This document provides information about barium swallow studies, including: - The learning objectives which are to describe the anatomy and physiology of the esophagus and the procedure for barium swallow studies. - Details of the anatomy of the esophagus and the indications for barium swallow studies such as dysphagia and heartburn. - The preparation, examination process, positioning, and critique criteria for barium swallow imaging including anterior-posterior, lateral, and oblique views. - Additional imaging modalities that can be used such as CT and MRI are also mentioned.

1. Barium Studies
Barium Swallow (BS)
Rad. Aminu Abubakar Abubakar
Radiography Department
Bayero University Kano
October, 2020

2. • By the end of this lecture student will be able to;
• Describe the anatomy and physiology of Esophagus
• Describe the methodology of BS.
• List the indications and contraindications of BS.
• Describe patient care prior, during and after the
procedure
• Describe the imaging procedure (Single or double
contrast).
• Describe the routine and alternative positioning.
• Film critique; positioning, image quality, radiographic
anatomy and pathology
• Describe other alternative imaging modalities.
Learning Objectives

4. Anatomy of Esophagus
• Is a tubular structure of 25-33cm long.
• Begins at the level of C6 as a continuation of the
pharynx.
• At T10 it pierces the diaphragm to join the stomach.
• Situated at the center, but inclines to left side at it
descends through the neck.
• Anatomically divided into; cervical, thoracic and
abdominal.
• Physiologically Divided into; Upper esophageal
sphincter, esophageal body and lower esophageal
sphincter.

15. Introduction
What is the function of esophagus?
Transport of food by peristalsis.

20. Introduction
• BS; Special radiologic contrast examination that involves the oral
cavity to the fundus of the stomach.
• Barium Sulpahate used as contrast.
• Digital fluoroscopy
• Spot films
• Double or single contrast studies
• Barium flows from the mouth to the stomach
• Erect or recumbent

21. Indications
• Dysphagia
• Odynophagia
• Heart burn
• Regurgitation
• Hiatus hernia
• Reflux Esophagitis
• Achalasia
• Strictures
• Diffuse esophageal
spasms
• Zenker’s Diverticulum
• Esophageal Atresia
• Tracheoesophageal
fistulae
• E. stenosis
• E. cyst
• Tracheobranchail
remnant
• Barretts’ E

28. Preparation
• No patient preparation is needed for an esophagram, unless it is to be followed
by an UGI.
• Greet the patient.
• Take History.
• (If the patient is female, then a menstrual history must be obtained . Irradiation
of an early pregnancy is one of the most hazardous situations in diagnostic
radiography.)
• Remove jewelry, check attire, snaps, pins, NG tubes, etc.
• Explain the exam in layman’s terms.
• Questions?
• Set technique before positioning.
• Control films.

29. Examination
Single Contrast Study
• Esophagrams begin under fluoroscopy, in the upright position.
• The patient holds a cup of barium, with a straw, In the right hand.
• Instructs the patient to drink, and films in the AP, RPO, and LPO positions.
• The patient is often put into an RAO before the table is lowered to horizontal. The
examination continues in the recumbent position.
• The patient is instructed to take three large bolus swallows.
• On the fourth, breathing is suspended and the exposure is made at the moment
the patient swallows.
• A shallow trendelenburg position will help keep the esophagus full.

30. Anterior Posterior Projection (Neck)
Erect
• Patient stands erect with back against the FT
• MSP perpendicular to the film
• Chin elevated slightly
• Images are recorded as the patients swallows a
mouthful of barium
• The horizontal central ray is centered in the
midline at the level of the T5
• DR acquisition or a split 14x17” lengthwise film
can be used

31. AP & PA Positioning
supine
• 14”x17”lengthwise.
• (7”x17”are also used)
• Supine.
• Head turned to the side
to allow drinking.
• CR 1”inferior to the
sternal angle.
• Top of the film 2”above
shoulders

32. PA Prone
• 14”x17”lengthwise.
• (7”x17”are also used)
• Prone.
• Head turned to the side to
allow drinking.
• CR1”inferior to the sternal
angle.
• Top of the film 2” above
shoulders

33. Critique Criteria (AP)
Entire esophagus should be filled with barium, in an unrotated frontal projection.
When there is inadequate filling of the
esophagus, under-penetration, and/or
insufficient density, the esophagus is
difficult to visualize against the
mediastinum.
Good filling, contrast, and
density, demonstrating a
condition called presby
esophagus

34. Lateral Projection
Erect
• Patient roted to 900 from the
• MSP to be parallel to the table top
• Chin elevated and shoulders are depressed to permit maximum
visualization of the soft tissues above the shoulder
• Images are recorded similar to AP
• Horizontal ray is centered at T5 region
• DR acquisition or a split 14x17” lengthwise can be used
•

35. Right Lateral Positioning
• 14”x17”lengthwise.
• (7”x17” are also used)
• Right lateral.
• CRtoT5-6 in the midcoronalplane.
• Top of film 2”above shoulders.
• The arms may be raised and
superimposed (like a lateral chest
position), or the left shoulder
may be rotated posteriorly for a
“swimmer’s lateral

36. Critique Criteria (Right Lateral)
• Entire barium filled
esophagus projected
posterior to heart, and
anterior to the T-spine.

37. Left Posterior Oblique (LPO)
Erect
• From the AP is rotated to 20-300 on the left
side under the control of F control until the OS
is projected clear off the spine
• Cenral ray
• 35x35cm film can demonstrate the entire OS

38. Critique Criteria (LAO)
• The LAO may provide
valuable diagnostic
information, but:
Contrasts the esophagus
against the hilar area of the
right lung.
Foreshortens the abdominal
esophagus at the
gasteroesophageal junction

39. Right or Left Posterior Oblique (R/LPO)
Supine
• Used as an alternate to erect projections
• RPO for reflux
• In the horizontal position patient rotated 20-300 on to the right or
left side under F control…
• Vertical central ray
• Centered at the T8 to include the lower end of the Os and
diaphragm
• Other imaging modalities
• CT
• RNI

40. Routine RAO or LAO Positioning
• 14”x17”lengthwise.
• (7”x17”are also used)
• •20º-30º RAO position
• Spine must be as straight as
possible, especially with tight
collimation.
• CR toT8.
• Several inches left to the
spinous processes.
• Top of film 2” above shoulders.

41. Critique Criteria (RAO)
• Like the RAO stomach, which is the
single best projection, the RAO is also
best for the esophagus.
• The heart provides a homogeneous
background to contrast it against.
• The distal esophagus, traversing the
esophageal hiatus, Is laid out in
profile.
• The RAO should demonstrate the
entire barium filled esophagus.
• The abdominal portion is more
important than the pharyngeal
portion, which may be evaluated by
direct inspection

42. Examination
Double Contrast (DC)
• Similar to SC except patient is given an
effervescent agent prior to the administration
of the barium
• IV hypotonic agent may also be given
• Patient is then instructed to drink several
mouthfuls of barium rapidly and is examined
using a similar protocol to that of SC