BARIUM SWALLOW

DR AKASH BHOSALE JR1

 BARIUM SWALLOW
• It is a imaging procedure used to examine
upper gastrointestinal tract ,which include the
esophagus and to a lesser extent the stomach.
• The contrast used is barium sulfate
 Anatomy
• The esophagus begins at the upper
esophageal sphincter at the level of C6 and
finishes at lower esophageal sphincter at T11
and is approx 25 cm
 CONSTRICTIONS
• superiorly: level of Cricoid cartilage, juncture
with pharynx
• Middle: crossed by aorta and left main
bronchi
• Inferiorly: diaphragmatic sphincter.
 SPHINCTERS
• Two high pressure zones prevent the backflow
of food:
• Upper Esophageal sphincter.
• Lower Esophageal sphincter.
• It is located at upper and lower end of
esophagus
 CONTRAST USED
• 100% BARIUM SULPHATE PASTE
• 80% BARIUM SULPHATE SUSPENSION
• 30% BARIUM SULPHATE SUSPENSION FOR
HIGH KV TECHNIQUE
• 200-250% HIGH DENSITY,LOW VISCOSITY FOR
DOUBLE CONTRAST STUDY
 INDICATIONS
• Dysphagia
• Heart burn, retrosternal pain, regurgitation & odynophagia.
• Hiatus hernia
• Reflux oesophagitis
• Stricture formation.
• Esophageal carcinoma.
• Motility disorder like i. Achalasia ii. diffuse esophageal
spasms.
• assessment for mediastinal masses
• zenkers diverticulum ii. cricoid webs iii.
 CONTRAINDICATIONS
• Suspected leakage from esophagus into the
mediastinum.
• Tracheo-esophageal fistula
 Patient Preparation
• None in particular but advisable NBM before
procedure.
• Procedure should be explained to patient .
• Written consent should be taken.
 TECHNIQUE
• PHARYNX
• -One mouthful contrast bolus (10-15ml) given and
fluoroscopic observation of act of deglutition is
observed in frontal and lateral view.
• - to get optimum mucosal coating,Patient is asked
to swallow once and stop swallowing there after.
-frontal and lateral view x-ray taken while patient
perform valsalva maneuver in erect position to
show distended pyriform sinuses and valecullae .
• ESOPHAGUS
• Single contrast
-Multiple mouthful 80% w/v barium suspension given.
- follow barium bolus down the esophagus and observe the peristalsis in
supine position.
-spot flims taken in erect postion RAO ,LAO ,frontal ,lateral
• Double contrast
-Contrast high density,low viscosity(200-250%). -15-20 ml given & asked to
swallow.
-Then effervescent powder given with another mouthful of barium.
-In erect posture,gas tend to stay up so adequate distention stays longer time.
Inj.buscopan I.V given before the procedure to keep esophagus distended for
longer time.
• spot films taken in frontal, latral,RAO,LAO
 Pathology
• Malignant esophageal tumors
• Benign esophageal tumors
• esophagitis(candida esophagitis)
• Reflux esophagitis
• Motility disorders
• Hiatus hernias
• Miscellaneous
 Malignant esophageal tumors

• Sqaumus cell carcinoma

• adenocacinaoma
-
 Sqaumus cell carcinoma

-Cigarette smoking and alcohol consumption are

risk factors which are thought to be synergistic
for the development of squamous cell
carcinomas.

-tylosis palmaaris plantaris and Plummer –

Vinsons syndrome
 Early esophageal cacinomas
• Tumor limited to mucosa and submucosa.
• early cancers on barium swallow are seen as
depressed, polypoid or plaque-like lesions.
 Advanced esophageal carcinima
• Regional lymph node involvement.
• Barium swallow most frequently shows a
stricture with an irregular lumen . Some
tumours show pronounced ulceration or
predominantly polypoidal lesion.
 Benign tumors
• Squamus papiloma
• Adenoma
• Inflammatory esopahagogastric polyp
• Leiomyoma
• Retention cyst
 Inflammatory esopahagogastric polyp

• Persistent gastro-oesophageal reflux may

result in an inflammatory swelling developing
at the top end of a lesser curve gastric fold.
The distinctive feature of the polyp is that its
lower margin merges with the gastric fold,
 leiomyoma
• Well encapsulated smooth muscle tumor,
found at lower esophagus.
• Mostly solitary
 esophagitis
• Candida esophagitis
• herpes esophagitis
• Cytomegalovirus esophagitis
• Tubercular esopaghitis
• Caustic esophagitis
 Candida esophagitis
• most frequently develops in
immunocompromised patients. Patients
present with odynophygia, dysphagia.
• Barium study shows mucosal plaque, diffuse
involvement may produce granular mucosa.
 Caustic esophagitis
• The ingestion of strong acids or alkalis causes
a severe oesophagitis.
• Initial mucosal necrosis is followed by
ulceration and mucosal sloughing, and finally
healing, often with fibrosis and stricture
formation.
Refux esophagitis
 Gastro esophageal reflux
• SIPHON TEST
• Fill the stomach with 50% barium(150-200ml) • Follow
this 1-2 mouthful of water to remove traces of barium in
esophagus
• Pt in supine with left side raised 15% up
• Keep one mouthful of water in pt mouth
• Ask pt to swallow water-a jet of barium will shoot into
water column as it enter GO junction
Alternatively with full stomach ,ask pt to roll side to side
• Reflux will be seen
Sliding hitus hernia
 Motility disorder.
• Normal peristalsis.
- When barium is swallowed, the tail end of the
peristaltic wave has the shape of an inverted `V' as it
passes down the oesophagus. Peristalsis starts in the
pharynx with contraction of the superior constrictor
muscle. As the inner circular muscle contracts and
narrows the lumen of the oesophagus, the outer
longitudinal layer contracts and shortens the
oesophagus, drawing the oesophagogastric junction
up into the chest.
• The primary peristaltic wave runs length of
the oesophagus and consists of a wave of
relaxation followed by a slightly slower wave
of contraction.
• A secondary peristaltic wave is initiated by
luminal distension or mucosal irritation, and
acts as an important protective mechanism,
quickly returning refluxed acid to the stomach.
• Abnormal motility
• Tertiary contractions are non-propulsive and
uncoordinated andtheir non-peristaltic nature
means they move the bolus up as well as
down the oesophagus. They are seen as
intermittent ripples along the wall of the
oesophagus lasting only a few seconds,or
multiple simultaneous contraction rings or
segmented barium column producing a
corkscrew appearance
• Diffuse esophageal spasm
-Diffuse oesophageal spasm is a condition in which
episodes of pronounced abnormal motility occur
without cause, and these spasms may be associated
with severe intermittent chest pain, dysphagia and
even food impaction.
• Nutcracker esophagus
-This is a manometric diagnosis in which patients with
non-cardiac chest pain have primary peristaltic
waves with pressures in excess of 180 mmHg
(normally 100 mmHg).
• Hypertrohic lower esophaeal sphincters.
- This again is a manometric finding in which the
resting lower esophageal sphincter pressure
is 40 mmhg
 Achalsia
• it is a motor disorder of the oesophagus generally
occurring in the 35-50 year age group. It is caused
by degeneration of neurons of Auerbach's plexus,
which is situated between the longitudinal and
circular muscle coats.
• there is a failure of relaxation of the lower
oesophageal sphincter.
• A barium swallow shows gastro-oesophageal
junction failing to open fully and tapering to a rat
tail or bird beak appearance
 Secondary achalsia
• when achalasia has developed rapidly, or after the
age of 50, the possibility of an underlying neoplasm
should be considered. Submucosal neoplastic
infiltration of Auberach's plexus of the distal
oesophagus may result from direct invasion from
carcinoma of the stomach, extrinsic invasion from
carcinoma of the tail of the pancreas or adjacent
malignant lymph nodes, or metastatic invasion by
carcinoma of the bronchus or breast.
 Scleroderma
• In scleroderma a vasculitis damages the smooth
muscle coat of the bowel. The lower two-thirds of
the oesophagus are most frequently affected.
• it is mainly the circular muscle coat that is affected,
and so the lower oesophagus dilates.
 Pulsion Diverticula
• They may develop when motility is abnormal,
presumably as a consequence of high
intraluminal pressure.
 oesophageal web
• More commonly occur in the cervical
oesophagus near cricopharyngeus muscle than in
the thoracic oesophagus. They typically arise
from the anterior wall and never from the
posterior wall; they can also be circumferential.
Associations
• Plummer-Vinson syndrome
• GERD (especially a distal oesophagus web)
• external beam radiation
 HIATUS HERNIA
• High abdominal pressure is required to demonstrate.
• Pt has to strain.
• Lie down,straighten legs & then raise them up. •
Manual compression of abdomen.
• Stomach should be distended to demonstrate HH.

. Displacement of the cardio-esophageal junction above

the esophageal hiatus . Part of the stomach is present
in the chest . Reflux of barium into the esophagus
 ESOPHAGEAL VARICES
• Varices are best demonstrated in mucosal
relief study after using Buscopan.
• Mild dilatation of the esophagus with multiple
persistent filling defects in the lower third of
the esophagus and/or longitudinal furrows
 Barrett’s oesophagus
• Premalignant condition.
• The reticular mucosa is characteristic of
Barrett's columnar metaplasia, especially with
the associated web-like (arrow) stricture.
 Zenker’s Diverticulum
• • A Zenker's diverticulum is false diverticulum
with only mucosa and submucosa protruding
through triangular posterior wall weak site
(Killian's dehiscence) between horizontal and
oblique components of cricopharyngeus
muscle. • The esophagram shows collection
with midline posterior origin just above
cricopharyngeus protruding lateral, usually to
left, and caudal with enlargement
 Esophageal diverticula
• Esophageal diverticula are either:
• true diverticula: include all esophageal layers
• false diverticula: contain only mucosa and submucosa
herniating through the muscular layer (e.g. Zenker
diverticulum)
• Esophageal diverticula are classified according to the
mechanism of formation into:
• traction diverticula: occurs secondary to pulling forces on the
outer aspect of the esophagus
• pulsion diverticula: occurs secondary to increased
intraluminal pressure (e.g. Zenker diverticulum)
 FELINE OESOPHAGU
• Feline oesophagus also known as oesophageal
shiver, refers to the transient transverse bands
seen in the mid and lower oesophagus on a
double contrast barium swallow.
• The appearance is almost always associated with
active gastro oesophageal reflux and is thought to
be due to contraction of the muscularis mucosae
with resultant shortening of the oesophagus and
'bunching up' of the mucosa in the lumen
 Dysphagia lusoria
• The oesophagus may be compressed by a
congenitally aberrant right subclavian artery.

• it is seen as oblique tubular extrinsic

compression in upper oesophagus.
 COMPLICATION
• • Leakage of barium from unsuspected
perforation
 Esophageal endoscopy
• Gold standard for diagnosis of esophagitis,
barrets esophagus
• Useful for biopsy purpose
 Endoscopic ultrasound
• Accurate estimation of depth of penetration in
malignancy , length of esophagus affected.
• FNAC can be performed.
 Ct scan
• Standard tool for regional and distant staging
of esophageal cancer.
• It may detect thickened esophagus , enlarged
lymph nodes, and involvement of lung, Liver.
Thank you