barium swallow

1. BARIUM SWALLOW
&OESOPHAGEAL DISEASES
PRESENTER –DR.NABA KUMAR BARMAN(JR 1)
MODERATOR –DR.NEERA KOHLI.MD (HOD,DEPT OF
RADIODIAGONOSIS,KGMU)

2. CONTRAST USED IS BARIUM SULPHATE
BARIUM SWALLOW IS THE CONTRAST STUDY FROM ORAL CAVITY
UPTO FUNDUS OF STOMACH

3. ANATOMY OF PHARYNX

4. PARTS
NASOPHARYNX-ANTERIOR PHARYNX JOIN NASAL CAVITY
OROPHARYNX –MIDPORTION OF PHARYNX JOIN NASAL CAVITY
HYPOPHARYNX-INFERIOR PHARYNX JOIN LARYNX AND OESOPHAGUS

6. ANATOMY OF OESOPHAGUS
FLATTENED MUSCULAR TUBE ,SIZE 18-26 cm BEGINNING OF LOWER BORDER OF CRICOID CARTI
OPPOSITE TO C6 CERVICAL VERTEBRA) AND ENDING OF CARDIAC ORIFICE OF STOMACH (OPPOS
VERTEBRA)
DIVIDED INTO 3 ANATOMICAL SEGEMENTS
A) CERVICAL
B)THORACIC
C)ABDOMINAL

7. CERVICAL OESOPHAGUS :EXTENDS FROM PHARYNGEAL JUNCTION
TO SUPRASTERNAL NOTCH AND IS
ABOUT 4-5 cm
At THIS LABEL OESOPHAGUS BORDERED ANTERIORLY BY TRACHEA ,POSTERIORLY BY VERTEBRAL
,LATERALY-CAROTID SHEATH AND THYROID GLAND
THORACIC OESOPHAGUS:EXTENDS FROM SUPRA STERNAL NOTCH (OPP T1 VERTEBRA) TO
DIAPHRAGMATIC HIATUS
(OPP T 10 VERTEBRA). 18 CM LENGTH
ANTERIORLY LIES TRACHEA ,RIGHT PULMONARY ARTERY ,LEFT MAIN BRONCHUS & DIAPHRAGM
POSTERIORLY IT REST ON VERTEBRAL COLOUMN AND CLOSELY RELATED TO THORACIC
DUCTS,AZYGOUS,
AND HEMI AZYGOUS VEIN
ABDOMINAL OESOPHAGUS:EXTENDS FROM DIAPHRAGMATIC HIATUS TO ORIFICE OF CARDIA OF ST
SIZE ABOUT 1cm. ITS RIGHT BORDER COTINIOUS WITH LESSER CURVETURE AND LEFT BORDER IS DE
FROM FUNDUS BY OESOPHAGOGASTRIC ANGLE OF IMPLANTATION (ANGLE OF HIS)

9. CONSTRICTIONS
• superiorly: level of Cricoid
cartilage, juncture with
Pharynx
• Middle: crossed by aorta and
left main bronchi
• Inferiorly: diaphragmatic
sphincter

10. SPHINCTERS
TWO HIGH PRESSURE ZONES PREVENTS THE BACKFLOW OF FOOD
Upper esophageal sphincter
Primarily formed by cricopharyngeal muscle.
•Located at the C5-C6 level
•Normally relaxes with bolus
•Abnormalities
• Delayed relaxation
• Early closure
• No relaxation: with or without symptoms; if symptomatic, termed
cricopharyngeal achalasia

11. • Lower esophageal sphincter
•Distal 2-4 cm esophageal high pressure zone defined by manometry. Corresponds to
vestibule on esophagram.
•Prevents gastroesophageal reflux.
•Drugs and many types of food and drink affect lower esophageal sphincter and can lead to
reflux.
•Glucagon relaxes the lower esophageal sphincter when used for air-contrast upper
gastrointestinal examination.
•The tubular esophagus extends to just above the diaphragm.
•Bulbous distention of the distal esophagus is called the vestibule and corresponds to the
manometrically-defined lower esophageal sphincter.
This distention is best demonstrated by breath holding in inspiration or a Valsalva
maneuver.

12. Oral phase
In the oral phase food is prepared for swallowing and
then transported to the pharynx.
This is a preparatory phase in which the food is held
within the mouth while the base of the tongue and the
soft palate close the oral cavity posteriorly to prevent
food spilling into the open larynx and trachea.
A bolus is formed in the central portion of the tongue
and then pushed posteriorly toward the pharynx with
an anterior-to-posterior tongue elevation.
As the bolus enters the pharynx the actual swallow or
pharyngeal reflex is triggered. oral preparatory
phase
Transport to pharynx
And subsequent trigger
Of actual swallowing
reflex
PHASES OF SWALLOWING

13. Pharyngeal phase
This phase is a reflex action. The bolus passes
through the pharynx quickly and then enters the
esophagus.
This takes place in less than a second.
The initiation of this process starts when the bolus
passes the anterior faucial arch and reaches the
posterior pharyngeal wall.
Elevation of the soft palate prevents material from
entering the nasal cavity.
This stage is followed by the pharyngeal
constrictor muscles pushing the bolus further into
the pharynx, toward the cricopharyngeal
sphincter.
The larynx prevents material from entering the
trachea by respectively closing the true vocal
cords, false vocal folds, and aryepiglottic folds.
Contraction of the lower pharyngeal constrictor is
followed by relaxation of the cricopharyngeal
muscle, allowing the bolus to pass into the
esophagus.
LEFT: Pharyngeal constrictors push the bolus
down.RIGHT: Together with the contraction of the
inferior constrictor, the cricopharyngeus relaxes.

14. CONTRAST
TYPES OF CONTRAST STUDY
SINGLE CONTRAST STUDY
DOUBLE CONTRAST STUDY

15. Barium :
 Advantages-
Excellent coating.
Less cost.
 Disadvantages-
Leakage into mediastinum or peritoneum can cause fibrosis.
Subsequent abdominal CT or US are rendered difficult.
100% BARIUM SULPHATE PASTE
80% BARIUM SULPHATE PASTE
30% BARIUM SULPHATE SUSPENSION FOR HIGH KV TECHNIQUE
200-250% HIGH DENSITY ,LOW VISCOSITY FOR DOUBLE CONTRAST
STUDY

16. Water soluble contrast media :
Like Gastromiro (non ionic) (Iopalmidol 61%
w/v) or
Gastrografin (ionic) (Meglumine & Sodium
diatrizoate 76% w/v)
 Indications:
Suspected perforation,
If aspiration is possibility.
 Complications:
Pulmonary edema if aspirated,
Hypovolemia in children,
May precipitate in hyperchlorhydric gastric
acid,
Allergic reactions – due to absorbed contrast
media

17. Carbon dioxide and less often air are used in
conjunction with barium to achieve a double
contrast effect.
For the upper gastrointestinal tract, CO2 is
admininstered in the form of gas producing
granules / powder.
The requirements of these agents are as
follows :
1. Production of adequate volume of gas 200-400 ml.
2. Non interference with barium coating.
3. No bubble production.
4. Rapid dissolution , leaving no residue.
5. Easily swallowed.
6. Low cost.
USES OF GASES

18. INDICATIONS
1.DYSPHAGIA AND OBSTRUCTION
2.PAIN DURING SWALLOWING
3.ASSESSMENT OF MEDIASTINAL MASSES
4.ASSESSMENT OF LEFT ATRIAL ENLARGEMENT
5.PREOP ASSESSMENT OF CARCINOMA BRONCHUS AND OESOPHAGUS
6.MOTILITY DISORDER OF OESOPHAGUS ,E.g.-ACHALESIA ,ESOPHAGEAL
SPASM,SCLERODERMA
7.ASSESSMENT OF SITE OF PERFORATION

19. RELATIVE CONTRAINDICATIONS
TRACHEOOESOPHAGEAL FISTULA
PERFORATION
Caution should be exercised when using water-soluble contrast agents in patients with
a risk for aspiration. Aspiration of high-osmolarity water-soluble contrast agents has
been associated with massive pulmonary oedema and subsequent death. A low
osmolarity agent such as Omnipaque may be used in this setting.

20. Examination technique depends on the indication of
study. Preparation needed for study is overnight fasting,
avoiding smoking or chewing gum to decrease the
secretions in oral cavity and pharynx.
TECHNIQUE
ENSURED THAT NO CONTRAINDICATION OF PHARMACOLOGICAL AGENT USED
CHECK PREGNANCY STATE
PROCEDURE SHOULD BE EXPLAINED TO THE PATIENT BEFORE UNDERGOING THE PROCEDURE

21. Evaluation of pharynx
•scout films are obtained to rule out any foreign body,
abscess or fistula
•the examination is performed in the upright lateral
position after swallowing high-density barium
•right lateral views should be obtained initially to rule out
aspiration or penetration, then frontal views are obtained
•dynamic videofluoroscopic examination should be
simultaneously acquired for optimal evaluation
•spots are obtained quickly during suspended respiration
and under phonation (patient instructed to say
"Eeeee....") to distend the hypopharynx

22. Evaluation of oesophagus
•double contrast barium swallow is the preferred mode of examination
•the patient swallows a packet of effervescent agent and then rapidly gulps a packet of high-
density barium
•frontal and left posterior oblique views are taken
•two exposures are centred on the upper/mid oesophagus and two on distal oesophagus
•then, the table is brought to the horizontal position and patient turns to right lateral position for
a view of gastric cardia and fundus
•the patient drinks low-density barium in prone right anterior oblique position
• two to five separate swallows are assessed to evaluate motility of the oesophagus
• this also permits evaluation of distal oesophagus and GE junction, delineating lower
oesophagal rings and strictures

23. •patient is finally turned onto the left side and then onto the back so that barium
pools in the gastric fundus
•GE junction is then observed fluoroscopically as the patient slowly turns to right, looking
for elicited gastro-esophageal reflux
•straight leg raising, Valsalva manoeuvre or drinking water (water syphon test) can also
elicit gastro-oesophageal reflux
•additional views like mucosal relief views are useful in suspected tumours, varices or
oesophagitis

24. On the lateral view, the tongue base and epiglottis are seen from the side, with the
vallecula between. A posterior indentation caused by contraction of the
cricopharyngeus muscle indicates the commencement of the cervical oesophagus.
On the frontal view, the piriform fossae are outlined by barium and the epiglottis
and the base of the tongue show as filling defects in the midline.
The cervical oesophagus lies on the ventral surface of the cervical spine.
The thoracic oesophagus is best demonstrated in the right anterior oblique
position.
RADIOGRAPHIC FEATURES

25. NORMAL AP/LAT –SCOUT VIEW

26. RAO VIEW

27. A simple way to analyze a swallowing study is to
concentrate on four easily detectable findings.
HOW TO ANALYZE SWALLOWING DISORDERS
•Asymmetry
•Stasis
•Cricopharyngeal dysfunction
•Aspiration

28. Asymmetric swallowing on an AP-view is usually the result of an asymmetric tilting of the
epiglottis.
Sometimes it is caused by rotation of the head, but in many cases no real explanation is
found.
Even when the head is not rotated, the epiglottis can tilt asymmetrically when it hits the
posterior pharyngeal wall.
This is more likely to occur when only a small bolus is given,as the pharynx will not fully
distend.
An asymmetric swallow may be followed by a symmetric swallow in the same patient when
a larger bolus is given.
If a patient has a unilateral pharyngeal paresis, turning of the head towards the affected
side will help the patient in preventing aspiration.
By turning the head towards the affected side, this side will be closed preventing stasis on
this side and possible secondary aspiration.
Asymmetry

29. symmetric swallowing due to head
turn. The head is turned to the left
and contrast is only seen in the right
food channel.

30. Stasis is the result of insufficient cleansing of
the pharynx, either due to an obstruction (i.e.
dysfunction of the cricopharyngeus) or due to
insufficient contraction of the pharyngeal
constrictors.
Insufficient contraction is the result of
pharyngeal paresis resulting from a
neuromuscular disorder.
Excessive movements of the tongue base and
larynx are sometimes seen on lateral
fluorographic studies to compensate for the loss
of function of the pharyngeal constrictors.
When the patient resumes breathing, aspiration
can occur (Figure).
STASIS
Stasis of contrast at the label of pyriform sin
(blue arrow) with subsequent aspiration(yello

31. Premature closure of the cricopharyngeus results
in an increased pressure in the hypopharynx, just
above the cricopharyngeus, as the pressurewave
of the pharyngeal constrictors pushes the bolus
downwards.
This increased pressure can result in an
outpouching at a weak spot in the posterior
pharyngeal wall (Killian's dehiscence).
First this will result in a small pouch, that in time
can increase and form a true Zenker's diverticulum
(Figure).
A Zenker's diverticulum is always the result of
cricopharyngeal dysfunction
CRICOPHARYNGEAL DYSFUNCTION

32. Esophageal peristalsis
Normal:
•Primary contraction: Propels bolus through the
esophagus
•Secondary contraction: Follows primary contraction
and propels any remaining bolus from thoracic
esophagus
Abnormal:
•Tertiary contractions: Nonpropulsive contractions
•Diffuse esophageal spasm
•Nutcracker esophagus
•Decreased peristalsis resulting from achalasia,
scleroderma, dermatomyositis, polymyositis,
esophagitis, and secondary to many other diseases
On the left tertiary contractions
on first swallow (left).
Normal primary contraction on
next swallow (right).
These tertiary contractions are
non-propulsive, transient, and
intermittent contractions that are
inconstant in location and not
accompanied by symptoms,
usually in older patients.

33. Diffuse esophageal spasm
Diffuse esophageal spasm
produces intermittent contractions
of the mid and distal esophageal
smooth muscle, associated with
chest symptoms.
Manometry shows simultaneous
non propulsive contractions on at
least 10% of swallows.
Diagnosis is based on imaging,
manometry, and symptoms
Barium swallow shows irregular areas of
narrowing and dilatation ----- “Shish kebab”
“corkscrew” “rosary bead“ esophagus
The esophageal muscle is hypertrophied, but
Histologically normal

34. Achalasia
•Presentation:
• Equal M:F incidence, most common in
middle-age
• Slow progression of dysphagia
• Increased incidence of carcinoma
•Etiology:
• Unknown, although esophageal ganglion
cells are decreased
• Incomplete or absent relaxation of LES with
swallowing
• Absent primary peristaltic waves
•Esophagram:
• Dilation with absent peristalsis
• Smooth tapering at esophageal hiatus
• Distal carcinoma may simulate achalasia
(pseudoachalasia)
Barium swallow showing dilatation of the
esophageal body
*With short segment stricture.
* A “bird-peak " like tapering of the esophagus
at the GE junction.

35. •A-Ring
•Muscular contraction at the label of vestibular and tubular esophagus
•No definite anatomic correlate
•B-Ring
•Mucosal ring at anatomic squamocolumnar junction (Z-line)
•Best or only seen with vestibular distension
•Normally
•May cause episodic dysphagia if esophagus is narrowed, then termed a Schatzki ring
•> 20 mm wide, no obstruction
•13-20 mm wide, may obstruct

36. The esophageal B-ring is located at the
squamocolumnar junction, also termed the 'Z'
line.
The appearance does not change during the
examination.
On the left a patient with a 'B' ring (arrows)
several cm above diaphragm at the apex of sliding
hiatus hernia.
Note unchanged appearance on these two images.

37. 1) May be demonstrated on highvolume
barium oesophagrams when
the oesophagus is fully distended .
2)a "jet effect" of contrast passing distal
to the web may be seen .
Esophageal 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.
Symptoms if more than 50 percent lumen compromised
Associations
• Plummer-Vinson syndrome
• GORD/GERD (especially a distal oesophagus web)
• external beam radiation.
an asymptomatic 52-
year-old man.
AP and Lateral views
show short, thin web
(arrows) with minimal
intraluminal extension.

38. To detect the level of obstruction in case of
radiolucent foreign
body in
esophagus,marsh mellow coated with
barium is swallowed.
• Passage of marsh
mellow will be hindered
at the level of
obstruction
oesophageal foreign body. Frontal oesophagogram
showing meat in the oesophagus (right arrow). The
nasogastric tube is the up arrow.
FOREIGN BODY

39. The relationship between hiatus hernia, reflux
and reflux esophagitis is controversial and
poorly understood.
Most patients with gastroesophageal reflux
disease (GERD) have hernias.
Many patients with hiatus hernias do not have
reflux.
Many patients with reflux do not have hiatus
hernias.
Presence of reflux correlates poorly with
GERD.
A sliding hiatus hernia is of doubtful
significance when an isolated finding in the
absence of clinical or imaging findings of
esophagitis.
Diagnosis of GERD is based on imaging or
endoscopic findings of esophagitis, not
presence of a hiatus hernia.
HIATUS HERNIA

40. High abdominal pressure is required to
demonstrate.
• Pt has to strain.
• Lie down,straighten legs & then raise
them up.
• Manual compression of abdomen.
• Pt stands upright,ask him to bend
downward with leg
straight.
• Stomach should be distended to
demonstrate HH.
Barium meal in Trendlenberg position.
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

41. Reflux esophagitis
The findings on barium studies are
listed in table
Air-contrast esophagram shows thick esophageal
mucosal folds (arrows) and an ulcer (arrowhead)
due to GERD.
Single contrast esophagram shows stricture
(arrow) and sliding hiatus hernia

42. Barrett's esophagus
Barrett's esophagus (columnar metaplasia) is the
result of long-standing reflux esophagitis.
Most patients have reflux and a hiatus hernia.
The diagnosis is strongly suggested by:
•Mid or high esophageal ulcer
•Mid or high esophageal web-like stricture
•Reticular mucosal pattern
The reticular mucosa is characteristic of Barrett's
columnar metaplasia, especially with the
associated web-like (arrow) stricture.

43. Candida Esophagitis :
-In immunocompromised patients
-Discrete plaque-like lesions
-Larger plaques may coalesce to produce
"cobblestone" appearance
-Ulcers invariably appear only on a background of
diffuse plaque formation , not as isolated findings
-Further coalescence produces (shaggy) contour
Shaggy esophagus associated with Candida infection ,
image "A "depicts the longitudinally oriented plaque-
like
lesions visible in Candida esophagitis ,
image "B" depicts the granular appearance of
the esophageal mucosa secondary to edema
and inflammation

44. Cytomegalovirus esophagitis in a
patient with AIDS
Double-contrast esophagram
shows a large flat ulcer in
profile (large arrows) in the
midesophagus with a cluster
of small satellite ulcers (small
arrows)
Cytomegalo virus
esophagitis

45. Eosinophilic esophagitis
This diagnosis may be suggested by peripheral
eosinophilia and confirmed by > 20 eosinophils per
HPF on biopsy.
Patients often have dysphagia and allergies.
Imaging finding include diffuse narrowing,
strictures, and a ringed appearance similar to
transverse (feline esophagus) folds that are
transient or associated with reflux.
Steroid therapy is often curative.
.
On the left a patient with eosinophilic esophagitis.
There is diffuse distal narrowing and corrugated
margins (arrows) due to ring-like indentations,
that are characteristic of eosinophilic esophagitis

46. Feline esophagus
The delicate, concentric and transiently appearing
folds of a feline esophagus should be distinguished
from the thicker, interrupted, fixed folds indicative
of longitudinal scarring from reflux esophagitis.
The characteristics of a feline esophagus are:
•Horizontal striations due to muscularis mucosa
contractions
•Normal in cats
•Most often transient and insignificant
•May be associated with gastroesophageal reflux or
esophagitis
The folds are 1-2 mm thick and run horizontally
around the entire circumference of the
oseophageal lumen.
The folds are angled with respect to centre of
oesophagus in a HERRING BONE pattern

47. ESOPHAGEAL VARICES
Best demonstrated in mucosal relief study after using buscopan
/Valsalva maneuver
Appear as mucosal fold irregularity or as multiple persistent
filling defects in the lower third of the esophagus and/or
longitudinal furrows.
Types –
UPHILL VARICES:
Result from portal hypertension.
Appear as serpentine filling defect in distal half of
thoracic portion of esophagus.
DOWNHILL VARICES:
Result from SVC obstruction.
Appear as serpentine filling defect in upper or middle
part of esophagus.

48. STRICTURES
BENIGN MALIGNANT
• SYMMETRIC AREA OF NARROWING
WITH A SMOOTH CONTOUR AND
TAPERED MARGINS.
• ASYMMETRIC AREA OF NARROWING
WITH AN IRREGULAR, ULCERATED
CONTOUR AND SHELFLIKE MARGINS

49. stricture has smooth
contour and tapered
borders
smooth, symmetric
ringlike constriction
resembling Schatzki’s
ring
concentric segment of narrowing
with smooth contour and tapered
borders
BENIGN STRICTURES

50. MALIGNANT STRICTURES
Narrowed segment has markedly irregular contour with areas of nodularity and ulceration
with shouldered , shelf – like margins.

51. DYSPHAGIA LUSORIA
• THE OESOPHAGUS MAY BE COMPRESSED
• BY A CONGENITALLY ABERRANT RIGHT SUBCLAVIAN
• ARTERY
• IF THIS IS SYMPTOMATIC ADIAGONOSIS OF
• DYSPHAGIA LUSORIA IS MADE
• HERE IT IS SEEN OBLIQUE TUBULAR EXTRENSIC
COMPRESSION
IN UPPER OESOPHAGUS

52. TRACHEOESOPHAGEAL FISTULA
A Ryle’s tube is introduced to the level of mid
esophagus & contrast is injected.
The tube is withdrawn slowly.
This will force the contrast through any small fistula.
Both lateral & prone views must to be assessed.

53. COARCTATION OF AORTA
On the chest film the 'Figure 3' shape of aortic knob
due to pre and post stenotic dilatation (arrows).
The barium study demonstrates the 'Reverse 3
figure' indentation of esophagus by pre and post
stenotic aortic dilatation (arrows).

54. COMPLICATION

55. Leakage of barium
from unsuspected
perforation

56. ASPIRATION

57. Aspiration
There are three instances when aspiration can
occur: before, during or after the actual swallow.
•Aspiration before swallowing is either the result of
insufficient closure of the oral cavity during the
preparatory phase or inability to start the swallow
reflex when contrast enters the pharynx.
•Aspiration during swallowing is due to insufficient
closure of the larynx.
•Aspiration after swallowing is the result of stasis
of contrast in the pharynx - when the larynx opens
the contrast leaks into the trachea.

58. Aspiration before swallowing
When tongue or soft palate are unable to prevent
spillage of food into the pharynx, aspiration may occur
since the larynx is still open.
Weakness of these muscles in the mouth and the throat
is due to paralysis or myopathy.
Aspiration during swallowing
This is due to an insufficient closure of the larynx when it should be
closed.
Closure of the larynx is a result of anterosuperior lifting of the larynx
which allows the true cords, false cords and finally, the aryepiglottic folds
to contract, followed by a backwards folding of the epiglottis over the
closed larynx.
The aryepiglottic folds are the main gatekeepers, while the epiglottis plays
only a minor role in preventing aspiration.
Both failure of these intrinsic muscles of the larynx as well as failure of
the extrinsic muscles (i.e. muscles that lift the larynx) may lead to
aspiration during swallowing.
Weakness of the extrinsic muscles is seen after radiotherapy, in neurologic
disorders and in recurrens nerve paralysis (i.e. neuromuscular
dysfunction).
ASPIRATION DURIN
SWALLOWING

59. Aspiration after swallowing
This is the result of stasis of contrast in the
pharynx due to insufficient contraction of the
pharyngeal constrictors or insufficient opening
of the cricopharyngeal muscle.
When the larynx opens the contrast may leak
into the trachea.

60. Limitations of barium swallow study
Not good for evaluating small ulcers
Cannot test for H. pylori or take biopsies of ulcers
Not specific for diagnosis of esophagitis
Not possible to provide interventions for any lesions
We know endoscopy has replaced
barium study in many aspects of
medical care..
Barium studies are still better in
detecting :-
abnormalities in peristalsis ,
fistulas and
diverticulas compared to
endoscopy.

61. THANK YOU