Barium Swallow and Esophagus Anatomy

Study Notes

A medical imaging procedure used to examine the upper gastrointestinal tract, including the esophagus and, to a lesser extent, the stomach.
Barium sulfate is used as a contrast agent.

The esophagus begins at the upper esophageal sphincter (level of C6) and ends at the lower esophageal sphincter (level of T11).
Approximately 25 cm long.
Cervical esophagus: extends from the cricoid cartilage to the suprasternal notch, approximately 4-5 cm long.
Thoracic esophagus: extends from the suprasternal notch (T1 level) to the diaphragmatic hiatus (T11 level), approximately 18 cm long.
Abdominal esophagus: extends from the diaphragmatic hiatus to the cardiac orifice of the stomach, approximately 1 cm long.
Anatomical constrictions:
- Superiorly: Level of the cricoid cartilage, where the esophagus meets the pharynx.
- Middle: Crossed by the aorta and left main bronchus.
- Inferiorly: Diaphragmatic sphincter.

Barium sulfate is the typical contrast agent used in exams of the alimentary tract, unless otherwise contraindicated.
Thin barium: useful for outlining the esophagus quickly; useful for diagnosing reflux (using water test, shallow LPO, compression, or toe-touch maneuver).
Thick barium (barium paste): mixed with water; coats and adheres to the mucosa; often mixed with cotton balls, marshmallows, or other foods.
No specific patient preparation usually needed for esophagram, unless it is to be followed by an upper gastrointestinal (UGI) series.

Usually no need for pre-procedure preparations, unless there will be other parts of the GI tract studies.
Patient is instructed to follow NPO (nothing per oral) before the procedure.
Remove any jewelry.
Ensure there are no contraindications to the pharmacologic agent used.
Check for pregnancy.
Explain the procedure to the patient before beginning.

Single contrast: involves multiple mouthfuls of 80% w/v barium suspension. Patient is placed prone and asked to swallow. Useful for assessing esophageal contractions, compression, displacement, and disordered motility.
Double contrast: using high-density, low-viscosity barium (200-250%); 15-20 mL given and patient asked to swallow. Then effervescent powder is given with another mouthful of barium. Best position for this study is upright; gas tends to stay up and allows for adequate esophageal distension. Injection of buscopan IV is sometimes performed to keep the esophagus dilated for a longer period.

Patient in lateral position while standing, with the midcoronal plane parallel to the bucky.
Collimating beam at both sides of the esophagus (about the width of a hand).
Central ray at the level of D6.
Esophagus seen anterior to the dorsal spine.

IR size: 18x24 cm.
Centering point: below the thyroid cartilage (AP), 2.5 cm below the thyroid cartilage (lateral/lat).
kVp range: 100-110.

Dysphagia
Heartburn, retrosternal pain, regurgitation, odynophagia
Hiatus hernia
Reflux esophagitis.
Esophageal stricture.
Esophageal carcinoma.
Motility disorder (achalasia, diffuse esophageal spasm).
Pressure or invasion from extrinsic lesions.
Assessment of pharyngoesophageal junction abnormalities (Zenker's diverticulum, cricoid webs, cricopharyngeal achalasia).

Suspected leakage from the esophagus into the mediastinum, pleura, or peritoneal cavities.
Tracheo-esophageal fistula.

Carcinoma of the Esophagus (CA): Preferably high-viscosity, normal-density barium used. Classical finding is a "rat-tail" appearance.
Achalasia: Barium swallow showing dilatation of the esophageal body, with a short-segment stricture, and a "bird-peak" like tapering at the gastroesophageal (GE) junction.