Comprehensive Guide to Barium Swallow Examination

Table of Contents

1. Introduction
2. Indications
3. Contraindications
4. Patient Preparation
5. Procedure
6. Film Techniques
7. Risks and Benefits
8. Complications
9. Conclusion

1. Introduction

A Barium Swallow, also known as an esophagram, is a fluoroscopic procedure used to examine the upper gastrointestinal tract, specifically the pharynx, esophagus, and upper stomach. The procedure involves the patient swallowing a barium sulfate suspension, which coats the inner lining of these organs, making them visible on X-ray images.

2. Indications

Barium Swallow examinations are indicated for patients with:

• Difficulty swallowing (dysphagia)
• Painful swallowing (odynophagia)
• Unexplained chest pain or heartburn
• Regurgitation
• Suspected esophageal motility disorders
• Evaluation of known esophageal conditions (e.g., achalasia, strictures)
• Suspected hiatal hernia
• Evaluation of surgical repairs of the esophagus
• Chronic cough or hoarseness (to rule out aspiration)

3. Contraindications

3.1 Absolute Contraindications

• Suspected or known esophageal perforation
• Recent esophageal surgery
• Tracheoesophageal fistula

3.2 Relative Contraindications

• Pregnancy (especially in the first trimester)
• Severe swallowing difficulty with high aspiration risk
• Allergic reaction to barium or similar contrast agents
• Inability to follow instructions or cooperate during the procedure

4. Patient Preparation

• The patient should fast for 6-8 hours prior to the examination
• Remove all metallic objects from the chest and neck area
• Inform the radiologist of any medications, allergies, or recent illnesses
• Obtain informed consent
• For female patients, confirm absence of pregnancy
• Explain the procedure to the patient, including the need to follow instructions during the examination

5. Procedure

1. Position the patient upright on the fluoroscopy table
2. Provide the patient with a cup of barium sulfate suspension (usually 60-120 mL)
3. Instruct the patient to take small sips and hold the barium in their mouth
4. When instructed, the patient swallows the barium while the radiologist observes the swallowing process under fluoroscopy
5. Various swallowing maneuvers may be requested:
   • Single swallow
   • Multiple rapid swallows
   • Valsalva maneuver
6. The patient may be rotated or positioned differently to obtain various views
7. Additional barium may be given to coat the entire esophagus
8. The examination typically lasts 15-30 minutes

6. Film Techniques

6.1 Standard Views

• Anteroposterior (AP) view
• Lateral view
• Right anterior oblique (RAO) view
• Left posterior oblique (LPO) view

6.2 Special Techniques

• Double-contrast technique: Using effervescent granules to distend the esophagus with air
• Prone position: To evaluate for subtle mucosal abnormalities
• Modified barium swallow: Focusing on the oral and pharyngeal phases of swallowing

6.3 Imaging Parameters

• kVp (kilovoltage peak): 65-80 kVp
  • This range allows for adequate penetration of the barium-filled esophagus while maintaining good contrast.
  • The exact value may be adjusted based on patient size and the specific area being imaged.
• mAs (milliampere-seconds): 15-20 mAs
  • This range provides sufficient radiation exposure to create a clear image while minimizing overall radiation dose.
  • The value may be adjusted based on the patient's body habitus and the speed of the examination.
• SID (Source to Image Distance): 42-53 inches (107-135 cm)
  • This range allows for proper magnification and coverage of the anatomical area.
  • The specific distance used may depend on the patient's height and the area of interest.
• Additional considerations:
  • Fluoroscopy time should be minimized to reduce radiation exposure. Pulsed fluoroscopy can be used to further reduce dose.
  • Collimation should be used to limit the field of view to the area of interest, reducing scatter radiation and improving image quality.
  • Automatic Exposure Control (AEC) may be employed to optimize exposure parameters based on patient thickness and density.

7. Risks and Benefits

7.1 Benefits

• Non-invasive evaluation of the upper GI tract
• Ability to assess both structural and functional abnormalities
• Real-time visualization of the swallowing process
• Helps in diagnosing various esophageal disorders
• Guides treatment decisions

7.2 Risks

• Radiation exposure (though generally low)
• Potential for aspiration of barium
• Allergic reaction to barium (rare)
• Constipation due to retained barium

8. Complications

8.1 Immediate Complications

• Aspiration of barium into the airway
  • Symptoms: Coughing, choking, respiratory distress
  • Management: Stop the procedure, suction if necessary, chest physiotherapy
• Allergic reaction
  • Symptoms: Itching, hives, difficulty breathing
  • Management: Stop the procedure, administer antihistamines or epinephrine if severe

8.2 Delayed Complications

• Constipation
  • Prevention: Encourage fluid intake after the procedure
  • Management: Laxatives if necessary
• Barium impaction
  • Rare but can occur in patients with pre-existing narrowing of the GI tract
  • Management: Endoscopic removal may be necessary

9. Conclusion

The Barium Swallow examination is a valuable diagnostic tool for evaluating the upper gastrointestinal tract. When performed correctly and in appropriate patients, it provides important information with minimal risk. However, radiologists and technicians must be aware of the potential complications and take necessary precautions to ensure patient safety.