When do you order an X-ray esophagram versus an upper GI (gastrointestinal) series, and when do you order an upper GI series with small bowel follow-through?

When to Order X-ray Esophagram vs Upper GI Series vs Upper GI with Small Bowel Follow Through

The choice between an X-ray esophagram, upper GI series, or upper GI with small bowel follow through should be based on the specific anatomical region of concern, with esophagram for esophageal symptoms, upper GI series for stomach/duodenal symptoms, and small bowel follow through when distal small bowel pathology is suspected. 1

X-ray Esophagram (Barium Swallow)

When to Order:

• Primary esophageal symptoms:
  • Dysphagia (difficulty swallowing)
  • Odynophagia (painful swallowing)
  • Suspected esophageal stricture or ring
  • Evaluation of hiatal hernia
  • Suspected reflux esophagitis
  • Esophageal motility disorders

Key Features:

• Provides anatomic and functional information on:
  • Esophageal length
  • Presence/size of hiatal hernia
  • Esophageal diverticula
  • Strictures
  • Gastroesophageal reflux with provocation 1
• Can be performed as single or double-contrast study:
  • Single-contrast: 77% sensitivity for esophagitis
  • Double-contrast: 80% sensitivity for esophagitis
  • Combined technique: 88% sensitivity (preferred approach) 1

Upper GI Series

When to Order:

• Stomach and duodenal symptoms:
  • Epigastric pain with nonspecific symptoms
  • Suspected gastritis
  • Suspected peptic ulcer disease
  • Suspected gastric cancer
  • Evaluation of large hiatal hernia (to assess stomach)
  • Post-surgical evaluation of gastric procedures

Key Features:

• Evaluates structural and functional abnormalities of:
  • Esophagus
  • Stomach
  • Duodenum 1
• Can detect:
  • Gastritis (enlarged areae gastricae, thickened folds, erosions)
  • Ulcers
  • Masses
  • Malignancy (ulcer with nodularity, mass effect, irregular folds) 1
• Particularly valuable for scirrhous gastric carcinoma, which may be difficult to diagnose with endoscopy 1

Upper GI Series with Small Bowel Follow Through

When to Order:

• Small bowel symptoms or suspected pathology:
  • Unexplained gastrointestinal bleeding
  • Suspected small bowel tumor
  • Small bowel obstruction
  • Crohn's disease
  • Malabsorption 2
  • Following completion of stomach examination when small bowel evaluation is also needed 3

Key Features:

• Extends the upper GI series to visualize the jejunum and ileum
• Can be performed:
  • Undiluted (higher density, slower transit)
  • Diluted 1:1 with water (lower density, faster transit) 3
• Typical adult dose: 340-750 mL of diluted or undiluted contrast 3
• Higher sensitivity than CT for detecting early mucosal lesions like aphthoid ulcers in Crohn's disease 4

Technical Considerations

Contrast Agents:

• Barium sulfate: Most commonly used
  • For esophagram: Undiluted for double-contrast examination
  • For stomach: Can be used undiluted or diluted 1:1 with water
  • For small bowel: Can be given undiluted or in 1:1 dilution 3
• Gastrografin (water-soluble contrast):
  • Used when perforation is suspected
  • Has mild laxative effect due to high osmolarity 5

Examination Types:

• Single-contrast: Uses low-density barium suspension
  • Better for detecting hiatal hernias, rings, strictures 1
• Double-contrast: Uses high-density barium suspension
  • Better for detecting inflammatory or neoplastic diseases 1
• Combined technique: Highest sensitivity (88%) 1

Common Pitfalls and Caveats

1. Incomplete evaluation: Ensure appropriate study is ordered based on symptoms

   • Esophagram alone will not evaluate the stomach adequately
   • Upper GI series without small bowel follow through may miss distal small bowel pathology

2. Patient preparation: Proper fasting is essential for all studies

   • Residual food can mimic lesions or obscure pathology

3. Radiation exposure: Consider radiation dose, especially in young patients

   • Use the most targeted examination for the clinical question

4. Complementary role with endoscopy:

   • Barium studies provide functional information that endoscopy cannot
   • Endoscopy allows for tissue sampling that radiography cannot provide 6

5. Small bowel follow-through limitations:

   • Conventional overhead-based small bowel follow-through has lower diagnostic yield
   • Fluoroscopy-based follow-through is more effective 2

By selecting the appropriate radiographic study based on the suspected anatomical region of pathology, clinicians can optimize diagnostic yield while minimizing unnecessary radiation exposure and cost.