How should an esophagram be performed on a patient with suspected esophageal disorder?

How to Perform an Esophagram for Suspected Esophageal Disorder

A biphasic esophagram is the preferred technique for evaluating suspected esophageal disorders, combining double-contrast views to detect mucosal lesions with prone single-contrast views to identify rings, strictures, and motility abnormalities. 1, 2

Core Technique Components

The biphasic esophagram must include three essential phases to maximize diagnostic yield 1, 3:

• Double-contrast phase: Upright views with high-density barium suspension to detect mucosal lesions (tumors, esophagitis, ulcers) with superior sensitivity 1, 3
• Single-contrast phase: Prone views with low-density barium suspension while the patient continuously drinks to optimally distend the distal esophagus and detect rings or strictures 1
• Mucosal relief views: Optional views with either barium density to further characterize structural abnormalities 3

Complete Anatomic Coverage Required

Always evaluate the entire esophagus from pharynx through gastric cardia, even when symptoms localize to one region, because distal esophageal or gastric cardia abnormalities frequently cause referred dysphagia to the upper chest or pharynx. 1, 2, 4

• In one study, 68% of patients with dysphagia had abnormal esophageal transit, and one-third had esophageal abnormalities as the only finding 1
• Failure to examine the complete esophagus is a critical diagnostic pitfall that misses synchronous lesions 2, 5

Clinical Scenario-Specific Modifications

For Oropharyngeal Dysphagia (Unexplained)

Combine videofluoroscopy with static pharyngeal images plus complete esophageal examination, as this provides higher diagnostic value than either study alone 1, 2, 4:

• Dynamic videofluoroscopy assesses oral and pharyngeal swallowing phases, laryngeal penetration, and aspiration risk 1, 2
• Static double-contrast spot films of the pharynx in frontal and lateral projections detect structural abnormalities like tumors or Zenker diverticulum 1, 2
• Complete esophageal evaluation is mandatory because referred symptoms are common 1, 4, 5

For Retrosternal/Esophageal Dysphagia

Perform standard biphasic esophagram as the initial test 2, 4, 6:

• This technique has 95% sensitivity for detecting lower esophageal rings and peptic strictures, superior to endoscopy which detects only 76% of rings 1, 4
• Videofluoroscopy demonstrates 80-89% sensitivity and 79-91% specificity for motility disorders compared to manometry 1, 4

For Immunocompromised Patients

Use biphasic esophagram to detect ulcers or plaques associated with infectious esophagitis (Candida, herpes, CMV) 1, 2:

• Biphasic technique is more accurate than single-contrast for detecting these lesions 1, 2
• If the patient is too debilitated to cooperate, perform single-contrast esophagram instead 1, 2

For Post-Surgical Evaluation

Use single-contrast esophagram with water-soluble contrast first if leak or fistula is suspected, followed by barium if negative 2, 4, 7:

• Water-soluble contrast minimizes complications if extravasation occurs 7
• For late postoperative complications, biphasic esophagram is appropriate 2

When to Use Single-Contrast Only

Single-contrast esophagram is appropriate for patients who cannot cooperate with the biphasic examination 1, 2:

• Elderly, debilitated, or obese patients who lack mobility 1, 2
• Severely ill immunocompromised patients 1, 2
• Immediate post-surgical evaluation for leaks 2, 4

Critical Technical Points

The prone single-contrast phase is essential because lower esophageal rings are 2-3 times more likely to be diagnosed on prone views than upright double-contrast views due to inadequate distal esophageal distention when upright. 1

• Give the patient a bolus challenge (solid food or barium tablet) if rings or strictures are suspected but not initially visualized 8, 9
• Assess motility throughout the examination by observing peristaltic waves and esophageal emptying 10, 3

Common Pitfalls to Avoid

• Never perform oral contrast studies in complete esophageal obstruction (inability to swallow saliva) due to increased aspiration risk; proceed directly to emergent endoscopy 4
• Do not rely solely on static imaging for oropharyngeal dysphagia, as this misses functional abnormalities requiring videofluoroscopy 1, 2
• Do not assume a cricopharyngeal bar or pharyngeal finding explains dysphagia without evaluating the entire esophagus for distal pathology 1, 2, 5
• Ensure adequate esophageal distention during the single-contrast phase, or rings and strictures will be missed 1, 8

Post-Procedure Management

Rehydrate patients immediately after barium studies to prevent bowel impaction 7:

• Routine use of mild laxatives (milk of magnesia or lactulose) is recommended unless contraindicated 7
• This is especially important in patients with constipation history 7

Integration with Other Diagnostic Tests

After esophagram findings 2, 4, 6:

• If motility disorder is detected, proceed to high-resolution manometry for definitive diagnosis and subtyping 2, 4
• Upper endoscopy with biopsies is mandatory to exclude mucosal lesions, eosinophilic esophagitis, and subtle inflammation not visible on barium studies 4
• If esophagram is normal but dysphagia persists, consider endoscopy to detect subtle mucosal disease 1, 4