Barium swallow test is a form of imaging in which a patient swallows a liquid medium that can be used for viewing the esophagus and the stomach. A barium swallow study helps to outline the any abnormality along the esophagus or in the stomach.

Uses/Indications for Barium Swallow in diagnoses of Disease Conditions

Pharyngeal pouch

This is a posterior mucosal protrusion arising in the upper neck just above the cricopharygeus muscle. The patient presents with dysphagia and regurgitation of food on lying down. Plain films may show a fluid level in the pouch but barium swallow is diagnostic with barium filling the pouch which is seen best in the lateral projection when the neck connecting it to the oesophagus can be seen.

A lateral view of the upper oesophagus during barium swallow examination. This shows a pharyngeal pouch lying posteriorly and compressing the main oesophageal lumen. The pouch lies in direct line of the pharynx whereas the oesophagus is displaced anteriorly. Food therefore enters the pouch in preference to passing down the oesophagus & the pouch gradually increases in size. When full, food spills over and passes down the oesophagus or is inhaled into the lungs, especially at night when lying down. The patient may present with aspiration pneumonia.

Achalasia of the esophagus shown by a Barium swallow test

Barium swallow for Achalasia

This is a functional disorder of motility resulting in inability of the lower oesophageal sphincter to dilate. The oesophagus becomes widened, sometimes becoming so large that it shows on a plain film of the chest as a mediastinal mass. Food stagnates in the oesophagus; there is regurgitation of food eaten some time previously with dysphagia & weight loss. Barium swallow shows gross oesophageal dilatation with tortuosity, the lower end usually lying horizontally, tapering down to the sphincter, which fails to open. The so-called cigar shape. The oesophagus contains food residue showing as a mottled appearance to the barium.

Barium swallow in a 12 yr. old boy with a long history of dysphagia. He was very undernourished for his age. The oesophagus is dilated and tapers to the cardia. He had achalasia.

Barium swallow in diagnosis of Hiatus Hernia

This a protrusion of a portion of the stomach through the oesophageal hiatus of the diaphragm into the chest may range in size from a very small transient hernia to a thoracic stomach. They may be classified as sliding or paraoesophageal. A sliding hernia is the commonest type and occurs when the gastro-oesophageal junction (cardia) and part of the stomach slip upwards above the diaphragm. It is associated with reflux and is usually reducible unless very large. If small, it may only be demonstrated in certain positions. When transient it may not be demonstrated on barium meal at all. With a paraoesophageal hernia, the cardia remains in the normal position and part of the stomach herniates alongside it. Reflux is not a feature and this type of hernia is often irreducible (incarcerated) in which case the hernia remains permanently above the diaphragm and may show as a mass on the chest X-ray containing a fluid level.

Use of Barium swallow in Oesophagitis

Inflammation of the oesophageal mucosa may be secondary to reflux, infections such as monilia, or due to accidental ingestion of a caustic solution. It causes mucosal irregularity with erosions and sometimes ulcers. Strictures may form. Benign strictures usually has smooth, tapering edges in contrast to a malignant stricture which shows an abrupt change in calibre (shouldering).

Barium swallow technique for diagnosis of Carcinoma

This causes a range of appearances depending on the tumour size and degree of malignancy. It is commonest in the distal third presenting as progressive dysphagia with weight loss. On barium swallow, it may present as a mass resulting in a filling defect in the lumen. If infiltrative, it results in narrowing of the lumen initially. Later there is also mucosal destruction and irregularity of the lumen.

A – Radiologic image; B – the modified and simple image; A long stricture on barium swallow in a middle aged man involving the mid oesophagus. There is irregularity of the lumen due to mucosal destruction. The transition from non-involved to involved oesophagus is more abrupt than with a benign stricture and is shouldered in appearance rather than tapered. The upper and lower limits are marked by arrows.

Functional disorders

A wide range of functional disorders occur in elderly patients. There may be disordered contractions resulting in a corkscrew appearance. There may be swallowing difficulties due to neuromuscular incoordination as a result of stroke. There is a danger of barium aspiration in these patients during the investigation. This does not usually cause any serious problems unless the patient is much debilitated or the barium of large amount. Physiotherapy is given if a significant amount of barium is aspirated into the smaller bronchi.

Complete obstruction to the flow of barium in this patient. The proximal oesophagus is dilated and there is a sharp cut off to the barium column characteristic for an impacted food bolus above a stricture. In this patient barium has aspirated into the bronchial tree and is outlining the lower lobe bronchi. This is not a serious complication unless gastrografin contrast has been used instead of barium

Oesophageal varices

These are venous anastomotic collateral veins, usually resulting from portal venous hypertension or portal vein obstruction. They commonly develop as a result of liver cirrhosis and are usually confined to the lower two thirds of the oesophagus. Endoscopy is the investigation of choice but a barium swallow can delineate the large submucosal veins in many cases. If the oesophagus is distended with barium the bulging varices may flatten against the wall and be hidden by the barium. Varices are best shown on films when the barium has passed but coated the oesophageal mucosa in its collapsed state. They show as serpiginous (worm-like) filling defects.

A barium swallow showing multiple filling defects due to esophageal varices.

Side effects (Complications) of Barium Swallow

1. Injury to the esophagus or stomach
2. Inflammation of the Mediastinum (Mediastinitis)
3. Peritonitis due to leakage of barium
4. Allergies