1. BARIUM SWALLOW.
AKA ESOPHAGRAM

2. Introduction
• Barium Procedures are Group of diagnostic tests
used to detect abnormalities of the Gastro-
Intestinal Tract using
X-ray imaging.
• Radio-opaque contrast used: Barium Sulphate
It coats lining of the digestive tract, allowing
accurate X-ray imaging of the part to be examined.

3. • Barium swallow is the non invasive contrast procedure used in
assessing the anatomy, physiology & pathology of upper GI
tract including esophagus & GE junction.
• Barium has superior contrast qualities and unless there are specific
contraindications, its use (rather than water-soluble agents) is
preferred.

4. Definition:-
 Barium provides a roadmap of GI tract pathologies in the form x-ray
examination of the esophagus, stomach, duodenum, small intestine
& large intestine.

5. Common Barium Procedures
1. Barium swallow - Pharynx to Fundus of the Stomach
2. Barium meal - Oesophagus to proximal jejunum
3. Barium meal follow through
4. Small bowel enema/Enteroclysis -
5. Barium Enema – Colon

6. • Barium Sulphate is mixed with water and is
swallowed.
• Following this a series of X-rays are taken.

7. Classification
Barium Studies :
1. Upper Gastro-Intestinal Series
2. Lower Gastro-Intestinal Series

8. Upper Gastro-Intestinal Series
1. Barium Swallow Examination
2. Barium Meal Examination
3. Barium Follow Through Examination
4. Enteroclysis / Small Bowel Enema

9. Lower Gastro-Intestinal Series
1. Barium Enema Examination

11. BARIUM SULPHATE - 250% OF HIGH DENSITY LOW VISCOSITY
• the most common material for radiographic visualisation of GIT.
• made up from pure barium sulphate.
• For stability particles are small (0.1 -3 micron)
• A non-ionic suspension medium is used to avoid clumping.
• Ph is 5.3 , which makes it stable in gastric acid.

12. WHY DO WE USE BARIUM SULPHATE?
Caracteristic of barium:-
The reason for using Barium sulphate for GI studies are :
1. Ba has a high atomic number 56. Therefore, it is highly radioopaque and
produces excellent bowel opacification.
2. Non absorbable (Therefore does not degrade throughout the bowel
), non-toxic.
3. Insoluble in water/lipid.
4. Inert to tissues.
5. Suitable for double contrast studies as it coats the mucosa in a thin layer, thus
allowing the introduction of 2nd or negative contrast agent without significant
degradation.

13. ADVANTAGES & DISADVANTAGES OF BARIUM
Advantages
• Not absorbed or degraded by the
GIT.
• coat the mucosa in a
thin layer for long period of
time, thus allowing the
introduction of a second or
negative contrast agent
without significant
degradation.
• Low cost
 DISADVANTAGES
 Leakage into mediastinum
or peritoneum can cause
fibrosis.
 Subsequent abdominal CT or
US are rendered difficult.
 Intravasation – this may
result
in a barium pulmonary
embolus, which carries a
mortality

14. • (a) Ba has a high atomic number
56. Therefore, it is
highly radioopaque
• (b) Non absorbable, non-toxic.
• (c) Insoluble in water/lipid.
• ( d) Inert to tissues.
• (e) Can be used for double
contrast studies
PROPERTIES OF AN IDEAL
BARIUM PREPARATION
1.High density for optimum study
being performed.
2.Stable suspension which does not
settle.
3.Should not flocculate
with secretions.
4.Low melting characteristics
to give a good and stable
mucosal coating.

15. Anatomy
The oesophagus begins at the upper oesophageal sphincter at the level of
C6 and finishes at lower oesophageal sphincter at T11 and is approx 25 cm.

16. Anatomy:

17. CONSTRICTIONS
• superiorly: level of Cricoid cartilage,
juncture with pharynx
• Middle: crossed by aorta and left main
bronchi
• Inferiorly: diaphragmatic sphincter

18. SPHINCTER
S

19. Anatomy

20. SPHINCTERS
Two high pressure zones prevent the backflow
of food:
• Upper Esophageal sphincter.
• Lower Esophageal sphincter.
• It is located at upper and lower end of
esophagus.

21. CONTRAST
• TYPES OF CONTRAST STUDY
(i) SINGLE CONTRAST STUDY
(ii) DOUBLE CONTRAST STUDY

22. CONTRAST USED
• 100% BARIUM SULPHATE PASTE
• 80% BARIUM SULPHATE SUSPENSION
• 30% BARIUM SULPHATE SUSPENSION FOR
HIGH KV TECHNIQUE
• 200-250% HIGH DENSITY,LOW VISCOSITY
FOR DOUBLE CONTRAST STUDY

23. INDICATIONS
• Dysphagia
• Heart burn, retrosternal pain, regurgitation & odynophagia.
• Hiatus hernia
• Reflux oesophagitis
• Stricture formation.
• Esophageal carcinoma.
• Motility disorder like
i. Achalasia
ii. diffuse esophageal spasms.
• Pressure or invasion from extrinsic lesions.
• Assessment of abnormality of
i. pharyngo esophageal junction including zenkers diverticulum
ii. cricoid webs
iii. cricopharyngeal Achalasia.

24. Barium Procedures
BY DR. HEERA RAM

25. Procedure
• Medical History
• Clinical Status
• Patient Consent
• Barium Study

26. What you should
expect in Barium
Swallow
• No special preparations are required.
• Study of the larynx, pharynx, and esophagus.
• A thick barium mixture(350-450 mL ) is
swallowed in supine position.
• Fluoroscopic images of the swallowing process
are made.
• The procedure is repeated several times with
the examination table tilted at various angles.
• Normally, 90% of ingested fluid should
have passed into the stomach after 15
seconds.

27. Normal Barium
Swallow

28. Barium Swallow
Radiological study of pharynx
and esophagus upto the level of
fundus of stomach with the help
of contrast.

29. Indications
1. Dysphagia
2. Heart burn, retrosternal pain, regurgitation & odynophagia
3. Hiatus hernia
4. Reflux oesophagitis
5. Stricture formation
6. Esophageal carcinoma
7. Motility disorder like – Achalasia , diffuse esophageal spasms
8. Pressure or invasion from extrinsic lesions
9. Assessment of abnormality of
1. Pharyngo esophageal junction including zenkers diverticulum
2. Cricoid webs
3. Cricopharyngeal Achalasia.

30. Contraindications
1. Barium should NOT be used initially if perforation is suspected.
If perforation is not identifed with a water-soluble contrast agent
then a barium examination should be considered.
2. Tracheo-esophageal fistula

31. Patient preparation
1. NPO for 6 hours prior to the examination.
2. Smoking should be avoided on the day of examination.
3. Muscle relaxants before the procedure
4 Ensure that no contra indication to the contrast
agent.
5 Check pregnancy status for female of child
bearing age.
6 Procedure should be explained to the patient
before under
7. Going the procedure and the duration the exam
may take.
8.Any other medical history needed.

32. Contrast
2 Types of contrast study
1. Single contrast study
2. Double contrast study

33. Contrast Media

34. Single vs double contrast:-
Single contrast
medium
Double contrast
medium
Only barium is given. 60-100%
w/v
Tooutline the structures, lumen
and large abnormalities.
Barium with gas producing agent
is given. 200-250% w/v
For detail viewing of the mucosal
pattern, making it easier to see
narrowed areas (strictures),
diverticula or inflammation.

35. Patient positioning for a single-contrast esophagram
Place the patient in the right anterior oblique (RAO)
position to offset the esophagus from the spine. The patient’s
right arm is placed alongside the body, with the left knee
flexed.
PA oblique esophagus, RAO position (the
midsagittal position forms an angle of 35°-
45° from the grid device).

36. The Radiographer should place the
cup barium in the patient’s left hand,
with the straw between the patient’s
teeth.
Patients who are unable to tolerate
this position may be imaged in the left
posterior oblique (LPO) position.
Position the fluoroscope so that the apex
of the left lung appears at the top of the
monitor.
The technologist will ask the patient to
continuously drink the barium. This fills and
distends the esophagus while the technologist
obtains images of the proximal esophagus,
midesophagus, and the distal esophagus,
including an open lower esophageal sphincter
(magnified if possible).
Single-contrast study of esophagus in RAO
position with table top in head-down -20°
position

38. Critique Criteria:
Right Anterior Oblique,Lateral Oblique's
The RAO should demonstrate the entire barium
filled Esophagus.
Like the RAO stomach , which is the single best projection,
the Right anterior oblique is also best for the esophagus.
The heart provides a homogeneous back ground to contrast
it Against and the distal esophagus traversing the
esophageal
Hiatus is laid out in profile.

39. Basic Positions
RAO (35° to 40°)
Lateral
AP
LAO

40. RAO
The esophagus is seen between the heart and the spine
The patient is rotate 35- 40 degrees with the RT side against the table

41. RAO-
LPO

42. Critique -
Criteria

43. R-Anterior
Oblique

44. Xray views
Lateral projection:-
 Place pt in lateral position.
 Center midcoronal plane to cassette.
 Bottom of cassette below xiphoid process.
 Pt must drink continuously before and
during exposure.
 Use shielding!

45. A.P Projection
• Erect
• Barium
filled
• cup

46. Xray views
AP or PA Projection:-
 Pt. supine or prone
 Center midsagittal plane to cassette
 Bottom of cassette should be placed just
below tip of xiphoid
 Pt. drinks contrast before exposure and
continues drinking during exposure.
 Shield!

47. Xray views
RAO or LAO Positions:-
 Tothrow the esophagus clear of the spine.
 Pt should be rotated 35 - 40 degrees
 Center about 2 inches lateral to MSP
 Bottom of cassette below xiphoid.

50. LATERAL

51. Radiographic
Projection -Lateral
D

52. Lateral
Because the esophagus is thrown away from the
spine, allowing better visualization

53. LAT - RAO
LAT

54. LAT - RAO
LAT

55. LAT - RAO
RAO

56. LAT - RAO
RAO

57. Complications
- Aspiration
- Leakage of barium from unsuspected
perforation.

58. g
Trendelenbug
position

59. Abnormalities

60. 1.Oesophageal
Varices

61. 1.Oesophageal
Varices
They appear inside the oesophagus and
occasionally they occur in the stomach. Varices
develop when most of the normal liver tissue has
been replaced by scar tissue. Because the scar
tissue pushes upon the veins in the liver, blood
cannot flow normally through the veins.

62. What is the radiographicappearance ?
• There are multiple submucosal filling defects in
a barium filled esophagus in AP view.

63. 2. Achalasia

64. 2. Achalasia

65. What is the radiographic appearance
?
• Dilated smooth outlined barium filled
esophagus with narrow tapering lower end of
the esophagus with smooth outline and
absence of fundal gas in stomach. .
( Rat Tail or Bird Beak Deformity)

66. 3. Zenker's
diverticulum (ZD)
Is a blind sac (pouch) that branches off the cervical esophagus. It is
the most common type of esophageal diverticulum.

67. 3. Zenker's
diverticulum (ZD)

68. 3. Zenker's
diverticulum (ZD)

69. 3. Zenker's
diverticulum (ZD)
Diverticula appeared as smoothly marginated
round-to-ovoid sacs. The size of the openings
of the diverticula depended on the location of
the barium bolus .

70. 4.Foreign body
Anteroposterior chest
radiograph depicts a penny at
the thoracic inlet of a 13-
month-old infant who refused
to eat.

71. 4.Foreign body
Lateral chest radiograph depicts soft-
tissue thickening at the
tracheoesophageal interface. A penny
was removed at esophagoscopy.