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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
Author and Disclosure Information

Brian C. Allen, MD
Imaging Institute, Cleveland Clinic

Mark E. Baker, MD
Imaging Institute and Taussig Cancer Institute, Cleveland Clinic

Gary W. Falk, MD, MS
Center for Swallowing and Esophageal Disorders, Digestive Disease Institute, and Taussig Cancer Institute, Cleveland Clinic; Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case, Western Reserve University

Address: Brian C. Allen, MD, Imaging Institute, Hb6, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH; e-mail allenb@ccf.org

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.

Modified esophagography to assess the oropharynx

The final or eighth phase of barium esophagography is called “modified barium esophagography” or the modified barium swallow. However, it may be the first phase of the examination performed or the only portion of the examination performed, or it may not be performed at all.

Modified barium esophagography is used to define the anatomy of the oropharynx and to assess its function in swallowing.12 It may also guide rehabilitation strategies aimed at eliminating a patient’s swallowing symptoms.

Most patients referred for this test have sustained damage to the central nervous system or structures of the oropharynx, such as stroke or radiation therapy for laryngeal cancer. Many have difficulty in starting to swallow, aspirate when they try to swallow, or both.

In this test, thin liquids are given to the patient in escalating amounts. The patient is then given thicker foods, including thick liquids, purees, and food requiring chewing. If the patient has difficulty swallowing, intervention and therapeutic strategies are initiated. If the test is done by itself and the speech pathologist cannot find a cause of the patient’s symptoms, then barium esophagography should be performed by a radiologist.

The final esophagographic report should document the findings of each phase of the examination (Table 2).

WHAT HAPPENED TO OUR PATIENT?

Our patient underwent barium esophagography (Figure 2). A distal mucosal ring that transiently obstructed a 13-mm tablet was found. The patient underwent endoscopy and the ring was dilated. No biopsies were necessary.

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