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GASTROINTESTINAL IMAGING |
Imaging Tips for Performing a
Perfect Barium Swallow
David J. DiSantis, MD The full digital presentation is available online.
Jacob I. Lewis, MD
Christine O. Menias, MD Along with all gastrointestinal (GI) fluoroscopic studies, the num-
Dennis M. Balfe, MD ber of esophagrams being performed has fallen in recent decades.
Desiree E. Morgan, MD
This trend stems from a concatenation of circumstances and
Joseph G. Cernigliaro, MD
perceptions that include (a) a growing shortage of teachers experi-
RADIOGRAPHICS FUNDAMENTALS
enced in performing GI fluoroscopy; (b) relatively low reimburse-
Abbreviation: GI = gastrointestinal
ment for fluoroscopic procedures; (c) the common view of barium
RadioGraphics 2019; 39:1325–1326 radiology as labor intensive, time consuming, and technically de-
[Link] manding; and (d) an endoscopy-first mentality among nonradiolo-
Content Code: gist physicians that undervalues the usefulness of obtaining barium
From the Department of Radiology, Mayo
swallow studies. Yet, fluoroscopic studies of the esophagus are not
Clinic, 4500 San Pablo Rd, Jacksonville, FL disappearing. Medicare data provided by the American College of
32224 (D.J.D., J.I.L., J.G.C.); Department Radiology Harvey L. Neiman Health Policy Institute indicate that
of Radiology, Mayo Clinic, Scottsdale, Ariz
(C.O.M.); Mallinckrodt Institute of Radiology, in 2017, more than 679 000 esophagrams were performed in the
Washington University School of Medicine, St United States alone, along with 1.3 million barium swallow studies.
Louis, Mo (D.M.B.); and Department of Ra-
diology, University of Alabama at Birmingham,
In trained hands, barium esophagography offers an excellent
Birmingham, Ala (D.E.M.). Recipient of a Cer- tool for assessing swallowing, evaluating esophageal morphology
tificate of Merit award for an education exhibit and motility, and demonstrating postoperative complications. As a
at the 2018 RSNA Annual Meeting. Received
March 10, 2019; revision requested May 1 and single test of both structure and function, its role is unique. Com-
received May 30; accepted June 7. The author pared with esophageal endoscopy, manometry, and pH monitoring,
D.J.D. has provided disclosures (see end of ar-
ticle); all other authors have disclosed no rel-
barium esophagography is quick, noninvasive, less expensive to per-
evant relationships. Address correspondence form, and does not require sedation. Because fluoroscopic studies
to D.J.D. (e-mail: djdisantis@[Link]). are less costly and widely available, they offer a particularly practi-
D.E.M. supported by a GE Healthcare grant. cal option in less sophisticated and less affluent health care settings.
©
RSNA, 2019 Consequently, both single- and dual-phase esophagrams remain
valuable tools in the contemporary radiology armamentarium,
and practitioners should be facile with both. While single-phase
TEACHING POINTS
■■ Barium esophagography remains a useful technique for evaluating esophageal structure
and function.
■■ The dual-phase esophagographic technique is easily learned and requires the use of basic
equipment only.
■■ Proper esophagographic technique permits diagnosis of a broad range of esophageal
pathologic conditions.
1326 September-October 2019 [Link]
esophagrams are particularly appropriate for
postoperative evaluation, imaging a patient who
is debilitated or immobile, assessing esopha-
geal motility, and depicting rings and strictures,
dual-phase esophagrams provide greater sensitiv-
ity for detecting mucosal pathologic conditions
such as infectious, inflammatory, and reflux
esophagitides. Fastidious technique is essential to
prevent false-negative and false-positive results.
For example, excess barium can hide a mucosal
pathologic finding, while undissolved effervescent
crystals can mimic pathologic conditions.
Because proper technique is fundamental
for obtaining quality barium esophagrams, the
central aim of our online presentation is to offer
step-by-step guidance on how to perform the
procedure. Written directions describe the se-
quence of steps, the use of contrast material, and
appropriate patient positioning for obtaining op-
timal images. This online presentation is supple- Figure 1. Lateral poste-
rior oblique double-con-
mented with a 6-minute instructional video that trast esophagram shows a
simultaneously displays what is happening in the stacked-rings contour of the
fluoroscopy suite and the imaging results on the lumen, a finding indicative
fluoroscopy screen. In addition, we have provided of eosinophilic esophagitis.
a short how-to guide or “recipe card,” which is a
suitable size for mounting on a fluoroscope tower
for quick reference during procedures. Finally, we
include examples of the wide array of pathologic
conditions detectable with these newly honed
esophagographic skills and provide advice regard-
ing the best techniques to use for detecting them
(Figs 1, 2).
Because of its versatility, barium esophagogra-
phy is one GI fluoroscopic study that continues
to be performed in nearly all radiology practices
every day. Since, for the foreseeable future, we
radiologists will continue to be performing these
studies, our patients deserve that we learn to
perform them well.
Acknowledgments.—The authors wish to acknowledge
Lauren Bacon, BAS, RT, and James Barlow for their
invaluable help.
Figure 2. Left posterior oblique single-contrast esoph-
agram shows cervical esophageal strictures (arrows) in a
Disclosures of Conflicts of Interest.—D.J.D. Activities patient with lichen planus.
related to the present article: disclosed no relevant rela-
tionships. Activities not related to the present article: hono-
rarium and travel expenses for four lectures from the on Barium Esophagography in Gastroesophageal Reflux
University of California at San Francisco. Other activi- Disease. AJR Am J Roentgenol 2016;207(5):1009–1015.
ties: disclosed no relevant relationships. Levine MS, Rubesin SE. Diseases of the esophagus: a pattern
approach. Abdom Radiol 2017;42(9):2199–2218.
Rubesin SE, Jessurun J, Robertson D, Jones B, Bosma JF,
Suggested Readings Donner MW. Lines of the pharynx. RadioGraphics
Koehler RE, Weyman PJ, Oakley HF. Single- and double- 1987;7(2):217–237.
contrast techniques in esophagitis. AJR Am J Roentgenol Tao TY, Menias CO, Herman TE, McAlister WH, Balfe DM.
1980;135(1):15–19. Easier to swallow: pictorial review of structural findings of
Levine MS, Carucci LR, DiSantis DJ, et al. Consensus Statement the pharynx at barium pharyngography. RadioGraphics
of Society of Abdominal Radiology Disease-Focused Panel 2013;33(7):e189–e208.
