Barium Swallow / Oesophagram

The barium swallow (oesophagram) is a dynamic fluoroscopic study of the pharynx and oesophagus used to assess swallowing, mucosal contour, luminal calibre and motility. Single-contrast, double-contrast and mucosal-relief phases are combined to evaluate structural and functional abnormalities. When perforation or aspiration is a concern the choice of contrast agent is altered to avoid the complications of barium in the mediastinum or lungs.

Indications

Dysphagia and odynophagia to localise and characterise the level of obstruction
Suspected benign or malignant stricture, web, ring (Schatzki) or oesophageal cancer
Suspected motility disorder such as achalasia, diffuse oesophageal spasm or scleroderma
Gastro-oesophageal reflux, hiatus hernia and assessment of post-fundoplication anatomy
Suspected pharyngeal or Zenker diverticulum, fistula or extrinsic compression

Contraindications & Cautions

Suspected oesophageal perforation or anastomotic leak: use water-soluble iodinated contrast first because extravasated barium causes mediastinitis
High aspiration risk: barium is inert if aspirated whereas hyperosmolar ionic water-soluble agents cause pulmonary oedema, so use a low-osmolar non-ionic agent when both perforation and aspiration risk coexist
If a water-soluble study shows no leak, follow with barium for superior mucosal detail
Complete high-grade obstruction where a large barium load may impact above the lesion
Inability to protect the airway or uncooperative patient at risk of massive aspiration

Patient Preparation

Nil by mouth for at least 4-6 hours to empty the oesophagus and stomach
Explain the procedure and the taste/texture of the barium suspension
Confirm no suspected perforation before selecting barium; screen for contrast allergy if iodinated agent needed
Remove radiopaque objects from the neck and chest
Assess swallowing safety and consider a modified barium swallow with speech therapy if aspiration is likely

Technique & Parameters

Begin with a scout image and, if perforation is suspected, an initial water-soluble contrast swallow
Double-contrast phase: effervescent granules for gas distension plus high-density barium, imaged erect in RAO and left lateral for mucosal detail
Single-contrast phase: low-density barium in the prone RAO position to distend the lumen and assess contour and strictures
Mucosal-relief views obtained after the lumen collapses to demonstrate fine mucosal folds
Motility assessed with the patient prone or supine swallowing single boluses under continuous fluoroscopy
Provocative manoeuvres (water siphon, Valsalva, marshmallow or barium tablet) to elicit reflux or reveal subtle rings

Systematic Review

Assess the pharyngeal phase, epiglottic tilt and laryngeal penetration or aspiration
Evaluate primary and secondary peristalsis and any tertiary non-propulsive contractions
Inspect mucosal pattern for ulceration, plaques, nodularity or varices
Measure luminal calibre and characterise any narrowing as smooth or irregular, focal or long-segment
Assess the gastro-oesophageal junction, hiatus hernia and reflux during provocative manoeuvres
Look for diverticula, webs, rings, extrinsic compression and fistulous tracks

Key Findings & Significance

Achalasia: dilated oesophagus with smooth tapering bird-beak narrowing at the gastro-oesophageal junction and absent primary peristalsis
Malignant stricture: irregular, shouldered, mucosal-destroying narrowing with abrupt transition
Peptic stricture: smooth tapered distal narrowing, often with a hiatus hernia and reflux
Schatzki ring: thin mucosal ring at the B-ring causing intermittent dysphagia to solids
Diffuse oesophageal spasm: corkscrew or rosary-bead appearance from non-propulsive tertiary contractions
Zenker diverticulum: posterior midline pharyngo-oesophageal outpouching above cricopharyngeus

Differential Considerations

Smooth stricture: peptic, radiation, caustic, anastomotic, or eosinophilic oesophagitis (ringed oesophagus)
Irregular stricture: adenocarcinoma, squamous cell carcinoma, or aggressive reflux
Filling defect: carcinoma, leiomyoma, fibrovascular polyp, food bolus or air bubble
Dilated aperistaltic oesophagus: primary achalasia versus pseudoachalasia from tumour, or scleroderma
Multiple outpouchings: intramural pseudodiverticulosis versus true diverticula

Pearls & Pitfalls

Always use water-soluble contrast first when leak or perforation is suspected, then barium if no leak is seen
When both aspiration and perforation are possible, choose a low-osmolar non-ionic iodinated agent
A barium tablet or marshmallow bolus unmasks subtle rings and strictures missed by liquid barium
Pseudoachalasia from an infiltrating cardia tumour can mimic primary achalasia; correlate with endoscopy
Assess for aspiration in real time and stop the study if the airway is threatened

Structured Report

State the contrast agent used and the reason if water-soluble was chosen
Describe pharyngeal function, aspiration, peristalsis and gastro-oesophageal reflux
Characterise any stricture by level, length, calibre and margin (smooth versus irregular)
Report diverticula, rings, webs, hiatus hernia and extrinsic compression
Give a concise impression and recommend endoscopy or manometry where appropriate

References

ACR-SPR Practice Parameter for the Performance of Esophagography and Upper Gastrointestinal Examinations
Levine MS, Rubesin SE. History and Evolution of the Barium Swallow for Evaluation of the Pharynx and Esophagus. RadioGraphics
Ott DJ et al. Radiographic Evaluation of Esophageal Dysphagia. RadioGraphics
Royal College of Radiologists iRefer: Making the Best Use of Clinical Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.

Barium Swallow / Oesophagram

📋 Indications

⛔ Contraindications & Cautions

🧑‍⚕️ Patient Preparation

⚙️ Technique & Parameters

🔎 Systematic Review

🩻 Key Findings & Significance

🧠 Differential Considerations

💡 Pearls & Pitfalls

📝 Structured Report

📚 References