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Barium swallow

Radswiki and Dr Jeremy Jones et al.

The barium swallow is a dedicated test of the upper GI tract and may be performed as a single or double contrast study.

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

However, there remain some situations where barium swallow is indicated:

high or low dysphagia
gastro-oesophageal reflux disease (GORD)
assessment of hiatus hernia
generalised epigastric pain
globus hystericus
post-operative assessment for leak
suspecated perforation
persistent vomiting
assessment of fistula
failed intubation during UIGE

Examination 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: It needs dynamic video-fluoroscopic examination as well as double contrast spot films. Scout films are obtained to rule out any foreign body, abscess or fistula. Right lateral and frontal views are obtained after patient swallowing high density barium. Patient is asked to avoid repeated swallowing. Spots are obtained quickly during suspended respiration and under phonation (patient instructed to say "Eeeee....").

Evaluation of oesophagus: Double 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 centered on upper/mid oesophagus and two on distal oesophagus.

Then, table is brought to horizontal position and patient turns to right lateral position for view of gastric cardia and fundus. Then, patient drinks low density barium in prone right anterior oblique position. Two to five separate swallows are assesed to evaluate motility of esophagus. This also permits evaluation of distal esophagus and GE junction, delineating lower esophageal rings (Schatzki's 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 and elicits Gastro-esophageal reflux. Straight leg raising, Valsalva manoevre or drinking water can also elicit the reflux.

Additional views like mucosal relief views are useful in suspected tumors, varices or esophagitis.