What is the best course of action for a patient with episodes of vomiting after eating, referred for a Modified Barium Swallow (MBS) study of the upper 1/3 of the esophagus with a Speech-Language Pathologist (SLP) present?

Management of Post-Eating Vomiting with MBS Referral

For a patient with episodes of vomiting after eating, refer to gastroenterology first to exclude structural and esophageal pathology before proceeding with a Modified Barium Swallow (MBS) study, as vomiting after eating typically indicates esophageal or gastric dysfunction rather than oropharyngeal dysphagia. 1

Initial Diagnostic Approach

The clinical presentation of vomiting after eating suggests esophageal or gastric pathology rather than oropharyngeal dysphagia, which typically manifests as difficulty initiating swallowing, coughing, choking during swallowing, or aspiration. 1, 2

Gastroenterology Referral Priority

• Esophagogastroduodenoscopy (EGD) is the initial test of choice for post-eating vomiting to identify structural lesions, strictures, gastric outlet obstruction, or mucosal abnormalities that may be causing symptoms. 1, 3
• Vomiting after eating in 30-60% of bariatric surgery patients is related to inappropriate eating behaviors, but can also indicate surgical complications such as band slippage, esophageal stricture, bowel obstruction, reflux, or gastric ulcers. 1
• Abnormalities of the distal esophagus or gastric cardia commonly cause referred symptoms to the throat, so pharyngeal symptoms do not necessarily indicate pharyngeal pathology. 1, 3

When MBS is Appropriate

The MBS study focuses specifically on the oral cavity, pharynx, and cervical esophagus to assess oropharyngeal swallowing function, not post-eating vomiting. 1, 4

MBS should be ordered when the patient has:

• Coughing or choking during swallowing (not after eating). 1, 5
• Nasal regurgitation of food, wet vocal quality after swallowing, or poor secretion management. 1, 5
• Known neurologic conditions (stroke, Parkinson's disease, dementia, ALS) that increase oropharyngeal dysphagia risk. 1, 5
• Suspected aspiration or silent aspiration (particularly in older adults). 1, 5

Algorithmic Decision Framework

Step 1: Determine timing and nature of symptoms

• If vomiting occurs after eating → suggests esophageal/gastric pathology → refer to GI for EGD. 1, 2
• If difficulty occurs during swallowing with coughing/choking → suggests oropharyngeal dysphagia → refer to SLP for MBS. 1, 5

Step 2: If GI workup is negative (normal EGD)

• Consider barium esophagram with solid food challenge to identify subtle structural abnormalities or functional disorders. 6
• Exclude eosinophilic esophagitis with esophageal biopsies even if endoscopy appears normal. 6
• Consider esophageal manometry if motility disorder suspected. 6

Step 3: If oropharyngeal symptoms coexist

• Refer to SLP for clinical swallowing evaluation first. 5, 3
• Proceed to instrumental assessment (MBS or FEES) only if clinical evaluation suggests oropharyngeal dysfunction. 1, 5

Critical Pitfalls to Avoid

• Do not order MBS for isolated post-eating vomiting without oropharyngeal dysphagia symptoms, as the study does not routinely evaluate the esophageal phase beyond the cervical region. 1, 7, 4
• Do not assume throat symptoms mean pharyngeal pathology—distal esophageal lesions frequently cause referred dysphagia to the upper chest or pharynx. 1, 3
• If persistent vomiting continues for >2-3 weeks, ensure thiamin supplementation to prevent neurological complications and monitor hydration status. 1
• Bedside clinical evaluation alone is insufficient in older adults or those with neurologic risk factors due to high rates of silent aspiration (55% of aspirating patients). 1, 3

Role of Speech-Language Pathologist

If MBS is ultimately indicated after GI evaluation, the SLP's role includes:

• Performing the MBS study to assess bolus manipulation, tongue motion, hyoid/laryngeal elevation, pharyngeal constriction, epiglottic tilt, and aspiration risk. 1, 5
• Testing effectiveness of compensatory strategies (postural techniques, dietary modifications) during the study. 3, 4
• Providing treatment recommendations based on specific swallowing impairments identified. 5, 4