Pharyngeal and esophageal swallow technique

Where possible, the barium swallow should be performed with the fluoroscopy table in the erect position and ideally using a carbonated barium solution. Timing of the swallow for imaging is all important and it is of value when explaining the requirements to give the patient a trigger word such as telling them to swallow when they hear the word ‘now’ as in ‘swallow now’.

Before commencement of formal imaging, the patient is given an initial swallow of barium, and its passage to the stomach is screened to check there is no mechanical obstruction. The patient is placed in the right anterior oblique or lateral position as this projects the esophagus away from the spine and trachea. In this position, there is a better chance of differentiating barium in the trachea originating from a tracheo-esophageal fistula from that which has been aspirated. Regardless of the cause of the barium in the trachea, the patient will cough if that reflex is present. Coughing will result in the barium coating the trachea which might subsequently make it difficult to determine the cause for the barium being present.

Imaging

As an optimal minimum, imaging patients with high dysphagia should include videofluoroscopy or rapid imaging sequences of the pharynx (e.g. at least 3–4 frames per second). Videofluoroscopic assessment of swallowing disorders is expored further in Chapter 7.

The pharynx is examined in the lateral, the left or right anterior oblique, and the anteroposterior projection. The alternate oblique need only be considered if an abnormality is suggested. If pharyngeal imaging options are limited, the lateral projection provides the greatest breadth of information and can demonstrate aspiration and pharyngeal abnormalities such as pharyngeal pouch, webs, pharyngeal neoplasm, prominence of the cricopharyngeus (Figures 8.1, 8.2, 8.3, 8.4 and 8.5) and osteophyte impression.

Figure 8.1 Lateral pharynx – pharyngeal pouch.

Figure 8.2 Lateral pharynx – web demonstrated.

Figure 8.3 Lateral pharynx – carcinoma.

Figure 8.4 Anteroposterior pharynx.

Figure 8.5 Right anterior oblique pharynx – carcinoma.

Imaging of the esophagus, esophago-gastric junction and gastric fundus must always be included whether symptoms suggest high or low dysphagia. Turning the patient towards the right anterior oblique position will demonstrate the esophagus away from the spine (Figures 8.6 and 8.7).

Figure 8.6 Upper esophagus.

Figure 8.7 Mid esophagus.

Demonstration of the esophagus can be achieved by asking the patient to drink the barium and keep swallowing as quickly as possible. Esophageal distension is maintained by the second swallow inhibiting the first and the third inhibiting the second etc. If the patient cannot cope with continuous swallowing, the alternative is to take a number of separate swallows, overlapping imaging of the distended esophagus.

The importance of obtaining full distenson of the esophagus cannot be emphasized enough as plaque lesions can be missed (Figure 8.8). If full distension is not considered to have been achieved the swallow must be repeated.

Figure 8.8 Plaque tumor above hiatus hernia.

Subtle esophageal strictures may not demonstrate convincingly on a liquid barium swallow; in these instances asking the patient to swallow a small barium sulfate coated marshmallow can be effective in demonstrating the point of hold-up.

Separate images should be taken of the esophago-gastric junction (Figures 8.9, 8.10 and 8.11); the optimal degree of obliquity can be identified from the initial screened swallow. Additional images should be considered as appropriate if an abnormality is suggested.

Figure 8.9 Lower esophagus and gastro-esophageal junction.

Figure 8.10 Carcinoma in lower esophagus.

Figure 8.11 Achalasia. Distended esophagus with debris.

Lesions in the gastric fundus can present as dysphagia and examination of this part of the stomach forms an integral part of the barium swallow. In the erect position, swallowed barium is likely to by-pass the fundus, gas from carbonated barium migrating to the fundus.

With the patient in the anteroposterior position, the table is tilted to horizontal. Coating the fundus with barium can be achieved by turning the patient to the left and then prone and finally to the right lateral position, tilting the table head up to a point that the barium drains out of the fundus to be replaced by the gas. Lateral (Figure 8.12) and then left anterior oblique (Figure 8.13) images of the upper body/lower fundus are taken at this point; reflux and motility are checked as described in the barium meal section below.

Figure 8.12 Left side raised lateral stomach.

Figure 8.13 Left anterior oblique upper body/lower fundus of stomach.

Images are taken of the fundus with the patient and table in the erect position (Table 8.2), then to complete the examination an overview can be taken of the stomach demonstrating gastric emptying. When the patient’s clinical condition severely limits movement, the barium swallow can still be considered. The table need only be tilted up from the horizontal position as far as the patient will tolerate.

Table 8.2 A quick reference guide to a standard barium swallow technique

Where possible, turning the patient onto their side will reduce the risk of accidental aspiration should the patient expel the contrast medium.

In patients with a poor swallow or gag reflex, examination of the lower esophagus can be achieved by the trans-nasal insertion of a fine bore tube into the distal esophagus or site of obstruction, followed by the infusion of a contrast medium which, if necessary, can be aspirated through the tube at the end of the examination (see Chapter 11).

Double contrast barium meal technique

The patient is starved for 4 hours to make sure the stomach is empty.

With a horizontal fluoroscopy table and the patient supported upon their elbow on their left side, the effervescent powder followed by the citric acid activating agent are given to the patient along with a high density barium such as 340 g EZ HD (E Z Em) diluted with 65 ml H₂O. The patient then, without sitting up, turns to lie on their back, thus keeping the barium within the gastric fundus. At this stage, an intravenous hypotonic agent is given (see Chapter 3).

Turning the patient to their right through 270 degrees enables the barium to wash over the posterior wall of the mid and distal stomach, the lesser curve and then the anterior wall with the patient prone. The greater curve is then coated with barium, ending with the patient on their left side with the barium flowing back into the fundus once again. If coating is not satisfactory, the turning should be repeated.

From the right side raised lateral position the patient is turned into the right anterior oblique position (RAO) (Figure 8.14) to demonstrate the gas filled gastric antrum before barium passes into the duodenum overlapping and possibly obscuring parts of the stomach.

Figure 8.14 Right anterior oblique stomach.

Maintaining the barium within the fundus, the patient is placed in the supine position (Figure 8.15), gas will then fill the body and upper body, although as the antrum is projecting posteriorly in this position it is not always gas filled or seen to its fullest extent.

Figure 8.15 Supine stomach.

Turning the patient onto their right side and tilting the table head up will enable the barium to drain out of the fundus and be replaced by gas distension. A left side raised lateral image of the fundus is recorded (see Figure 8.12). The barium passes to the gastric antrum and on into the duodenum.

Controlling the patient’s movement, they are then turned towards the left anterior oblique under fluoroscopic control. The practitioner is watching for the movement of barium and gas to demonstrate the fundus and upper body distal to the esophago-gastric junction. The optimum position is immediately before the barium gas interchange occurs (see Figure 8.13). Depending on the shape and size of the stomach, altering the table position may or may not be of value.

With the patient supine, the table is returned to the horizontal position where barium is confirmed to be in the duodenum. Tilting the table up enough to drain barium out of the duodenal bulb, the patient is turned to the left lateral position and the table returned to the horizontal with barium in the third/fourth part of the duodenum and gas refills the antrum. With a pad held in the midline of the epigastrium, the patient is turned prone onto the pad. Pad compression of the stomach against the spine minimizes the passage of barium and optimizes the viewing of the duodenal loop (Figure 8.16).

Figure 8.16 Prone duodenal loop demonstrating an adenoma.

Returning the patient onto their left side, magnified views are taken of the duodenal bulb in varying degrees of obliquity starting with the RAO (Figure 8.17A–D). Should the gas be expelled and the bulb collapse, it only requires turning the patient onto their left side once more to enable the bulb to reinflate.

Figure 8.17 (A–D) Four views of the duodenal cap with the table horizontal.

The patient and table are tilted to the erect position, being aware that the patient may feel they are falling forwards during travel through the last few degrees to the vertical. Gas will migrate to the fundus so that an erect image can be acquired of stomach and, in particular, the distended dome of the fundus (Figure 8.18). In the erect position, an RAO is taken of the duodenal bulb (Figure 8.19), in particular to demonstrate the apex of the bulb. The LAO may be of value, but imaging is often limited by overlapping gastric or duodenal anatomy.

Figure 8.18 Erect stomach showing the dome of the fundus.

Figure 8.19 Erect right anterior oblique demonstrating the apex of the duodenal bulb.

The esophagus is now imaged as described in the barium swallow section of this chapter. Once imaging of the stomach and duodenum is completed it does not matter about the additional barium entry from examining the esophagus.

Reflux. Anyone can be made to reflux and, in checking for its presence, it should not be forced. Options to check for reflux could include tilting the table head down with the patient slightly in the LAO position, bringing the barium in the fundus in contact with the esophago-gastric junction. Peristalsis as a result of the patient going through the act of swallowing should demonstrate reflux should it be present. An alternative method is to raise the patient’s legs and ask them to cough.

Motility. A simple test to assess motility is to have the patient in the prone position with their head turned to the side. Ingesting a mouthful of barium in one swallow and observing its passage will enable the stripping of the primary and secondary peristaltic wave to be observed. It is important the patient does not swallow twice in succession as the second swallow will inhibit assessment of the first. A method of inhibiting a second swallow is for the patient to open their mouth immediately after the first swallow (Table 8.3).

Table 8.3 Quick reference guide to the double contrast barium meal

Intubation

A tube is placed in the second part of the duodenum and enough barium is infused to coat the whole of the duodenal loop. The patient may need to be turned from the supine to the left and then prone to coat the anterior wall. Returning to the supine position, air is gently infused through the tube. Images are taken in the RAO, supine and LAO and, if possible, prone position with magnified views as required. The benefit of this technique is that there will be no barium in the stomach to overlie the duodenal loop.

Oral ingestion

The technique for transmitting barium and effervescent agent to and around the duodenum is similar to that for the barium meal. The disadvantages of this technique are the barium in the stomach overlying the duodenum and the possibility of suboptimal lumen distension.