Disease: Integrating the Barium
Gastroesophageal reflux disease (GERD) is a common
medical problem in the United States. As a result, laparo-
scopic antireflux surgery is a common surgical procedure.
At the authors’ institution, the barium esophagram before
and after antireflux surgery is a critical examination in
patients with GERD. This article summarizes the authors’
examination protocol and describes how the findings are
integrated in the care of these patients.
? RSNA, 2007
1From the Cleveland Clinic Center for Swallowing and
Esophageal Disorders, Department of Diagnostic Radiol-
ogy (M.E.B., D.M.E., B.R.H., E.M.R., G.A.M., E.E.), Depart-
ment of Cardiovascular Surgery, Section of Thoracic Sur-
gery (T.W.R.), and Department of Gastroenterology and
Hepatology (J.E.R.), the Cleveland Clinic Foundation, 9500
Euclid Ave, Cleveland, OH 44195. Received January 13,
2005; revision requested March 17; revision received
October 7; accepted November 7; final version accepted
January 30, 2006; final review and update by M.E.B.
November 22. Address correspondence to M.E.B.
2Consulting Radiologists, Minneapolis, Minn.
3Department of Medicine, Temple University School of
Medicine, Philadelphia, Pa.
? RSNA, 2007
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fecting large numbers of individuals and
consuming health care dollars (1–3).
While the majority of patients with
GERD are treated medically and re-
quire neither a barium examination nor
endoscopy (4), there is no consensus as
to what tests should be performed in
evaluating patients with GERD either
before or after antireflux surgery. At
many institutions, because of lack of
training or disinterest on the part of
radiologists, and because of the bias of
gastroenterologists and surgeons, en-
doscopy has almost completely replaced
the barium examination in the evalua-
tion of the esophagus.
For the past 10 years at the Cleve-
land Clinic Foundation, there has been a
multidisciplinary center for swallowing
and esophageal disorders, where more
than 2400 patients with GERD are eval-
uated per year. Virtually all of these pa-
tients undergo barium esophagography
as part of their evaluation prior to sur-
gery. Since the inception of the center,
astroesophageal reflux disease
(GERD) is a substantial health
problem in the United States af-
physicians from the departments of gas-
troenterology, otolaryngology and speech
disorders, radiology, and thoracic sur-
gery have met biweekly to review and
discuss the clinical, radiographic, mano-
metric, and endoscopic findings in pa-
tients with esophageal diseases. In
those discussions, the barium esopha-
gram is often critical in the evaluation of
the patient. As a result of these case
discussions, we have over time devel-
oped a focused approach to the role of
the esophagram in the evaluation of pa-
tients with GERD both before and after
With the advent of laparoscopic fun-
doplication in the United States, we are
evaluating more patients before and af-
ter antireflux surgery. Because our ap-
proach is multidisciplinary and is ap-
plied to a large number of patients, we
thought it timely to communicate our
esophagography technique, the impor-
tant factors we evaluate, and how the
findings are integrated into the care of
patients with GERD both before and af-
ter antireflux surgery.
The barium examination of the esopha-
gus requires a tailored and flexible ap-
proach by the radiologist. We start with
a short history to determine the pres-
ence and frequency of symptoms, in-
cluding solid and liquid dysphagia,
chest pain, regurgitation, and heart-
burn, and we tailor our examinations
accordingly. Our examination of the
esophagus can be separated into seven
phases (5,6): (a) the timed barium swal-
low (7); (b) the upright, mucosal or air-
contrast phase; (c) the motility phase;
(d) the distended or single-contrast
phase; (e) reflux identification; (f) the
solid food phase; and (g) the oropharyn-
geal phase. In our practice, the oropha-
ryngeal phase of the examination is not
routinely used in patients with GERD.
Timed Barium Swallow Phase:
Technique and Findings prior to
Some patients with GERD symptoms do
not have reflux disease but rather a mis-
diagnosed motility disorder. The classic
symptoms of achalasia, which include
chest pain, regurgitation, both solid and
especially liquid dysphagia, and heart-
burn, may overlap with those of GERD.
Therefore, any patient with liquid dys-
phagia is always evaluated first with a
timed barium swallow study to assess
esophageal emptying as a manifestation
of impaired motility and lower esopha-
geal sphincter relaxation (Fig 1) (7).
This simple technique rapidly and accu-
rately quantifies esophageal emptying,
an early and essential step in detecting
and assessing achalasia or another se-
vere esophageal motility disorder such
as a diffuse esophageal spasm (Fig 2)
(8,9). If the timed barium swallow
phase shows no substantial emptying
problems, we then continue with the
standard study, starting with the up-
right air-contrast portion of the exami-
nation. If emptying is impaired, we of-
ten move to an assessment of motility.
Anecdotally, if a timed barium swallow
study is performed prior to the upright
air-contrast phase of the examination,
then the mucosal coating does not seem
to be substantially altered.
Upright Air-Contrast Phase: Technique
and Findings prior to Antireflux Surgery
Since all of our preoperative patients with
GERD have undergone or will undergo
endoscopy, we believe that the most im-
portant aspect of the upright double-con-
trast or mucosal phase of the barium ex-
amination is not the detection of mucosal
abnormalities but the detection of a fore-
shortened esophagus. This reflects an in-
stitutional bias but is also the standard in
other medical centers (4). However, the
air-contrast portion of the examination
may be the only assessment of the mu-
cosa in patients. In other institutions, the
barium examination is used as an alterna-
Published online before print
Radiology 2007; 243:329–339
GERD ? gastroesophageal reflux disease
Authors stated no financial relationship to disclose.
? The barium esophagram provides
essential information in the pre-
and postoperative assessment of
patients with gastroesophageal
reflux disease (GERD).
? Preoperatively, the most impor-
tant finding in a patient with
GERD is a foreshortened esopha-
gus; the most common findings of
a foreshortened esophagus are a
large (? 5-cm) hiatal hernia, a
hiatal hernia that does not reduce
when the patient is in the upright
position, and a stricture.
? Postoperatively, the cause of
symptoms can often be best iden-
tified with the esophagram.
? A common finding in a patient
with recurrent reflux is a dis-
rupted and/or herniated fundopli-
? A common finding in a patient
with postoperative dysphagia is a
tight, long fundoplication sur-
rounding the stomach.
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