sequences or a dysphagia can be demonstrated during ingestion of a solid meal containing beef although the standard tests with water were normal. Thus, in 5 patients abnormal motility was observed including nonperistaltic waves, incomplete relaxation or absence of complete relaxation of the LES.
This study shows that esophageal motility during the ingestion of food differs from that observed in standard manometry, and that tests carried out during ingestion of food may allow better observation of abnormal motility in the symptomatic patient.
Davies  has compared the manometric findings with the radiologic evidence in patients exhibiting dysphagia or thoracic pain, using a liquid meal or a solid meal containing bread impregnated with barium. Using the solid meal technique, spasms were demonstrated in 20 out 40 patients, whereas liquid barium and manometry were positive in only 5 and 14 cases respectively. The results of solid meals and liquid barium were compared in 53 patients. Esophageal spasm was observed in 49 p. cent with a solid meal and in 9 p. cent with a liquid meal.
He concludes that the solid meal technique may be useful for the study of motor disorders of the esophagus. The solid meal is more sensitive than conventional liquid barium studies in the demonstration of disorders of motility.
The usefulness of radiology with recording is markedly inferior in some cases to that of manometry and scintigraphy . From the radiologic aspect, although disorders of motility were observed in 76 p. cent of patients, the diagnosis of diffuse
spasm was made in only 2 out of 17 patients and 10 patients were classified as « nonspecific esophageal motor disorder ». The sensitivity of radiology varies from 30 p. cent  to 76 p. cent for diffuse spasm of the esophagus .
The majority of patients with diffuse esophageal spasm have abnormal motility in the radiographs, but these findings are not specific and require to be supplemented by clinical and manometric studies to permit a diagnosis.
Dynamic recording of motor disorders of the esophagus is of value. It allows a detailed study which can be analysed repetitively for purposes of research. Radiologic test using solid meals may be useful when combined with dynamic recording.