THE RELATIVE SENSITIVITY OF BARIUM
SWALLOW EXAMINATION
Vikas Sinha 1, Shalina Ray s
INTRODUCTION
Dysphagia is a vaguely defined "catch all" term for a
symptom that can have numerous causes located in a
variety of organs and structures. It encompasses pain on
swallowing as well as functional and physical difficulty in
swallowing.
Ingestion of caustics or corrosives result in immediate
dysphagia and pain. If the oesophagus is not perforated,
the acute symptoms subside in two or three days and
normal swallowing returns without pain after the first week
of ingestion. The symptoms evolve insidiously when there
is more than superficial penetration. Dysphagia develops
after 5th or 6th week when the scar tissue contracts.
The barium swallow done soon after corrosive ingestion
may show some irregular narrowing due to oedema and
spasm, but the narrowed segment is not sharply
demarcated from the normal oesophagus and thus will be
largely uninformative. Therefore examination with
contrast media should be postponed to the time when scar
tissue contraction may have started (3-6 weeks). Formed
strictures will show as concentric narrowed areas with
dilations above this point. When there is deep penetration
endoscopy should be avoided in the earlier stages to avoid
perforation. Later endoscopy in most cases will show
oesophageal narrowing especially if the penetration has
been circumferential.
The peptic stricture is an obvious, marked narrowing
which is never effaced. There is often diffuse superficial
oesophagitis proximal to the stricture but of variable
severity and often minimal and difficult to identify in the
dialated oesophagus. If only small amounts of barium
goes by, the stricture appears to be considerably longer
than its true extent. On endoscopy, peptic strictures are
abrupt and located distal to the most inflamed area. Wall
of the strictured segments are rigid and markedly
inflammed. The mucosal surface at this level is very
irregular and often ulcerated with marked areas of
inflammation which may simulate tumour infiltration.
Radiological examination is the first method of definitive
diagnosis in malignancy of the oesophagus. Radiological
appearances closely correspond with the gross
pathological findings ofpolypoidal ulcerating or infiltrating
tumor with mixtures of various types. The ulceration
carcinomas usually produce an area of minimal narrowing
of the lumen and irregularities indicating m u c o s a l
destruction. In early cases, this may be missed unless
care is taken. Infiltrating malignancy presents an
appearance of anomalous blood vessels, scars from
previously ingested corrosive agents, foreign bodies,
deformities from previous peptic oesophagitis and
achalasia can be confusing from the radiological stand
point, especially at the lower end of the oesophagus,
where special techniques must be employed to bring out
diagnosable features. Early oesophageal malignancy may
be missed by a barium swallow. Endoscopy should be
carried out in all patients in whom we suspect malignancy.
The use of large swallows of thick barium is recommended
to identify webs. Films should be taken in the frontal and
lateral views as the bolus passes through the suspected
areas. Webs are best seen in lateral views with barium
distending the oesophagus. They appear as thin membranes
at right angles to the wall and protruding into the lumen of
the oesophagus usually from anterior to posterior.
O B S E R V A T I O N AND D I S C U S S I O N
We carried out a study of 75 patients with dysphagia
comparing their symptoms with barium swallow and
endoscopic examination. All patients presented with
dysphagia as the main symptom. Other associated
symptoms were throat pain, vomiting, regurgitation, and
change of voice. In all the cases barium swallow was
carried out prior to endoscopy except in two cases of
foreign body oesophagus. They were grouped as per
tablel.
On comparing the barium swallow and endoscopic
reports, it was found that there were large number of
cases of Plummer Vinson syndrome not identified by
'Prof. & Head, ENT, 24th year Resident, ENT, The Department of Otorhinolaryngology, B. J. Medical College, Civil Hospital,
Ahmedabad
314
The Relavtive Sensitivity o f Barium Swallow Examination
Table -I
I.
II.
Malignancy
Benign Strictures
Post Corrosive
Peptic Strictures
III. P V Syndrome
IV. Achalasia Cardia
V.
Retro Pharyngeal Abcess
VI. Pulision Diverticuli
VII. Leiomyoma
VIII. F B Oesophagus
Normal
Sliding Hiatus Hernia
Cases
21
13
6
7
16
4
2
1
1
4
12
1
be attributed to perception and technical failure. Single
contrast Barium, Swallow can miss some lesions like
oesophagitis and oesophageal ulcer and hence mucosal
lesions can be missed. The false positive results of barium
reported as upper oesophageal narrow segment could be
due to normal aortic arch deviating the oesophagus. False
level of lesion reported could be due to inability of the
patient with severe dysphagia to swallow enought dye to
distend the oesophagus. Early strictures and diverticulam
may be missed by endoscopy.
REFERENCES
1.
A.V. Admassie D. (1996 Mar.) : Relative sensitivity of barrium
swallow. East African Medical Journal. 73 (3) : 201-3.
2.
Bruce Leipzig M. D. ; James Dean Klug and the Panendoscopy
study group. (1985 Sept.) : The Role of Endoscopy in Evaluating
patients with Head Neck Cancer Arch Otolaryngol. Vol 3.
3.
Cornelius E Dooly, M. B. B. Ch; Alan W Larson M. D. Nigel H
stace, M.B. Chb. (1984): Double contrast Barium Examination
and Upper Gastrointestinal Endoscopy. A comparative study
Annals of Internal Medicine. 101,538-545.
4.
David W. Gerfand, David J OH and Yu Men Chen (1987 Sept)
Primary panendoscopy : A Radiologist's response AJR. 149 :
519-520.
5.
Derowe A. Ophir D. (1994 Jan -Feb) : Negative findings for
suspected foreign bodies. American Journal of otolaryngology.
15 (1) : 41-5.
6.
Grossman T.W. Kita MS Toolhill R. J. (1987 Sept ) : The
Diagnositic accuracy of pharyngooesophagram compared to
oesophagoscopy in patients with head and neck cancer.
Laryngoscope 97(9) : 1030 : 2.
CONCLUSION
In all the cases of P.V Syndrome, it is better to find out
by endoscopy even if barium swallow is normal. Thus in
E V. syndrome, the accuracy of barium swallow is only
19% and 81% are reported as false negative.
7.
Martin T. R., Vennes J. A, Silvis. S. E. et al (1987 Sept) : UGI
Endoscopy versus radiography; is radiography obsolete
gastroenterolog, vol 80, AJR 149.
8.
M. Cochrani, G. S. Sokhi, L. H. Blumgart. Comparative study
of the diagnositic upper gastrointestinal endoscopy. British
Society for Digestive Endoscopy.
In strictures and malignancies, the level of lesion reported
by barium swallow should not be relied upon in all the
cases, and they should be confirmed by endoscopy.
9. Nino Murcia M. D., Muriam E. Vincent, M. D. Charles (1990
Aug.) : Esophagography and Esophagoscopy. Arch Otolaryngol
Head Neck Surgery Vol 16.
barium swallow. Out of a total of 16 cases of Plummer
Vinson syndrome, only 2 cases were identified by barium
swallow. Barium Swallow is not very accurate to identify
lesions in malignant and benign strictures. There were
two false @ositive reports on barium swallow, in which
no lesion was found on endoscopy. So in this study, the
relative sensitivity, of barium swallow is only 76% with
an error rate of 24%.
Another interesting finding is that there were 10 cases
with dysphagia with normal barium swallow but
endoscopic findings were normal.
Endoscop2~ provides us with a definite diagnosis and
allows biopsy and hence histological confirmation. Barium
Swallow is an important examination that can be used to
rule out certain lesions. So endoscopy can be avoided in
these patients. Failure rate of Barium Swallow can mostly
Address for C o r r e s p o n d e n c e :
Vikas Sinha
Prof. and Head, ENT
B. J. Medical college
Ahmedabad
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 4, October - December 2002
