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FLUOROSCOPY
OesophagusDemonstration data

Barium Swallow / Oesophagram

The barium swallow (oesophagram) is a dynamic fluoroscopic study of the pharynx and oesophagus used to assess swallowing, mucosal contour, luminal calibre and motility. Single-contrast, double-contrast and mucosal-relief phases are combined to evaluate structural and functional abnormalities. When perforation or aspiration is a concern the choice of contrast agent is altered to avoid the complications of barium in the mediastinum or lungs.

Indications

  • Dysphagia and odynophagia to localise and characterise the level of obstruction
  • Suspected benign or malignant stricture, web, ring (Schatzki) or oesophageal cancer
  • Suspected motility disorder such as achalasia, diffuse oesophageal spasm or scleroderma
  • Gastro-oesophageal reflux, hiatus hernia and assessment of post-fundoplication anatomy
  • Suspected pharyngeal or Zenker diverticulum, fistula or extrinsic compression

Contraindications & Cautions

  • Suspected oesophageal perforation or anastomotic leak: use water-soluble iodinated contrast first because extravasated barium causes mediastinitis
  • High aspiration risk: barium is inert if aspirated whereas hyperosmolar ionic water-soluble agents cause pulmonary oedema, so use a low-osmolar non-ionic agent when both perforation and aspiration risk coexist
  • If a water-soluble study shows no leak, follow with barium for superior mucosal detail
  • Complete high-grade obstruction where a large barium load may impact above the lesion
  • Inability to protect the airway or uncooperative patient at risk of massive aspiration

Patient Preparation

  • Nil by mouth for at least 4-6 hours to empty the oesophagus and stomach
  • Explain the procedure and the taste/texture of the barium suspension
  • Confirm no suspected perforation before selecting barium; screen for contrast allergy if iodinated agent needed
  • Remove radiopaque objects from the neck and chest
  • Assess swallowing safety and consider a modified barium swallow with speech therapy if aspiration is likely

Technique & Parameters

  • Begin with a scout image and, if perforation is suspected, an initial water-soluble contrast swallow
  • Double-contrast phase: effervescent granules for gas distension plus high-density barium, imaged erect in RAO and left lateral for mucosal detail
  • Single-contrast phase: low-density barium in the prone RAO position to distend the lumen and assess contour and strictures
  • Mucosal-relief views obtained after the lumen collapses to demonstrate fine mucosal folds
  • Motility assessed with the patient prone or supine swallowing single boluses under continuous fluoroscopy
  • Provocative manoeuvres (water siphon, Valsalva, marshmallow or barium tablet) to elicit reflux or reveal subtle rings

Systematic Review

  • Assess the pharyngeal phase, epiglottic tilt and laryngeal penetration or aspiration
  • Evaluate primary and secondary peristalsis and any tertiary non-propulsive contractions
  • Inspect mucosal pattern for ulceration, plaques, nodularity or varices
  • Measure luminal calibre and characterise any narrowing as smooth or irregular, focal or long-segment
  • Assess the gastro-oesophageal junction, hiatus hernia and reflux during provocative manoeuvres
  • Look for diverticula, webs, rings, extrinsic compression and fistulous tracks

Key Findings & Significance

  • Achalasia: dilated oesophagus with smooth tapering bird-beak narrowing at the gastro-oesophageal junction and absent primary peristalsis
  • Malignant stricture: irregular, shouldered, mucosal-destroying narrowing with abrupt transition
  • Peptic stricture: smooth tapered distal narrowing, often with a hiatus hernia and reflux
  • Schatzki ring: thin mucosal ring at the B-ring causing intermittent dysphagia to solids
  • Diffuse oesophageal spasm: corkscrew or rosary-bead appearance from non-propulsive tertiary contractions
  • Zenker diverticulum: posterior midline pharyngo-oesophageal outpouching above cricopharyngeus

Differential Considerations

  • Smooth stricture: peptic, radiation, caustic, anastomotic, or eosinophilic oesophagitis (ringed oesophagus)
  • Irregular stricture: adenocarcinoma, squamous cell carcinoma, or aggressive reflux
  • Filling defect: carcinoma, leiomyoma, fibrovascular polyp, food bolus or air bubble
  • Dilated aperistaltic oesophagus: primary achalasia versus pseudoachalasia from tumour, or scleroderma
  • Multiple outpouchings: intramural pseudodiverticulosis versus true diverticula

Pearls & Pitfalls

  • Always use water-soluble contrast first when leak or perforation is suspected, then barium if no leak is seen
  • When both aspiration and perforation are possible, choose a low-osmolar non-ionic iodinated agent
  • A barium tablet or marshmallow bolus unmasks subtle rings and strictures missed by liquid barium
  • Pseudoachalasia from an infiltrating cardia tumour can mimic primary achalasia; correlate with endoscopy
  • Assess for aspiration in real time and stop the study if the airway is threatened

Structured Report

  • State the contrast agent used and the reason if water-soluble was chosen
  • Describe pharyngeal function, aspiration, peristalsis and gastro-oesophageal reflux
  • Characterise any stricture by level, length, calibre and margin (smooth versus irregular)
  • Report diverticula, rings, webs, hiatus hernia and extrinsic compression
  • Give a concise impression and recommend endoscopy or manometry where appropriate

References

  • ACR-SPR Practice Parameter for the Performance of Esophagography and Upper Gastrointestinal Examinations
  • Levine MS, Rubesin SE. History and Evolution of the Barium Swallow for Evaluation of the Pharynx and Esophagus. RadioGraphics
  • Ott DJ et al. Radiographic Evaluation of Esophageal Dysphagia. RadioGraphics
  • Royal College of Radiologists iRefer: Making the Best Use of Clinical Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.