Barium Swallow

Barium swallow (esophagography) is the cineradiographic, radiographic, or fluoroscopic examination of the pharynx and the fluoroscopic examination of the esophagus after ingestion of thick and thin mixtures of barium sulfate. This test, most commonly performed as part of the upper GI series, is indicated in patients with histories of dysphagia and regurgitation. Further testing is usually required for definitive diagnosis.

Cholangiography and the barium enema test, if necessary, should precede the barium swallow because ingested barium may obscure anatomic detail on the X-rays

Purpose

• To diagnose hiatus hernia, diverticula, and varices
• To detect strictures, ulcers, tumors, polyps, and motility disorders
• To verify gastroesophageal reflux disease

Patient preparation

• Explain to the patient that this test evaluates the function of the pharynx and esophagus.
• Instruct him to fast after midnight the night before the test. (If the patient is an infant, delay feeding to ensure complete digestion of barium).
• Describe the test, including who will perform it, where it will take place, and its expected duration (approximately 30 minutes).
• Describe the milk shake consistency and chalky taste of the barium preparation he is required to ingest. Although it's flavored, he may find it unpleasant to swallow. Tell the patient he'll first receive a thick mixture, then a thin one, and that he must drink 12 to 14 oz (355 to 415 ml) during the examination.
• For a double-contrast study (barium and air), the patient may be asked to eat effervescent granules ("fizzies"). Tell the patient to avoid burping.
• Inform him that he'll be placed in various positions on a tilting X-ray table and that X-rays will be taken.
• Withhold antacids if gastric reflux is suspected.
• Just before the procedure, instruct the patient to put on a gown without snap closures and to remove jewelry, dentures, hair clips, or other radiopaque objects from the X-ray field.

Procedure and posttest care

• The patient is placed in an upright position behind the fluoroscopic screen and his heart, lungs, and abdomen are examined.
• He is then instructed to take one swallow of the thick barium mixture, and the pharyngeal action is recorded using cineradiography. (This action occurs too rapidly for adequate fluoroscopic evaluation.)
• The patient is then told to take several swallows of the thin barium mixture. The passage of the barium is examined fluoroscopically and spot films of the esophageal region are taken from lateral angles and from right and left posteroanterior angles. Esophageal strictures and obstruction of the esophageal lumen by the lower esophageal ring are best detected when the patient is upright. To accentuate small strictures or demonstrate dysphagia, the patient may be requested to swallow a special "barium marshmallow" (soft white bread that has been soaked in barium), or a barium pill.
• The patient is then secured to the X-ray table and is rotated to the Trendelenburg position to evaluate esophageal peristalsis or demonstrate hiatus hernia and gastric reflux.
• He's instructed to take several swallows of barium while the esophagus is examined fluoroscopically, and spot films of significant findings are taken when indicated. After the table is rotated to a horizontal position, the patient is told to take several swallows of barium so that the esophagogastric junction and peristalsis may be evaluated. The passage of the barium is fluoroscopically observed, and spot films of significant findings are taken with the patient in supine and prone positions.
• During fluoroscopic examination of the esophagus, the cardia and fundus of the patient's stomach are also carefully studied because neoplasms in these areas may invade the esophagus and cause obstruction.
• Check that additional spot films and repeat fluoroscopic evaluation haven't been ordered before allowing the patient to resume his usual diet.
• Administer a cathartic, if prescribed.
• Inform the patient that stools will be chalky and light colored for 24 to 72 hours. Record description of all stools passed by the patient in the hospital.
• Barium retained in the intestine may harden, causing obstruction or fecal impaction. Notify the doctor if the patient fails to expel barium in 2 or 3 days

Precautions

• Barium swallow is usually contraindicated in a patient with intestinal obstruction.

Normal Findings

After the barium sulfate is swallowed, the bolus pours over the base of the tongue into the pharynx. A peristaltic wave propels the bolus through the entire length of the esophagus in about 2 seconds. When the peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens, allowing the bolus to enter the stomach. After passage of the bolus, the cardiac sphincter closes. Normally, the bolus evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.

Abnormal findings

Barium swallow may reveal hiatus hernia, diverticula, and varices. Aspiration into the lungs will also be revealed. Although strictures, tumors, polyps, ulcers, and motility disorders (pharyngeal muscular disorders, esophageal spasms, and achalasia) may be detected, definitive diagnosis commonly requires endoscopic biopsy or, for motility disorders, manometric studies.

Interfering factors

• Aspiration of barium into lungs due to poor swallowing reflex