Swallowing and oesophageal disorders
Cervical pouch with web (arrow) and aspiration from pharyngeal retention
The classic "Barium Swallow" is a fluoroscopic examination using standard barium suspension to assess oro-pharyngeal and oesophageal function. An image of the stomach is taken to exclude any pathology that might present as an oesophageal problem. The tendency over the last decade has been to use endoscopy for primary diagnosis and cross sectional imaging to stage any neoplasia. Barium studies can also diagnose structural pathology, but are complementary to endoscopy in the investigation of swallowing problems in being able to show functional disorders. These are common, but require experience for accurate diagnosis.
Swallowing may be considered in oral, pharyngeal and oesophageal phases. Oro-pharyngeal transport is complex, requiring adequate muscular strength and neurological control via the cortex and brain stem of bolus movement by the tongue, initiation of the swallowing reflex, and closure of larynx to prevent aspiration. Disordered swallowing is seen in a variety of neurological and other conditions. These require careful assessment, sometimes with different fluid and food textures, and possibly in association with a speech therapist to assess how the swallow may be modified to prevent aspiration and make it safe for the patient to eat or drink. These studies may therefore be termed "modified video swallows".
Although manometry may be the gold standard in assessing oesophageal peristalsis, barium studies may be very helpful in sorting out oesophageal dysfunction. Intermittent bolus dysphagia due to a Schatzki ring is best diagnosed radiological as it is frequently missed endoscopically. Bolus studies, with either bread or marshmallow soaked in barium are useful to assess hold up from any stricture and in diagnosing the tender oesophagus syndrome, where patients have exaggerated sensitivity to the passage of a solid bolus. Reflux is a more contentious issue. Impedance studies have shown that pH monitoring is not the gold standard, and there is a useful role for provocative radiological tests, such as the water siphon test (water swallows with the patient supine, the stomach partly filled with barium and distended with gas), to demonstrate reflux, sliding hiatus hernias that are a common association and to rule out any peristaltic disorder.
The barium swallow is a very safe and quick examination that can reveal early and subtle changes in both structure and function in all aspects of the swallow, and remains a very useful part of the investigation of swallowing and oesophageal disorders.
Barium swallow
. Standard examination
. ± solid bolus to assess oesophageal clearance and tender oesophagus syndrome
. ± water siphon test for reflux
Modified video swallow
. With speech therapist to plan management with swallowing difficulties