Fluoroscopic examinations of the pharynx, esophagus and stomach

CHAPTER 8 Fluoroscopic examinations of the pharynx, esophagus and stomach






The barium swallow


The barium swallow is a simple, safe and effective examination for patients with symptoms of dysphagia. It can provide a significant amount of information both on its own or complementary to endoscopy or esophageal motility studies (Esfandyari et al., 2002; Hansmann and Grenacher, 2006).


The clinical indications for a barium swallow are high (pharyngeal) or low (esophageal/esophago-gastric) dysphagia, the root cause being either neuromuscular or mechanical. Common causes for high and low dysphagia are given in Table 8.1.


Table 8.1 Potential causes of dysphagia









High (pharyngeal) dysphagia Low (esophageal/gastro-esophageal) dysphagia

















CVA: cerebrovascular accident


The objective of the barium swallow is for the practitioner to:







The optimum objectives can be aided by using a CO2 impregnated contrast agent such as 100% w/v Baritop 100 (Sanochemia UK).




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.







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).




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.



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.


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Dec 26, 2015 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Fluoroscopic examinations of the pharynx, esophagus and stomach

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