Barium swallow

Barium swallow is a dedicated test of the pharynx, oesophagus, and proximal stomach, and may be performed as a single or double contrast study. The study is often "modified" to suit the history and symptoms of the individual patient, but it is often useful to evaluate the entire pathway from the lips to the gastric fundus.

Upper GI endoscopy (UGIE or EGD) has largely replaced the barium swallow for the assessment of peptic ulcer disease and the assessment of haematemesis.

Indications

However, there remain many indications for a barium barium swallow including:

• high or low dysphagia
• gastro-oesophageal reflux disease (GORD/GERD)
• assessment of hiatus hernia
• generalised epigastric pain
• globus hystericus
• persistent vomiting
• assessment of fistula
• inability to pass the endoscope during during UGIE

Contraindications

Water-soluble contrast agents should be used instead of barium in the following cases:

• suspected perforation
• suspected tracheo-oesophageal or broncho broncho-oesophageal fistula
• post-operative assessment for leak

Caution should be exercised when using water-soluble contrast agents in patients with a risk for aspiration. Aspiration of high-osmolarity water-soluble contrast agents has been associated with massive pulmonary oedema and subsequent death. A low osmolarity agent such as Omnipaque may be used in this setting.

Technique

Examination technique depends on the indication of study. Preparation needed for study is overnight fasting, avoiding smoking or chewing gum to decrease the secretions in oral cavity and pharynx.

Evaluation of pharynx

• scout films are obtained to rule out any foreign body, abscess or fistula
• the examination is performed in the upright lateral position after swallowing high density barium
• right lateral views should be obtained initially to to rule out aspiration or penetration, then frontal views are obtained
• dynamic video-fluoroscopic examination should be simultaneously acquired for optimal evaluation
• spots are obtained quickly during suspended respiration and under phonation (patient instructed to say "Eeeee....") to distend the hypopharynx

Evaluation of oesophagus

• double contrast contrast barium swallow is the preferred mode of examination
• patient swallows a packet of effervescent agent and then rapidly gulps a packet of high density barium
• frontal and left posterior oblique views are taken. 
• two exposures are centeredcentred on upper/mid oesophagus and two on distal oesophagus
• then, the table is brought to horizontal position and patient turns to right lateral position for view of gastric cardia and fundus
• the patient drinks low density barium in prone right anterior oblique position:
  • two to five separate swallows are assessed to evaluate motility of esophagusoesophagus
  • this also permits evaluation of distal esophagusoesophagus and GE junction, delineating lower esophagealoesophageal rings and strictures
• patient is finally turned onto the left side and then onto back, so that barium pools in the gastric fundus
• GE junction is then observed fluoroscopically as the patient slowly turns to right, looking for elicited elicited gastro-esophageal reflux
• straight leg raising, Valsalva manoeuvre or drinking water (water siphon test) can also elicit gastro-oesophageal reflux
• additional views like mucosal relief views are useful in suspected tumorstumours, varices or esophagitisoesophagitis.

Radiographic features

On the lateral view, the tongue base and epiglottis are seen from the side, with the vallecula between. A posterior indentation caused by contraction of the cricopharyngeus muscle indicates the commencement of the cervical esophagusoesophagus. 

On the frontal view, the piriform fossae are outlined by barium and the epiglottis and the base of the tongue show as filling defects in the midline. 

The cervical esophagusoesophagus lies on the ventral surface of the cervical spine.

The thoracic esophagusoesophagus is best demonstrated in the right anterior oblique position.