Overview of Barium Swallow
A barium swallow study, also known as a barium esophagogram or esophagram, is a particular type of x-ray that helps doctors get a detailed view of your throat and esophagus, which is the tube connecting the throat to the stomach. This is done using a contrast agent called barium, which helps these areas to show up clearer on the x-ray images.
It’s important not to confuse this with a “modified barium swallow” study or a “videofluoroscopic swallow study.” The latter focuses on looking at how you swallow and is performed with the help of a speech pathologist.
A barium swallow study can help diagnose a wide variety of conditions such as problems with throat and esophagus muscle movement, narrowing of the esophagus, and small holes or perforations in its wall. It can also help identify issues further down the digestive tract such as hiatal hernias (where a part of your stomach bulges out through the diaphragm), gastroesophageal reflux (where stomach acid flows back up into your throat), or gastric volvulus (a serious condition where the stomach twists on itself).
Although this test can give us some information about the act of swallowing at the throat level, a Videofluoroscopic Swallow Study is often a better option for this particular assessment.
The barium swallow study is non-invasive, meaning it doesn’t require any cuts or incisions to the body. All it requires is taking x-ray images after you’ve swallowed the contrast medium, barium. Despite the fact that we now have more advanced technologies like CT scans, barium swallow studies remain useful due to their simplicity and ease of use. In fact, the use of barium as a contrast medium is thought to produce better, clearer images compared to other agents such as Gastrografin or diatrizoate.
Anatomy and Physiology of Barium Swallow
Interpreting an image obtained from a barium esophagram—a type of X-ray examination—requires an understanding of how our bodies are built and work. This is especially true for the esophagus, a 20-25 cm tube forming part of our digestive system. The esophagus transports food and drink from the mouth down to the rest of our digestive system.
The esophagus starts from a point near the cricoid cartilage in the throat, where specific muscles called the inferior pharyngeal constrictor and the cricopharyngeus meet. This point is called the upper esophageal sphincter (UES), which ensures air doesn’t go into the digestive tract and food doesn’t go back up into the throat.
The esophagus ends at the lower esophageal sphincter (LES), a thick band of muscle where the esophagus goes through a hole in the diaphragm, a muscle that helps with breathing. Common issues such as heartburn can occur if the LES isn’t working properly, for instance, with a condition called a hiatal hernia.
Just like the UES, the LES also prevents food and digestive juices from going back up the esophagus. Normally, LES is closed, but it relaxes unexpectedly at times for unknown reasons. As mentioned, issues like heartburn and a condition called Barrett’s esophagus can occur if the LES isn’t working properly.
Between these two points, the body of the esophagus pushes food down to the stomach in waves, a process known as peristalsis. It’s usually a smooth tube, but it does have narrowing points which could lead to digestive issues. The narrowing areas occur at the UES, under pressure from the aortic arch (part of the heart) and left mainstem bronchus (left main airway), and at the LES.
Structurally, the esophagus consists of several layers. The inner layer, mucosa, is made of a specific type of cells called squamous epithelial. Then, there is a muscular layer and adventitia as the outermost layer.
Blood is supplied to the esophagus through several arteries including the lower thyroid artery, the left gastric and lower phrenic arteries, and branches off the aorta. The removal of blood from the esophagus happens via the azygos, hemiazygos veins, and the coronary vein, which leads to the liver. The nerves controlling the esophagus are the vagus nerve and the adjacent sympathetic trunk.
Why do People Need Barium Swallow
A barium swallow test is used to examine the structure and workings of the esophagus, which is the tube that leads from your mouth to your stomach. This test can help doctors identify issues such as tears or holes in the esophagus, tumors, hernias and pouch-like structures called diverticula. It can also help to spot certain disorders that affect the movement of food through the esophagus, due to the changes these conditions cause in the shape of the esophagus. For example, a condition called achalasia might give the esophagus a ‘bird beak’ look, while diffuse esophageal spasm might cause a ‘corkscrew’ appearance.
Barium swallow tests can also help doctors to study damage to the esophagus caused by harmful chemicals. If the damage has been present for some time, a type of barium swallow test using a special contrast material can help to identify narrowing of the esophagus or ulcers. However, this type of test should not be used if the chemical injury has just occurred, as it can make the damage worse.
For patients who have experienced trauma, such as a gunshot wound, the type of contrast material used for the swallow test can be very important. Guidelines often suggest first using a water-soluble contrast material such as Gastrografin/diatrizoate. If this does not show any issues but the doctor still suspects a problem, a different type of test using a thin consistency of barium can be done. The water-soluble contrast is easier to wash out during surgery but the barium is better at finding perforations or tears. If the test shows a problem, surgery can be done quickly to wash out the contrast material and minimize potential complications. There are risks associated with both types of contrast material if they get into the airway, but barium tends to cause less severe inflammation of the lungs.
When a Person Should Avoid Barium Swallow
A Barium swallow study is a test that checks for problems in the esophagus (the tube that connects your throat to your stomach). The test might not be suitable if there’s a chance that it could cause irritation and swelling in the area between your lungs, a condition called ‘inflammatory mediastinitis’. However, the risk of inflammatory mediastinitis isn’t a definite reason to avoid this test, it should be considered alongside its benefits, like making a diagnosis quickly.
The person being tested should be able to swallow large amounts of a contrast substance (a kind of dye that helps the doctor see the esophagus clearly) on their own and should be able to prevent it from entering their windpipe.
If it’s thought that the person might have a sudden, chemical injury to their esophagus, the Barium test should not be performed. This is because this test wouldn’t be very useful for finding helpful information in this situation.
Preparing for Barium Swallow
If the medical test is focused on the throat and food pipe, there isn’t much preparation needed. However, it’s crucial that patients are comfortable swallowing liquids for the test.
How is Barium Swallow performed
A barium swallow exam is a method used by doctors to examine your throat and esophagus (the tube that connects your throat to your stomach). Different institutions may have different ways of performing this exam, but the basic concept is the same. The examination usually includes two parts: looking at the throat and the top part of your esophagus, and the rest of the esophagus. They use a type of x-ray called fluoroscopy for this.
Here is a typical breakdown of the steps for this test:
1. Standing up – The test begins with you swallowing an effervescent sodium bicarbonate granules (these are like fizzy crystals) followed by drinking water to make your esophagus expand.
2. Standing up – You’ll then be asked to stand in a certain way (known as the left posterior oblique position) and drink a thick liquid containing barium. This helps your doctor see the esophagus more clearly while he or she is taking specific images from your neck region to where your esophagus meets your stomach (gastroesophageal junction).
3. Standing up – Next, you’ll switch to a side-lying position. You will have to drink a thinner barium liquid as the doctor takes video images and still photos of your throat area. During this, you’ll be asked to make “aaaaa” and “eeeee” sounds.
4. Standing up – Then, you’ll need to stand straight (anteroposterior position). Again, the doctor takes video images and still photos while you swallow the thin barium. You will make “aaaaa” and “eeeee” sounds for this too. You may also be asked to do a “trumpet Valsalva” which is a technique used to open up or “distend” your throat with air.
5. Lying down – In this position, you’ll lie on your stomach and slightly turned to one side (right anterior oblique). You will drink a thin barium liquid through a straw. Your doctor will then observe and take images of the barium moving down your esophagus and into your stomach. They will look closely for things like a hiatal hernia (when part of your stomach pushes through your diaphragm into your chest), reflux (backward flow of fluid), or signs of dysmotility (when there’s some problem with the movement of the muscles in your esophagus). You may also be placed on your back and asked to cough as they continue to observe and take images. Lastly, you may be asked to swallow a barium tablet with little water and observed till it successfully passes into your stomach.
While performing the test, there are certain things to keep in mind:
- When you’re lying on your stomach, your left arm and knee will be bent and your head will be turned towards the left side. This helps to uplift your left side slightly.
- You will typically swallow around 100 to 200 cc of barium during each swallow.
- The goal is generally to expand the esophagus for better viewing. The thickness of the barium and the amount can be adjusted if needed to spot anything unusual.
- The exact thickness of the barium and the amount you swallow could depend on the protocols of the place where you’re having the test and the reason for the exam.
- The doctor can still get necessary information using equipment that only takes still images.
Possible Complications of Barium Swallow
Taking oral barium contrast, a substance used to improve the visibility of the gastrointestinal tract in medical imaging, generally has few side effects in common medical practice. The most frequent complaints from patients are feelings of sickness and the urge to vomit, usually occurring within half an hour of taking it. While rare, some patients have reported allergic reactions. The more serious side effects are usually associated with the contrast substance leaking into the area around the heart or being inhaled into the airway of the lungs.
What Else Should I Know About Barium Swallow?
A barium esophagram is a common and efficient test that helps doctors diagnose and monitor a wide range of esophagus-related diseases. Sometimes, this may be the only imaging test needed. This test can also help doctors plan surgeries by pinpointing the location of abnormalities first spotted during other procedures such as endoscopy.
The esophagus is the tube that connects your mouth to your stomach. Various health issues can develop in the esophagus, including:
Structural issues
- Esophageal diverticula, which are small pouches that protrude outward.
- Strictures, or abnormal narrowing of the esophagus.
- Ulcerations, which are open sores.
- A hiatal hernia, when a part of the stomach pushes up through the diaphragm into the chest.
Benign tumors
- Fibrovascular polyps, which are non-cancerous growths.
- Lipomas, which are benign fatty tumors.
- Leiomyomas, which are benign muscle tumors.
Malignant tumors
- Adenocarcinoma, which is esophagus cancer that begins in the cells that make and release mucus and other fluids.
- Small cell carcinoma, which is a rare type of esophagus cancer.
- Leiomyosarcoma and gastrointestinal stromal tumors, which start in the muscle or soft tissues of the esophagus.
Mobility issues
- Achalasia, a condition that makes it hard for food and liquid to pass into your stomach.
- Diffuse esophageal spasm, a problem that involves the muscles in the throat and function of the esophagus.
Traumatic injuries
- Injuries caused by medical procedures, including endoscopy and laryngoscopy.
- Esophageal perforation, or tears, caused by trauma or effort.
- Stricture caused by damage due to ingestion of corrosive substances (chemical burns).
Pediatric conditions
- Esophageal atresia or stricture, a birth defect in which part of the baby’s esophagus doesn’t form properly.
- Tracheoesophageal fistula, another birth defect where there is abnormal connection between the esophagus and the trachea (windpipe).
No matter what kind of abnormality is found during an esophagram, any masses, strictures or difficulties swallowing should be followed up with a comprehensive review using an endoscopy. This will ensure that nothing has been overlooked.
