BARIUM SWALLOW

Dr Riyas Ahamed
Dr Umamageshwari
• Barium swallow is the non invasive contrast procedure used
in assessing the anatomy, physiology & pathology of upper Gl
tract including esophagus & GE junction.
• Barium has superior contrast qualities and unless there are
specific contraindications, its use (rather than water-soluble
agents) is preferred.
BARIUM SULPHATE - 250% OF
HIGH DENSITY LOW VISCOSITY
• The most common material for radiographic visualization of GIT.
• Made up from pure barium sulphate.
• The particles of barium must be small (0.1–3 µm), since this makes
them more stable in suspension.
• A non-ionic suspension medium is used to avoid clumping.
• Ph is 5.3, which makes it stable in gastric acid.
BARIUM SULPHATE
• Ba has a high atomic number -56. Therefore, it is highly radioopaque.
• Non absorbable, non-toxic.
• Insoluble in water/lipid.
• Inert to tissues.
• Can be used for double contrast studies
Advantages and Disadvantages of Barium
Advantages Disadvantages

• Not absorbed or degraded by the GIT. • Leakage into mediastinum or

• Coat the mucosa in a thin layer for peritoneum can cause fibrosis.
long period of time, thus allowing the • Subsequent abdominal CT and US are
introduction of a second or negative difficult to interpret
contrast agent without significant • Intravasation - this may result in
degradation. pulmonary embolus, which carries a
• Low cost mortality of 80%
• Long standing barium deposits are
carcinogenic
Barium suspension and dilution with water to
give lower density
 Indications of Barium Swallow
1. Dysphagia and obstruction.
2. Pain during swallowing.
3. Assessment of mediastinal masses.
4. Assessment of left atrial enlargement.
5. Pre-op assessment of carcinoma bronchus and oesophagus.
6. Motility disorders of oesophagus, E.g.: Achalasia and diffuse oesophageal
spasm, scleroderma.
7. Assessment of site of perforation.
8. Zenker's diverticulum and cricoid webs. In these cases water soluble
contrast media are used. E.g. : Gastrograffin or dionosil aqueous
RELATIVE CONTRAINDICATIONS
• Tracheo-oesophageal fistula.
• Perforation.
TECHNIQUE

• Patient is placed in erect RAO position(clear oesophagus of spine)

• Ample mouthful of Barium is swallowed and spot films are taken

(rapid sequence)

• Spot films of upper and lower oesophagus are taken

• Further rapid radiographic sequence are taken

 PHARYNX
• Patient is given one mouthful (10–15 ml) of barium sulphate paste.
• Fluoroscopic observation of swallowing (deglutition) is done in:
• Frontal view
• Lateral view
• Patient is in erect (standing) position during the observation.
• To get optimum pharyngeal distension:
• Exposure is taken when the hyoid bone reaches its highest point during
swallowing.
• Lateral film is taken in erect position.
• Frontal film is taken in supine position.
Technique to Get Optimum Mucosal Coating
• Patient is given one mouthful of barium sulphate paste.
• Instruct the patient to swallow once and then stop swallowing.
• Spot films are taken in frontal and Lateral view
• For better mucosal coating, Ask the patient to keep their mouth open or
instruct the patient to say “eee... eee...” after the single swallow.
• Alternatively, the patient can perform the Valsalva maneuver, done in erect
position with nose closed.
• These techniques help to show distended pyriform sinuses and valleculae.
 Oesophagus -Single Contrast
•Patient is given multiple mouthfuls of 80% w/v barium suspension.
•Barium bolus is followed down the oesophagus to observe peristalsis
•Observation is done in supine position.
Films are taken in erect position when the oesophagus is well distended:
•RAO (Right Anterior Oblique)
•LAO (Left Anterior Oblique)
•Frontal
•Lateral
•RAO view is preferred as it shows the oesophagus away from the spine.
•The escape of contrast at the level of the diaphragmatic hiatus should
not be confused for reflux
•Mucosal film is taken in RAO after the oesophagus is empty
•Then the fundus of the stomach, & G-0 junction are assessed with spot
films in different obliquities in erect and recumbent positions.
 Double Contrast
• Use high-density, low-viscosity barium (200–250% concentration).
• 15–20 ml of barium is given orally and the patient is asked to swallow.
• Then, effervescent powder is given along with another mouthful of
barium to produce gas.
• Erect position helps gas stay at the top, leading to better and longer-
lasting oesophageal distension compared to the supine position.
• Prone position also retains more gas for adequate distension.
• To prolong oesophageal distension:
• Use hypotonic agents such as Inj. Buscopan 2 ml IV or Glucagon
• Filming is done in Frontal, Lateral, RAO, LAO views
• Gas can also be introduced using a tube passed into the upper
oesophagus if needed.
 MUCOSAL RELIEF FILMS

• It is defined as films taken of collapsed esophagus with esophageal

folds visible & coated with barium suspension.
• Patient is asked to take one or two swallows of dense barium
suspension & after peristalsis has stripped most of the barium into
the stomach, radiographs are taken.
• It is important in the diagnosis of reflux esophagitis, infectious
esophagitis & esophageal varices.
 Evaluation of Pharynx
• Scout films - to rule out any foreign body, abscess / fistula

• Examine - Upright lateral view

• Right lateral views - to rule out aspiration or penetration

Evaluation of Esophagus
 Indentations of the Esophagus
•First Indentation – Aortic Arch
Caused by the arch of the aorta
Seen at the level of T4 vertebra

•Second Indentation – Left Main Bronchus

Caused by the left principal (main) bronchus
crossing the esophagus
Seen at the level of T5–T6 vertebrae

•Third Indentation – Left Atrium

Caused by the posterior surface of the left
atrium
Seen at the level of T7–T8 vertebrae
Becomes prominent in left atrial enlargement
 Oesophageal sphincter
Upper esophageal sphincter
• Primarily formed by cricopharyngeal muscle.
• Located at the C5-C6 level
• Normally relaxes with bolus
Abnormalities
• Delayed relaxation
• Early closure
• No relaxation: with or without symptoms; if symptomatic, termed
cricopharyngeal achalasia
Lower esophageal sphincter
• Distal 2-4 cm esophageal high pressure zone defined by manometry.
• Prevents gastroesophageal reflux.
 Lower Esophageal Rings

A-Ring
• Muscular contraction at the junction of tubular and vestibular esophagus
• No definite anatomic correlate
B-Ring
• Mucosal ring at anatomic squamocolumnar junction (Z-line)
• Best or only seen with vestibular distension
• Normally
May cause episodic dysphagia if esophagus is narrowed, then termed a
Schatzki ring
> 20 mm wide, no obstruction
13-20 mm wide, may obstruct
 Esophageal Web
Can be congenital or acquired
• More commonly occur in the cervical esophagus near
cricopharyngeus muscle Majority protrude from anterior esophageal
wall
• They typically arise from the anterior wall and never from the
posterior wall
• Symptoms if lumen > 50% compromised

Associations
• Plummer-Vinson syndrome (iron-deficiency anemia + dysphagia +
esophageal web).
• graft-versus-host disease
• gastro-esophageal reflux disease (especially a distal esophagus web)
• external beam radiation
• Symptoms: Intermittent dysphagia to solids, may be asymptomatic.
• Increased incidence of carcinoma
 Achalasia
• "Bird beak" sign:
• Smooth, tapered narrowing at the lower esophageal sphincter (LES).
• Looks like a bird’s beak pointing downward at the gastroesophageal junction.
• Marked dilatation of the proximal esophagus above the narrowed segment.
• Diameter may be >4 cm in chronic cases.
• No visible primary peristaltic waves during swallowing.
• Barium column shows delayed emptying.
• Air fluid level visible in upright films due to stasis.
• Due to chronic LES obstruction, no air enters the stomach, so the usual
gastric bubble is absent or reduced.
Dilated esophagus with
smooth, tapered narrowing
just above the level of the
gastroesophageal junction.
Esophageal peristalsis was
absent at fluoroscopy
Long-standing achalasia with a
sigmoid esophagus. There is a
massively dilated esophagus with a
tortuous distal configuration and
tapered narrowing(arrow) above
the gastroesophageal junction
caused by incomplete opening of
the [Link] sigmoid esophagus is a
sign of end-stage achalasia
 Pseudoachalasia
• Tapered narrowing at distal esophagus, similar to achalasia.
• most common causes is a malignancy (often submucosal gastric cancer)
• Often longer, irregular, or shouldered margins, unlike the smooth taper in
true achalasia.
• Margins of the distal esophagus may appear asymmetric, nodular, or
irregular, suggesting tumor infiltration.
• On imaging, may be less dilatation of the esophagus despite severe
narrowing — correlates with rapid onset.
• Shouldering - Abrupt transition between normal and narrowed segment.
• Indicates extrinsic or infiltrative mass, not typical in primary achalasia.
• Dilatation and contrast media stasis are
seen in the esophageal lumen,
with irregular long segment distal
narrowing inferring pseudoachalasia.
• There is usually more marked mucosal
irregularity of malignant lesions in
pseudoachalasia compared to the
primary achalasia.
 Diffuse Esophageal Spasm
• Chest pain and dysphagia are the primary complaints
• Corkscrew or Rosary Bead Esophagus
• Appears as multiple, simultaneous, non-peristaltic
contractions.
• The esophagus looks irregularly narrowed with
alternating dilatation and constriction — like a
corkscrew or a string of beads.
• Esophageal manometry is the gold standard:
Shows simultaneous, high-amplitude contractions in
multiple segments of the esophagus.
 Zenker’s Diverticulum
• A pharyngoesophageal (hypopharyngeal) pulsion diverticulum.
• Occurs through Killian’s dehiscence, a weak area between the
thyropharyngeus and cricopharyngeus muscles.
• Outpouching at the Posterior Hypopharynx (Posterior midline or left-
sided)
• Located just above the upper esophageal sphincter.
• Best seen in lateral views.
• Arises typically at C5-C6 level
A large contrast-filled out
pouching is seen in the posterior
aspect of the lower part of the
hypopharynx, inferring Zenker
diverticulum.
 Killian-Jamieson Diverticulum
• A pulsion diverticulum (like Zenker’s) but arises below the
cricopharyngeal muscle.
• Originates from the Killian-Jamieson area, which is lateral to the
esophagus, just below the upper esophageal sphincter.
• Arises anterolaterally from the cervical esophagus.
• Most commonly right-sided (though can be bilateral or left-sided).
• Best visualized on oblique or lateral barium swallow views.
• There is an 18 mm Killian-
Jamieson esophageal diverticulum
protruding on the left just inferior
to the cricopharyngeus.
• In addition, there is a Zenker
diverticulum arising from the
posterior wall immediately above
the level of the cricopharyngeus,
measuring 20 mm in maximum
diameter.
 Mid-Esophageal Diverticulum
• Usually a traction diverticulum.
• Commonly arises in the middle third of the esophagus, near the
carina (T6–T8 level).
• Often associated with inflammatory or fibrotic conditions, such as:
Mediastinal lymphadenitis (e.g., from TB or histoplasmosis)
Fibrosis from prior infections or surgeries.
• Location- Middle third of the esophagus, near or just above the
carina. Usually posterior or right-sided, due to anatomical pull from
the mediastinum.
• Small, triangular, or flask-
shaped outpouching.
• Points away from the
esophageal lumen, due to
external traction.
• May be symmetrical and
broad-based (traction
diverticulum) unlike pulsion
diverticula.
Epiphrenic diverticula
• Epiphrenic diverticula are pulsion diverticula of the
distal esophagus arising just above the lower esophageal sphincter,
more frequently on the right posterolateral wall.
• They are associated with:
• achalasia and other forms of neuromuscular dysfunction of the
esophagus
• hiatus hernia
• esophageal stricture
• esophageal web
• Large wide necked diverticulum
arising several centrimetres
proximal to the GEJ.
• The diverticulum contains a
progressively filling air fluid-level
following barium consumption.
 Pseudodiverticulosis

• Esophageal intramural
pseudodiverticulosis is an
uncommon condition in
which there are numerous
small outpouchings within
the esophageal wall.
• Dilated submucosal glands
causing multiple small
outpouching, usually due to
chronic reflux esophagitis.
 Barrett Esophagus
signs of reflux esophagitis
• reflux
• long stricture in the mid or lower esophagus
• large deep solitary ulcer
• fine reticular mucosal pattern
• thickened irregular mucosal folds
• earliest signs of developing adenocarcinoma: localized
flattening, stiffening, or irregularity in the wall of a stricture
• There is a ~70% chance of Barrett esophagus in a
midthoracic esophageal stricture
• . There is a ringlike constriction
(arrow) in the midesophagus.
• A smooth, tapered area of
narrowing (arrow) is seen in the
midesophagus. In the presence of a
hiatal hernia and gastroesophageal
reflux, a midesophageal stricture
should be strongly suggestive of
Barrett’s esophagus.
Barrett’s esophagus with a reticular mucosal pattern
 GERD
• Gastroesophageal reflux
(GERD) is the most
common cause of
esophagitis
• Thick esophageal mucosal
folds (arrows) and an ulcer
(arrowhead) due to GERD.
• Single contrast
esophagram shows
stricture (arrow) and
sliding hiatus hernia
 Hiatus Hernia
Type 1: sliding hiatal hernia (~95%)
• GE junction > 2 cm above hiatus
Type 2: para-esophageal hiatal hernia with the gastro-esophageal junction in a
normal position
• Gastric fundus protrudes through the hiatus
Type 3: mixed or compound type, paraesophageal hiatal hernia with displaced
gastro-esophageal junction. Gastric fundus herniates beside distal esophagus
Type 4: mixed or compound type hiatal hernia with additional herniation of viscera
Sliding hernia
Paraesophageal hernia
• gas filled gastric
fundus protrudes
through hiatus but GE
junction (arrow) is
below diaphragm.
Mixed hernia
• Distal esophagus is
adjacent to the herniated
gastric fundus, but unlike a
paraesophageal hernia, the
gastroesophageal junction
(arrow) is above rather
than below the diaphragm.
Candida esophagitis

The barium stury shows numerous fine erosions

and small plaques due to Candida albicans in
immunocompromised patient.
CMV Esophagitis
• Large, Linear Ulcers
• Appears as longitudinal or
transverse linear
ulcerations, usually in the
mid-to-distal esophagus.
• Ulcers are typically
shallow and well-defined
with smooth margins.
Eosinophilic Esophagitis
• Imaging finding include diffuse narrowing,
strictures, and a ringed appearance similar to
transverse (feline esophagus) folds that are
transient or associated with reflux.
Steroid therapy is often curative.
• On the left a patient with eosinophilic
esophagitis.
There is diffuse distal narrowing and
corrugated margins (arrows) due to ring-like
indentations, that are characteristic of
eosinophilic esophagitis.
 Feline Esophagitis
• Feline esophagus also known as esophageal
shiver, refers to the transient transverse bands
seen in the mid and lower esophagus on a
double-contrast barium swallow.
The characteristics of a feline esophagus are:
• Horizontal striations due to muscularis mucosa
contractions
• Most often transient and insignificant
• May be associated with gastroesophageal
reflux or esophagitis