Overview of Barium Swallow
A barium swallow study, also known as a barium esophagogram, is a type of x-ray test that’s often used to examine the esophagus, the tube that connects your mouth and stomach. Doctors use this test to see the shape and condition of the esophagus. It’s important to know that this is different from a “modified barium swallow” study or a “videofluoroscopic swallow study,” which looks at how well you swallow and is done with the help of a speech pathologist.
The barium swallow study can help diagnose a variety of conditions, such as disorders that affect how your esophagus moves, narrow areas (strictures), and holes (perforations). It can also help to identify other conditions affecting the lower part of the esophagus, like hiatal hernias (when part of the stomach pushes up through the diaphragm), gastroesophageal reflux (when stomach acid backs up into the esophagus), or gastric volvulus (twisting of the stomach). Although the barium swallow study can also give some information about swallowing at the level of the throat, this is usually examined more completely with a videofluoroscopic swallow study.
The barium esophagogram is a simple, non-invasive procedure that only needs an x-ray machine and a special substance called a contrast medium. Despite the availability of more advanced methods such as CT scans, this test is still very useful. Barium sulfate is commonly used as the contrast medium. It is considered to give a more detailed x-ray image compared to other substances like Gastrografin/diatrizoate because barium provides better contrast images.
Anatomy and Physiology of Barium Swallow
The esophagus is a 20 to 25 cm stretch of the digestive system that sits between your mouth and stomach, allowing both solid and liquid food to pass through. It begins at the level of the structure in your throat called the cricoid cartilage. This is also where two muscles meet – the inferior pharyngeal constrictor muscle and the cricopharyngeus muscle – forming an area known as the upper esophageal sphincter (UES). The esophagus ends at the lower esophageal sphincter (LES), a ring of muscles where the esophagus goes through a hole in the diaphragm. If the normal structure of the LES is affected by conditions like a hiatal hernia, the muscles might not work properly, leading to problems such as acid reflux.
The UES plays an essential role in preventing air from getting into your digestive system and stopping food from going back up into your throat. It’s found about 15 cm from your incisors (front teeth). It also features a muscle known as the cricopharyngeus muscle, which, if accidentally damaged, for instance, during an endoscopy, can create a hole (iatrogenic perforation).
Just like the UES, the LES also helps prevent food from refluxing, or moving backward, into the esophagus. At rest, the LES is closed but will occasionally relax, although it’s not clear why this happens. As previously mentioned, if this muscle isn’t working correctly, it can lead to health problems, like gastroesophageal reflux disease (GERD) and Barrett’s esophagus. The LES is about 40 cm away from your incisors.
Between the two esophageal sphincters, you’ll find the esophagus’s main body, which pushes food towards your stomach through a process called peristalsis. While it’s a smooth tube, there are three main points where the esophagus narrows: at the UES, the mid-portion, and at the LES.
Under a microscope, the esophagus has several layers from inside out: the lining (mucosa) made up of squamous (flat) cells, a muscle layer, and the outer layer (adventitia). Notably, other parts of the digestive system have a different outer layer known as the serosa.
Blood reaches the esophagus via the inferior thyroid artery in the neck part, through the left gastric and inferior phrenic arteries in the abdominal part, and through branches from the bronchial arteries and the aorta otherwise. Blood drains out through branches leading to the azygos and hemiazygos veins except at the lower end, where it drains into the coronary vein and then into the liver blood flow (portal circulation). This is important because these veins can swell (varices) in liver diseases like cirrhosis.
Lastly, the esophagus receives signals from the vagus nerve and nearby sympathetic trunk, which helps control its functions.
Why do People Need Barium Swallow
A barium swallow is a procedure that allows doctors to examine the inside of your esophagus, or food pipe. It’s primarily used to look at the structure of the esophagus and has the ability to detect various conditions. This includes things like tears in the esophagus, tumors, hernias that develop where the stomach and esophagus meet, or pouches called diverticula.
Barium swallow can also help identify some disorders that affect how well your esophagus moves, or “motility disorders.” These disorders can change the shape of the esophagus, making them visible during a barium swallow. However, most conditions affecting how well your esophagus works when swallowing will need a more in-depth evaluation. For example, achalasia, a specific kind of swallowing disorder, gives the esophagus a “bird beak” shape and can cause it to twist and swell. Another condition called diffuse esophageal spasm can be seen on a barium swallow as a “corkscrew” shape of the esophagus.
Barium swallow may also be used to study the effects of chemical injuries to the esophagus. This should be done well after the initial injury to identify any complications such as strictures (narrowing) or ulcers (sores) that may have developed. However, it’s important to avoid using a barium contrast – a substance which makes images clearer – right after a chemical injury, as this might make the injury worse.
Choice of substance to use for making images clearer during a swallow procedure is an important factor when dealing with trauma, such as a gunshot wound. Typically, a substance called Gastrografin/diatrizoate is used as it is easier to remove than barium if there are any leaks into the chest cavity. But barium is used as a follow-up since it can detect leaks better than Gastrografin/diatrizoate. In emergency situations, timing is critical, and a likely surgical exploration might quickly remove any leaks, thus reducing risks associated with barium and enhancing diagnostic accuracy.
One risk with Gastrografin/diatrizoate is that if it accidentally enters the lungs, it can cause a severe lung inflammation called pneumonitis. Barium can also cause pneumonitis, but it usually isn’t as severe.
When a Person Should Avoid Barium Swallow
A barium swallow test can be used if doctors suspect there might be a problem with the esophagus (the tube that connects your throat to your stomach), but this test should only be used after thinking about the risk of inflammation in the space in the chest between the lungs, known as mediastinitis. This doesn’t mean that you absolutely cannot have a barium swallow test, but the risk of inflammation in the chest area has to be weighed against the benefit of getting a diagnosis quickly. For this test, patients need to be able to swallow large amounts of a special liquid called barium without help, and they need to be able to protect their airway from this liquid.
If it is suspected that there is a sudden, chemical injury to the esophagus, doctors should not use a barium swallow test. This is because the test won’t provide useful information in this specific scenario.
Preparing for Barium Swallow
When doctors want to study the throat and the food pipe, there’s very little preparation needed for the patient. However, it’s important that the patient can comfortably swallow liquids.
How is Barium Swallow performed
A barium swallow exam is performed by a radiologist to study the patient’s throat and esophagus. The way it is done may vary across different hospitals or health centers. Usually, this test is done in two stages: one focusing on the upper section of the esophagus near your pharynx (the tube that connects your throat to your windpipe), and the other on the longer section of the esophagus inside your chest cavity. These are the main steps:
1. To begin with, you’ll be asked to stand in an upright position. You’ll be given some crystals to consume along with water. These crystals work to enlarge or expand your esophagus making it easier for the doctor to examine.
2. You’ll remain upright and be positioned slightly to the left, allowing the radiologist to get a better view of your throat and esophagus. After drinking a thick barium liquid, several images will be captured from your throat to your stomach.
3. Still upright, now you’ll be asked to switch your position to lateral or sideways. Now as you swallow a thinner barium liquid, your radiologist will record a video and take X-ray images. They will ask you to make sounds like “aaaaa” and “eeee” to further expand your throat.
4. Next, you’ll be asked to turn to face towards the X-ray machine. A video will be taken while you again swallow the barium liquid. Your radiologist may also ask you to hold your breath and take a special shot called a “trumpet Valsalva” in order to see the throat more clearly with the help of air you’re holding in.
5. For the next stage, you’ll need to lay down flat on your stomach. In this position while drinking the barium solution through a straw, your radiologist will watch the liquid move down the esophagus. X-ray images will be taken of the lower part of the esophagus, near the stomach. Here, the doctor will be checking for any unusual features like hiatal hernia (a condition when your stomach pushes up into your chest), acid reflux or movement issues.
In some cases, extra images might be taken when the patient is lying on their back, especially if we are looking for acid reflux signs. You might be asked to fake cough for these pictures, but this is not always necessary as this generally doesn’t provide any additional information.
Finally, in standing position again you’ll need to swallow a barium pill for the radiologist to watch its journey down to your stomach.
While positioning you on your stomach, your left arm and knee will be slightly bent, and your head will be turned to the left. The quantity of barium you swallow each time could be between 100 to 200 milliliters. The main goal is to expand your esophagus as much as possible for clearer pictures. Depending on the findings or the difficulty of the process, more or less barium may be used, or it may be diluted with water. Every hospital or health center might follow slightly different protocols regarding the thickness of contrast and amount, and also the reason for the exam. In some scenarios, a normal X-ray machine is just enough for this exam.
Possible Complications of Barium Swallow
Drinking a barium contrast, which is a special substance used for certain medical imaging tests, generally causes few side effects. Some people might feel sick and possibly throw up around 30 minutes after drinking it. Allergic reactions to the drink are possible but quite rare. Most side effects are actually caused if the contrast substance leaks out into the chest area or if it’s accidentally inhaled.
What Else Should I Know About Barium Swallow?
A barium esophagram is a type of imaging test that helps doctors diagnose and keep an eye on a wide range of conditions affecting the esophagus, the tube connecting your throat to your stomach. In many instances, this test is the only one needed. It can also be used to plan surgeries by helping pinpoint the exact location of problem areas that have been seen during other tests, like endoscopies.
Here are some examples of the types of esophageal conditions that could benefit from an esophagram:
– Structural issues: These are physical alterations or damages in the esophagus including Zenker’s diverticula, which is a small pouch in the throat that collects food particles; strictures, which are narrow areas; ulcers or sores; and hiatal hernias, when part of your stomach pushes upward into your chest.
– Benign neoplastic: These are non-cancerous growths that can occur in the esophagus, such as fibrovascular polyps, lipomas (fat tissue growths), and leiomyomas (muscle tissue growths).
– Malignant neoplastic: These are cancerous growths like adenocarcinoma, small cell carcinoma, gastrointestinal stromal tumor and leiomyosarcoma.
– Mobility issues: These are conditions that affect how food moves from your throat into your stomach. They include achalasia (a disorder that makes it hard for food and liquid to pass into your stomach), hypertensive lower esophageal sphincter (a muscular ring at the point where the esophagus and stomach meet being unusually tight), diffuse esophageal spasm (abnormal contractions of the esophagus muscles that can interfere with swallowing), and ineffective esophageal motility (weak contractions of the esophagus muscles which slows down or prevents food from reaching the stomach).
– Traumatic conditions: These are injuries to the esophagus that can be caused by certain procedures like endoscopy or laryngoscopy, blunt or penetrating trauma, intense effort that can lead to the rupture of the esophagus (Boerhaave’s Syndrome), and stricture or narrowing of the esophagus that can happen due to injuries from corrosive substances.
– Pediatric conditions: These are conditions that can occur in infants and children, like esophageal atresia, a birth defect where the esophagus doesn’t develop properly and tracheoesophageal fistula, an abnormal connection between the esophagus and the windpipe.
It’s important to keep in mind that even if a problem area is spotted during an esophagram, all lumps, narrow areas, and swallowing difficulties should be evaluated with an endoscopy, which provides a more thorough inspection. This test uses a thin, flexible tube with a camera to photograph and examine the digestive tract.