The barium esophagram is an integral part of the assessment and management of patients with gastroesophageal reflux disease (GERD) before, and especially after, antireflux procedures. While many of the findings on the examination can be identified with endosocopy, a gastric emptying study and an esophageal motility examination, the barium esophagram is better at demonstrating the anatomic findings after anti-reflux surgery, especially in symptomatic patients. These complementary examinations, when taken as a whole, fully evaluate a patient with suspected GERD as well as symptomatic patients after antireflux procedures.
Key points
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The barium esophagram is an integral part of the assessment and management of patients with gastroesophageal reflux disease (GERD) before, and especially after, antireflux procedures.
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While many of the findings on the examination can be identified with endosocopy, a gastric emptying study and an esophageal motility examination, the barium esophagram is better at demonstrating the anatomic findings after antireflux surgery, especially in symptomatic patients.
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These complementary examinations, when taken as a whole, fully evaluate a patient with suspected GERD as well as symptomatic patients after antireflux procedures.
In the age of endoscopy, pH studies, and high-resolution manometry and impedance, the barium esophagram has been deemphasized in the diagnosis and management of patients with suspected gastroesophageal reflux disease (GERD). Unfortunately, as a result, as in most luminal gastrointestinal radiology, training for this important examination has suffered, resulting in the inability of recently trained radiologists to perform an adequate examination. Nevertheless, this examination is a vital part of a patient’s workup when GERD is suspected. This examination helps define both the morphology and function of the esophagus, identifying important findings relevant to treatment as well as suggesting diagnoses other than GERD. The authors believe that the examination is essential in defining the anatomic causes of symptoms after antireflux surgery. At the Cleveland Clinic many, if not most patients with suspected GERD are evaluated with a barium esophagram, especially if antireflux surgery is contemplated. Furthermore, all symptomatic patients after antireflux procedures are also evaluated with a barium esophagram.
Esophagram: important general elements of the examination
Several factors are important to the success of a well-performed barium esophagram. First, the complete examination should be recorded in some fashion. A DVD recorder directly set up to the fluoroscopy unit will burn a DVD of the examination. With modern PACS (picture archiving and communication system), it is now possible to capture the fluoroscopic examination directly in DICOM (digital imaging and communications in medicine) format, and save the study without the hard-copy problems of a disk. Second, to reduce radiation exposure a pulsed-fluoroscopy unit is best, generally at 15 pulses per second, to reduce frame flickering. Third, if the patient has a specific complaint, such as dysphagia, before the start of the examination, the radiologist should encourage the patient to voice these symptoms when they occur during the examination.
Just before the examination, a brief history should be elicited from the patient including the presence of dysphagia, regurgitation, chest pain, and heartburn, as well as duration of symptoms and significant weight loss. Symptoms of GERD are often similar to those of a severe dysmotility disorder, most commonly achalasia and less commonly diffuse esophageal spasm. Therefore, when a patient complains of dysphagia, the examiner must know whether it is to solids alone or to both solids and liquids. When liquid dysphagia is a significant part of the history, the patient starts in the upright position, swallowing a small amount of low-density barium. If there is any delay in emptying, or findings suggesting achalasia, such as a dilated esophagus or a bird-beak appearance of the distal esophagus, the patient proceeds to a timed barium swallow. If the examiner starts the study of a patient with unsuspected achalasia with the routine, air-contrast examination, using gas-producing crystals and high-density barium, the subsequent study is largely ruined.
There are multiple phases of a barium esophagram, not all of which need be performed ( Box 1 ). It is important to tailor the examination to the patient based on condition, signs and symptoms, and ability to ingest various densities of barium, a barium tablet, or various foodstuffs.
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Timed barium swallow (assesses esophageal emptying with the patient in the upright position)
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Upright phase (most often performed using air-contrast techniques)
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Motility phase performed primarily in the right anterior oblique position (performed in the semiprone position)
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Distended or full-column phase performed primarily in the right anterior oblique position (performed in the semiprone position with the patient rapidly drinking)
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Mucosal relief phase (observed at the end of the distended or full-column phase of the examination)
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Reflux assessment (after esophagus has emptied, with the patient in the supine or left posterior oblique position)
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“Solid” food assessment (13 mm barium tablet, marshmallow, or offending food)
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Gastric findings, including emptying (observing the gastric motility fluoroscopically)
Esophagram: important general elements of the examination
Several factors are important to the success of a well-performed barium esophagram. First, the complete examination should be recorded in some fashion. A DVD recorder directly set up to the fluoroscopy unit will burn a DVD of the examination. With modern PACS (picture archiving and communication system), it is now possible to capture the fluoroscopic examination directly in DICOM (digital imaging and communications in medicine) format, and save the study without the hard-copy problems of a disk. Second, to reduce radiation exposure a pulsed-fluoroscopy unit is best, generally at 15 pulses per second, to reduce frame flickering. Third, if the patient has a specific complaint, such as dysphagia, before the start of the examination, the radiologist should encourage the patient to voice these symptoms when they occur during the examination.
Just before the examination, a brief history should be elicited from the patient including the presence of dysphagia, regurgitation, chest pain, and heartburn, as well as duration of symptoms and significant weight loss. Symptoms of GERD are often similar to those of a severe dysmotility disorder, most commonly achalasia and less commonly diffuse esophageal spasm. Therefore, when a patient complains of dysphagia, the examiner must know whether it is to solids alone or to both solids and liquids. When liquid dysphagia is a significant part of the history, the patient starts in the upright position, swallowing a small amount of low-density barium. If there is any delay in emptying, or findings suggesting achalasia, such as a dilated esophagus or a bird-beak appearance of the distal esophagus, the patient proceeds to a timed barium swallow. If the examiner starts the study of a patient with unsuspected achalasia with the routine, air-contrast examination, using gas-producing crystals and high-density barium, the subsequent study is largely ruined.
There are multiple phases of a barium esophagram, not all of which need be performed ( Box 1 ). It is important to tailor the examination to the patient based on condition, signs and symptoms, and ability to ingest various densities of barium, a barium tablet, or various foodstuffs.
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Timed barium swallow (assesses esophageal emptying with the patient in the upright position)
- •
Upright phase (most often performed using air-contrast techniques)
- •
Motility phase performed primarily in the right anterior oblique position (performed in the semiprone position)
- •
Distended or full-column phase performed primarily in the right anterior oblique position (performed in the semiprone position with the patient rapidly drinking)
- •
Mucosal relief phase (observed at the end of the distended or full-column phase of the examination)
- •
Reflux assessment (after esophagus has emptied, with the patient in the supine or left posterior oblique position)
- •
“Solid” food assessment (13 mm barium tablet, marshmallow, or offending food)
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Gastric findings, including emptying (observing the gastric motility fluoroscopically)
The preoperative barium esophagram
Initial Upright Phase
If there is liquid dysphagia, an initial timed barium swallow is performed ( Fig. 1 ). With the patient in the upright position, the patient is asked to ingest up to 250 mL of low-density barium. The patient is told that the volume is entirely self-regulated and based on his or her tolerance level. The patient is allowed to ingest the barium over 45 seconds after which an upright spot film is taken, attempting to include the entire barium column on this film. If the column is too high, 2 spot films are take, 1 lower and 1 upper. If barium does not empty, the authors then take 2- and 5-minute films. Unless the barium has emptied in the interval, the 1- and 5-minute films are compared, measuring the height and width of the barium column on both. It is important to keep the image intensifier or tower at the same distance from the patient for all the spot films, so as not to alter the level of magnification. The amount of barium ingested is also recorded. A normal esophagus should empty 250 mL of low-density barium within seconds.
If there is no significant liquid dysphagia, the examination should start with the patient in the upright position, preferably using an air-contrast technique. In the authors’ practice, the upright position helps in identifying a foreshortened or short esophagus (also known as a fixed, hiatal hernia) ( Fig. 2 ). Many surgeons, especially thoracic surgeons, consider it important to preoperatively identify a foreshortened esophagus, as this often leads to the addition of a Collis gastroplasty or lengthening procedure, rather than a Nissen fundoplication alone. Their belief is that with a short esophagus the hernia often cannot be completely mobilized and reduced below the diaphragm, especially using abdominal, laparoscopic techniques. If the esophagus is not adequately mobilized and the hernia reduced, the hernia repair is under tension, given the propensity of the foreshortened esophagus to pull back into the mediastinum; this often leads not only to disruption of the hiatus repair and a recurrence of the hernia, but also to a disruption of the fundoplication. It should be noted that not all surgeons believe in the concept of a short esophagus.
In most practices, endoscopy is used to identify reflux esophagitis and Barrett esophagus. Nonetheless, the air-contrast portion of the examination can identify findings of reflux esophagitis and Barrett esophagus, although with much lower sensitivity. The findings of mild reflux esophagitis include a fine nodular or granular mucosal pattern. Changes of moderate to severe reflux esophagitis vary from shallow ulcers and erosions to longitudinal fold thickening and submucosal ridging. Peptic stricture formation is the most significant finding of severe esophagitis. A high esophageal stricture or ulcer and a reticular pattern are strongly associated with Barrett esophagus ( Fig. 3 ). Using meticulous technique, the air-contrast portion of the examination can identify patients at low, moderate, or high risk for Barrett esophagitis. In a blinded retrospective study of 200 patients with severe reflux symptoms examined with double-contrast esophagrams and endoscopy, moderate risk was considered present when there was a distal stricture or esophagitis, and high risk if there was a high stricture or ulcer or a reticular pattern. The sensitivity of the esophagram for moderate or severe esophagitis was 71% and for severe esophagitis 85%, with endoscopy detecting only 20 of 46 (43%) of radiographically diagnosed strictures, and with endoscopy failing to identify any stricture not identified on esophagography. Using the esophagram as a method of selecting patients based on moderate or high risk for Barrett esophagus, the overall radiologic sensitivity was 95% (21 of 22) but the specificity was only 65% (116 of 178). The positive predictive value was only 25% (21 of 83) but the negative predictive value was 99% (116 of 117).
If the air-contrast phase cannot be performed, it is still essential to attempt to examine the patient in the upright position with low-density barium to identify a fixed hiatal hernia (ie, foreshortened esophagus).
Semiprone or Right Anterior Oblique Phase
The motility portion of the examination is important because it demonstrates the presence and state of peristalsis and bolus transfer, something that only impedance can show. Seminal work by Ott and Richter showed that if 4 of 5 single swallows on a barium esophagram were normal, showing normal bolus transfer in an aboral fashion, then the manometry was normal as well. The examiner must focus attention on the inverted V of the tail end of the barium column to properly assess the motility (this corresponds to the upstroke of the pressure wave identified on manometry) ( Fig. 4 ). In one retrospective series of 151 patients, the frequency of dysmotility (defined by intermittent weakened or absent peristalsis without or with multiple transient indentations on the barium column as the peristaltic wave traversed the esophagus) was much higher in patients with GERD than in those without.
With the full implementation of high-resolution manometry and the concurrent use of high-resolution impedance with high-resolution manometry, the impact of the barium assessment of motility has been reduced. The combination of these 2 techniques will show whether low-amplitude peristalsis will have any effect on bolus transit. Regardless, unsuspected and severe motility disorders can be identified during the esophagram, leading to a more detailed analysis with these new techniques. Conversely, if 4 of 5 separate swallows are normal, it is very unlikely that a motility disorder exists.
The full-column, distended, or rapid-drinking phase of the examination identifies overall esophageal distensibility, extrinsic compression or narrowing, strictures, and distal mucosal rings. It may be difficult for patients with long-standing, significant dysphagia to rapidly drink, as they have mentally accommodated over time to not do so. It is important for the examiner to encourage the patient to drink as rapidly as tolerable. During this phase, the authors often slowly pan down the entire course of the esophagus during fluoroscopy, not taking spot films, to identify contour abnormalities and assess the distensibility of the lumen. Special attention should be focused on the distal esophagus, in the region of the epiphrenic ampulla and gastroesophageal junction, a common site of disease. Diffuse, subtle narrowing of the esophagus can result from GERD, but other causes must be considered, especially eosinophilic esophagitis (EOE). EOE is increasingly recognized as a common cause of dysphagia, but unfortunately many of the patients have been misdiagnosed with GERD, as EOE and GERD symptoms overlap.
Directly after the cessation of the rapid drinking is the start of the mucosal relief portion of the examination. This underutilized part of the evaluation is important in several respects. First, the ringed esophagus sometimes present in EOE is often only identified during this phase. Second, thickened esophageal folds from esophagitis are best identified during this phase. If one is unable to adequately coat the esophagus with high-density barium, the only other way to diagnose mild to moderate esophagitis is by identifying fold thickening.
Reflux Identification Phase
The next phase of the examination is to identify gastroesophageal reflux. While the patient remains in the semiprone position, after the mucosal relief stage the esophagus is fluoroscopically assessed for retained barium. If present, the table is raised to the semierect position and the patient is given some water to clear the esophagus of barium. Then, after resuming the horizontal position, the patient is turned to the supine position and the esophagus is examined fluoroscopically. If barium is present in the esophagus, it must have refluxed with motion. If barium is not present the authors proceed with a series of maneuvers starting with a cough or Valsalva maneuver, and then to a water siphon test.
This graded approach in a well-performed investigation increased the sensitivity of identifying reflux when compared with 24-hour pH monitoring studies. When reflux occurs the authors record the cause, if not spontaneous, the height of the reflux (distal, mid, and proximal thoracic and cervical) as well as the length of time the barium remains in the esophagus (<30 or >30 seconds).
This phase of the examination is less important vis-à-vis continuous pH monitoring using a catheter or capsule. However, it is important when there is repeated, continuous, and spontaneous reflux to the cervical esophagus. Trace, intermittent, or low-volume reflux identified on barium studies has little to no clinical significance.
Solid Food Ingestion Phase
The next part of the examination is to assess for the passage of solid food. The authors generally use a 13-mm barium tablet and have the patient ingest the tablet with water. If tablet passage is impaired, the patient ingests low-density barium to identify the precise site and cause, and whether symptoms were elicited (again, before the examination, the patient should be encouraged to voice symptoms if such symptoms occur during the examination). It is common for the tablet to transiently hang up at the level of the transverse aorta and at the level of the gastroesophageal junction. Some institutions administer a standard 30 × 30-mm or a smaller 13 × 12-mm marshmallow (sometimes used in hot chocolate) rather than a 13-mm barium tablet in patients with a distal mucosal ring.
If the patient has consistent dysphagia with a particular food, it is best for the referring physician to have the patient bring that food to the fluoroscopy suite. Ingesting the food, combined with barium paste, can be instructive in 2 ways. First it can show the site and cause of obstruction. More often in the authors’ experience, it shows that there is no obstruction. When patients view the examination and sees that there is nothing causing obstruction their anxiety is often relieved, and their often chronic symptoms may resolve.
Feline Esophagus
The feline esophagus is a transient finding on barium esophagrams, most often fleetingly seen during the air-contrast portion of the examination when the esophagus is collapsing. The finding is that of narrowly spaced, transverse folds, giving a crenulated or accordion appearance, a finding caused by contraction of the longitudinal muscles in the esophagus. The cat esophagus has a similar appearance, hence the naming of this finding.
There is controversy as to whether this finding is caused by GERD or is merely associated with GERD. In a recent investigation from the University of Pennsylvania, during a 2-year period 20 of 224 patients examined with a barium esophagram had a feline esophagus, which was detected during barium reflux in 17 of these 20 patients. Gastroesophageal reflux (GER) of barium was present in all 20 patients, of whom 10 had marked GER and 7 moderate GER (marked GER as defined by reflux of barium to or above the thoracic inlet; moderate GER as defined by reflux of barium to the level of the midthoracic esophagus or aortic arch). From this and other investigations, it seems prudent to investigate patients with this finding for the presence of GERD.
Distal Mucosal Ring (Schatzki Ring)
A distal mucosal ring is an idiopathic ridge of tissue composed of mucosa and submucosa located at the gastroesophageal junction ( Fig. 5 ). It is often only identified during the semiprone distended phase of the examination, and by definition is associated with a small, often sliding type I hiatal hernia. It was first described by Templeton in 1944, and later reported by Schatzki and Gary and Ingelfinger and Kramer in 1953. Later reports just identify the ring as the Schatzki ring. Because multiple investigators have described the ring, the authors prefer to use the term distal mucosal ring. There is controversy as to the etiology of this redundant tissue, but the finding, like the feline esophagus, is strongly correlated with GERD. Some gastroenterologists recommend that patients with this finding be evaluated for GERD with pH monitoring.
