Role of barium esophagography in evaluating dysphagia

Cleveland Clinic Journal of Medicine. 2009 February;76(2):105-111 | 10.3949/ccjm.76a.08032

February 1, 2009|Cleveland Clinic Journal of Medicine

Brian C. Allen, MD;Mark E. Baker, MD;Gary W. Falk, MD, MS

ABSTRACTPatients with dysphagia can initially undergo either endoscopic or radiologic evaluation, depending on the clinical history and physician preference. We usually recommend that most patients with dysphagia initially undergo barium esophagography, and in this paper we discuss its role in evaluating dysphagia.

KEY POINTS

Dysphagia can be due to problems in the oropharynx and cervical esophagus or in the distal esophagus.
Radiologic evaluation of dysphagia has distinct advantages over endoscopy, including its ability to diagnose both structural changes and motility disorders.
A barium evaluation can include a modified barium-swallowing study to evaluate the oropharynx, barium esophagography to evaluate the esophagus, and a timed study to evaluate esophageal emptying.
Often, the true cause of dysphagia is best approached with a combination of radiographic and endoscopic studies.

BARIUM ESOPHAGOGRAPHY HAS EIGHT SEPARATE PHASES

Barium esophagography is tailored to the patient with dysphagia on the basis of his or her history. The standard examination is divided into eight separate phases (see below).¹⁴ Each phase addresses a specific question or questions concerning the structure and function of the esophagus.

At our institution, the first phase of the examination is determined by the presenting symptoms. If the patient has liquid dysphagia, we start with a timed barium swallow to assess esophageal emptying. If the patient does not have liquid dysphagia, we start with an air-contrast mucosal examination.

The patient must be cooperative and mobile to complete all phases of the examination.

Timed barium swallow to measure esophageal emptying

The timed barium swallow is an objective measure of esophageal emptying.^16–18 This technique is essential in the initial evaluation of a patient with liquid dysphagia, a symptom common in patients with severe dysmotility, usually achalasia.

Figure 1. Timed barium swallow in a patient with achalasia. The patient consumed 140 mL of low-density barium. There is no emptying of barium between the 1-minute and 5-minute films.

In the upright position, the patient is asked to ingest up to 250 mL of low-density barium, as tolerated. The height and width of the barium column at 1 minute and 5 minutes are measured and recorded (Figure 1).

We use this examination in our patients with suspected or confirmed achalasia and to follow up patients who have been treated with pneumatic dilatation, botulinum toxin injection, and Heller myotomy.^17,18 In addition, this timed test is an objective measure of emptying in patients who have undergone intervention but whose symptoms have not subjectively improved, and can suggest that further intervention may be required.

Air-contrast or mucosal phase

Figure 2. Esophagographic phases in a patient with solid-food dysphagia and a significant distal mucosal ring. A. The upright, mucosal phase of the examination shows no abnormalities. B. The distended or full-column phase of the examination shows the distal mucosal ring (arrow) as a sharply defined, ridge-like filling defect in the barium column above a small, sliding-type hiatal hernia (HH) (brought out by the increased intra-abdominal pressure with the patient in the semiprone position). C. The mucosal relief phase again shows the circumferential nature of the distal ring (arrows), as well as the hiatal hernia. D. Spontaneous reflux of gastric barium (arrows) with the patient in the supine position. The barium refluxed to the level of the thoracic inlet. E. Obstruction of the ingested 13-mm tablet (T) at the level of the distal mucosal ring. Barium above the tablet was given to precisely identify the location of the obstruction.

The air-contrast phase of the examination is designed to evaluate the esophageal mucosa and to determine if there is a fixed (nonreducible) hernia. In the upright position, the patient ingests CO₂ gas-producing crystals with a small amount of water and then ingests high-density barium in order to coat the mucosa. Spot films are taken of the gas-distended, barium-coated esophagus (Figure 2A).

Although this phase is not as sensitive as endoscopy, it can detect masses, mucosal erosions, ulcers, and—most importantly in our experience—fixed hernias. Patients with a fixed hernia have a foreshortened esophagus, which is important to know about before repairing the hernia. Many esophageal surgeons believe that a foreshortened esophagus precludes a standard Nissen fundoplication and necessitates an esophageal lengthening procedure (ie, Collis gastroplasty with a Nissen fundoplication).¹⁴

Motility phase

The third phase examines esophageal motility. With the patient in a semiprone position, low-density barium is given in single swallows, separated by 25 to 30 seconds. The images are recorded on digital media to allow one to review them frame by frame.

The findings on this phase correlate well with those of manometry.¹⁹ This portion of the examination also uses impedance monitoring to assess bolus transfer, an aspect not evaluated by manometry.^20,21 Impedance monitoring detects changes in resistance to current flow and correlates well with esophagraphic findings regarding bolus transfer.

While many patients with dysphagia also undergo esophageal manometry, the findings from this phase of the esophagographic examination may be the first indication of an esophageal motility disorder. In fact, this portion of the examination shows the distinct advantage of esophagography over endoscopy as the initial test in patients with dysphagia, as endoscopy may not identify patients with achalasia, especially early on.⁴

Single-contrast (full-column) phase to detect strictures, rings

The fourth phase of the esophagographic evaluation is the distended, single-contrast examination (Figure 2B). This is performed in the semiprone position with the patient rapidly drinking thin barium. It is done to detect esophageal strictures, rings, and contour abnormalities caused by extrinsic processes. Subtle abnormalities shown by this technique, including benign strictures and rings, are often not visualized with endoscopy.

Mucosal relief phase

The fifth phase is performed with a collapsed esophagus immediately after the distended, single-contrast phase, where spot films are taken of the barium-coated, collapsed esophagus (Figure 2C). This phase is used to evaluate thickened mucosal folds, a common finding in moderate to severe reflux esophagitis.

Reflux evaluation

Provocative maneuvers are used in the sixth phase to elicit gastroesophageal reflux (Figure 2D). With the patient supine, he or she is asked to roll side to side, do a Valsalva maneuver, and do a straight-leg raise. The patient then sips water in the supine position to assess for reflux (the water siphon test). If reflux is seen, the cause, the height of the reflux, and the duration of reflux retention are recorded.

Solid-bolus phase to assess strictures

In the seventh phase, the patient swallows a 13-mm barium tablet (Figure 2E). This allows one to assess the significance of a ring or stricture and to assess if dysphagia symptoms recur as a result of tablet obstruction. Subtle strictures that were not detected during the prior phases can also be detected using a tablet. If obstruction or impaired passage occurs, the site of obstruction and the presence or absence of symptoms are recorded.

References

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