What is the purpose and procedure of a barium swallow?

Purpose and Procedure of a Barium Swallow

A barium swallow is a fluoroscopic examination used to evaluate the structure and function of the pharynx and esophagus, with the primary purpose of diagnosing conditions causing dysphagia (difficulty swallowing), detecting structural abnormalities, and assessing swallowing function. 1, 2

Types of Barium Swallow Examinations

• Standard Barium Swallow/Esophagram: Evaluates the esophagus and can be performed as a single-contrast or biphasic (double-contrast) examination 1

• Modified Barium Swallow: A video fluoroscopic procedure performed with a speech therapist that focuses on the oral cavity, pharynx, and cervical esophagus to assess swallowing function 1

• Timed Barium Swallow: A standardized protocol that specifically assesses esophageal emptying, particularly useful for evaluating achalasia and treatment response 3, 4

Procedure Components

Standard Barium Swallow/Esophagram

• Patient swallows barium sulfate contrast material while fluoroscopic images are obtained 1
• Biphasic examination includes:
  • Double-contrast phase with high-density barium to optimize detection of mucosal lesions 1
  • Single-contrast phase with low-density barium to better evaluate hiatal hernias, rings, or strictures 1
  • Various patient positions (upright, prone) to fully evaluate the esophagus 1

Modified Barium Swallow

• Focuses on the oral cavity, pharynx, and cervical esophagus 1
• Patient swallows various consistencies of barium and barium-impregnated food 1
• Dynamically evaluates:
  • Bolus manipulation and tongue motion
  • Hyoid and laryngeal elevation
  • Pharyngeal constrictor motion
  • Epiglottic tilt
  • Laryngeal penetration and aspiration
  • Cricopharyngeus muscle function 1

Clinical Indications

• Oropharyngeal Dysphagia: Modified barium swallow is preferred for initial evaluation 2

  • Particularly useful in patients with neurological disorders (stroke, dementia, myasthenia gravis) 1
  • Can detect aspiration, including silent aspiration 5

• Retrosternal Dysphagia: Biphasic esophagram is preferred 1

  • Evaluates for structural abnormalities (strictures, rings, tumors) and motility disorders 1

• Unexplained Dysphagia: Combined examination of oral cavity, pharynx, esophagus, and gastric cardia is recommended 1

  • Important because distal esophageal abnormalities can cause referred sensation to the pharynx 1

• Post-surgical Evaluation: Single-contrast with water-soluble contrast is preferred in immediate post-operative period 2

• Suspected Motility Disorders: Can provide valuable diagnostic information before proceeding to manometry 2, 3

Special Patient Considerations

• Elderly or Debilitated Patients: Single-contrast technique may be better suited as they may be unable to fully cooperate with biphasic examination 1

• Bariatric Patients: Standard barium swallow tests may be limited by equipment weight restrictions and altered post-surgical anatomy 6

  • Single-contrast esophagrams with water-soluble contrast are often preferred 6

• Risk of Aspiration: Caution should be used in patients with history of food aspiration or unknown integrity of swallowing mechanism 7

  • If aspiration occurs, further administration should be discontinued immediately 7

Advantages and Limitations

Advantages

• Non-invasive evaluation of both structure and function 3
• Can simultaneously assess swallowing function, esophageal motility, and structural abnormalities 8
• May have higher sensitivity than endoscopy for detecting subtle strictures 3

Limitations

• Exposes patient to radiation 9
• May not provide as detailed mucosal assessment as endoscopy 10
• Protocols and interpretation terminology are often subjective and non-standardized 3

Post-Procedure Considerations

• Important to rehydrate the patient quickly to prevent impaction of the bowel by barium sulfate 7
• Mild laxatives such as milk of magnesia or lactulose may be recommended following the examination, especially in patients with history of constipation 7

By providing both structural and functional information about the pharynx and esophagus, barium swallow examinations remain a valuable diagnostic tool in the evaluation of dysphagia, despite advances in other diagnostic modalities.