What are the indications for an esophagram (esophageal swallow study)?

Indications for Esophagram

The primary indications for an esophagram (esophageal swallow study) include dysphagia, suspected structural or functional esophageal abnormalities, evaluation of immunocompromised patients with retrosternal symptoms, and assessment of postoperative complications. 1

Primary Indications

Dysphagia Evaluation

• Oropharyngeal dysphagia: When patients experience difficulty initiating swallowing

  • Especially when combined with video fluoroscopy to assess swallowing mechanics 1
  • Useful for detecting structural abnormalities like Zenker diverticulum and pharyngeal tumors

• Retrosternal dysphagia: When patients experience sensation of blockage between thoracic inlet and xiphoid process

  • Biphasic esophagram is preferred for initial evaluation 1
  • Can detect both structural and functional abnormalities

Structural Abnormality Detection

• Esophageal carcinoma (96% sensitivity with biphasic technique) 1
• Strictures (95% sensitivity, sometimes detecting strictures missed by endoscopy) 1
• Lower esophageal rings (95% detection rate, superior to endoscopy which detects only 76%) 1
• Esophagitis
• Mucosal lesions
• Webs and diverticula 2

Functional Abnormality Assessment

• Esophageal motility disorders (80-89% sensitivity, 79-91% specificity compared to manometry) 1
• Achalasia
• Diffuse esophageal spasm
• Gastroesophageal reflux 1, 2

Special Clinical Scenarios

• Immunocompromised patients with dysphagia/odynophagia:

  • Detection of infectious esophagitis (Candida, herpes simplex virus, cytomegalovirus) 1
  • Biphasic technique preferred for detecting ulcers or plaques 1

• Postoperative evaluation:

  • Assessment for leaks, strictures, or fistulae after neck, esophageal, or gastric surgery 1
  • Evaluation of swallowing function after laryngectomy 1
  • Assessment of complications after cervical spine surgery 1

Technique Selection Based on Indication

Biphasic Esophagram

• Best for: Initial evaluation of retrosternal dysphagia, suspected structural lesions
• Combines double-contrast views (for mucosal lesions) with prone single-contrast views (for rings/strictures) 1
• Superior for detecting mucosal abnormalities and cancer 1

Single-Contrast Esophagram

• Best for: Debilitated patients who cannot cooperate with biphasic technique
• Evaluation of postoperative leaks (using water-soluble contrast) 1
• Assessment of anastomotic strictures 1

Modified Barium Swallow

• Best for: Oropharyngeal dysphagia and swallowing dysfunction 1, 3
• Focuses on oral and pharyngeal phases of swallowing
• Limited in evaluating the entire esophagus 1

Clinical Pitfalls to Avoid

1. Inadequate esophageal distention: May miss important lesions like Schatzki's ring or peptic strictures 3

   • Solution: Ensure proper bolus challenge during examination

2. Relying solely on modified barium swallow for retrosternal symptoms:

   • Modified barium swallow does not evaluate the entire esophagus 1
   • Complete esophageal examination needed when pharyngeal symptoms exist

3. Missing synchronous lesions:

   • Patients with pharyngeal carcinomas have increased risk of esophageal carcinomas 1
   • Always evaluate the entire esophagus when a pharyngeal tumor is identified

4. Overlooking lower esophageal rings:

   • Prone single-contrast views are 2-3 times more likely to detect these than upright double-contrast views 1
   • Include prone positioning with continuous drinking for optimal detection

5. Assuming endoscopy is always superior:

   • Esophagram can detect certain strictures and rings missed by endoscopy 1
   • Radiologic and endoscopic approaches are often complementary 4

By selecting the appropriate esophagram technique based on the clinical presentation, clinicians can maximize diagnostic yield while minimizing unnecessary testing or missed diagnoses.