This document provides guidance on performing a modified barium swallow study to assess for dysphagia and other esophageal disorders. It describes using barium sulfate of varying densities to visualize the pharynx and esophagus during swallowing in multiple positions. Both single and double contrast techniques are outlined to optimally distend and observe the esophagus. Specific protocols are provided for evaluating various conditions like achalasia, hiatal hernia, and reflux.

3. Miodified and cookie swallow

4.  Indication
 Dysphagia and obstruction
 Pain during swallowing
 Assessment of mediastinal masses
 Pre assessment of carcinoma bronchus
 Motility disorders of oesophagus e.g. aclasia
and diffuse oesophageal spasm, scleroderma
 Assessment of site of perforation

5.  Zenker’s diverticulum and cricoid webs. In these
cases water soluble contrast media are used.
E.g. Gastrograffin or dinosial aqueous
 Relative contraindications-
 Tracheo oesophageal fistula
 perforation
 Contrast-
 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

6.  Pharynx-
 One mouthful( 10-15 ml) of contrast media
(barium sulphate paste) is given and
fluoroscopic observation of act of deglutition
is observed in frontal and lateral view with
patient erect.
 To get optimum distension of the pharynx,
exposure is triggered at the time when hyoid
bone is at highest point during swallowing.

7.  For this , a string is tied just above the level
of larynx. The rotor is kept running and
patient is asked to swallow.
 Exposure is released when larynx comes
above the string.
 Lateral film is taken erect and front film in
supine position.

8.  One mouthful of contrast media ( barium
sulphate paste) is given to patient and
patient is instructed to swallow once and
stop swallowing thereafter.
 Spot films are taken in frontal and lateral
projection.
 Patient performs valsalva maneuver in erect
position with nose closed.
 Frontal and lateral spots are taken to show
distended pyriform sinuses and vallecullae.

9.  Oesophagus-
 Single contrast- multiple mouthful of 80%
W/V barium suspension are given.
 Follow the barium bolus down the
oesophagus and observe the peristalsis
always in supine position.
 Films are exposed in erect position – RAO,
LAO, frontal and lateral views when the
oesophagus is well distended.
 The escape of contrast at the level of the
diaphragmatic hiatus should not be confused
for reflux.

10.  Mucosal film is taken in RAO after the
oesophagus is empty.
 Then fundus of stomach and GO junction are
assessed with spot film in different obliquities
in erect and recumbent position.
 Double contrast-
 Barium contrast should be high density, low
viscosity(200-250%).
 15-20 ml barium is given in the mouth and
patient is asked to swallow.
 Then , effervescent powder is given with
another mouthful of barium.

11.  In erect position , gas tends to stay up,
resulting in adequate distension which stays
foe longer time as compared to supine
position.
 Prone position also retains more gas within
the esophagus and gives adequate
distension.
 Hypotonia using Buscopan or glucagon
keeps the oesophagus keeps the
oesophagus distended for longer time .
 Filming is done in frontal , lateral, RAO, and
LAO.

12.  Introduction of gas for double contrast
studies can also be done through a tube
passed into upper oesophagus.
 Specific Condition –
 Dysphagia for both solids and liquid.
 Pharyngeal web
 Foreign body impaction ( marsh mallow
coated with barium is swallowed as whole).
The passage of marsh mallow will be
hindered at the level of obstruction

13.  In carcinoma ( high viscosity, normal density
liquid barium is given).
 Achlasia – the oesophagus should be
cleaned thoroughly( aspirate and wash) so
that secondary achlasia due to ca
oesophagus not be missed.
 Barium 80% W/V is used and patient is
studied in erect position .
 To differentiate achlasia, from other condition
showing abnormal peristalsis , mecholyl test
is done.

14.  Hiatus hernia- high abdominal pressure
required .
 Patient is asked to lie down , straighten legs
and then raise them up.
 Stomach should be well distended,
otherwise hiatus hernia may not be
demonstrated.
 Gastro – oesophageal reflux

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