An esophagram is a specialized diagnostic imaging procedure focused on the esophagus, the muscular tube that transports food and liquid from the throat to the stomach. Also known as a barium swallow, this examination uses fluoroscopy to visualize the anatomy and function of the esophagus in real-time. The patient swallows a liquid containing barium sulfate, a contrast material that coats the inner lining of the digestive tract. Barium appears bright white on X-ray images, highlighting any abnormalities.
Preparing for the Esophagram
The accuracy of the esophagram relies on a clear, empty esophagus, so patient preparation centers on fasting. Patients are instructed to maintain nothing by mouth (NPO) status for several hours before the examination, typically four to six hours. This restriction ensures that no residual food or liquid is present, which could obscure the lining of the esophagus or mimic a structural problem.
During the procedure, the patient is positioned in front of the fluoroscopy unit, which projects a continuous X-ray beam to create a live video feed. The patient swallows the barium contrast, which may be thin or thick, and often receives a gas-producing agent to distend the esophagus for better visualization. The technologist or radiologist captures a sequence of images as the barium travels down, sometimes asking the patient to shift positions to observe flow and pooling.
Structural Conditions Revealed
The esophagram is effective at identifying fixed, physical abnormalities that impede the flow of swallowed material. These structural issues are revealed as interruptions or distortions in the smooth column of barium as it passes through the esophagus. Narrowing, known as an esophageal stricture, appears as a localized area of concentric luminal constriction.
Abnormal outpouchings, called diverticula, are seen as sacs extending outward from the esophageal wall that trap the barium contrast. The procedure can also detect a hiatal hernia, visualized when a portion of the stomach pushes upward through the diaphragm and into the chest cavity. Abnormal growths such as masses, polyps, or tumors are identified as areas that displace the barium column or cause an irregular contour on the mucosal lining.
The contrast agent effectively outlines these fixed lesions, helping to distinguish them from functional disorders. When mucosal detail is important, such as looking for ulcers or subtle masses, a double-contrast technique may be employed. This technique uses gas-producing crystals to distend the esophagus and provide a thin coating of barium for enhanced visualization. The esophagram also serves to locate foreign bodies lodged within the esophageal lumen, which appear as a filling defect within the contrast column.
Functional and Motility Disorders Diagnosed
Beyond static structure, the esophagram provides dynamic insight into swallowing and the coordinated movement of the esophagus, known as peristalsis. This function-focused evaluation is used for diagnosing motility disorders, which involve problems with the muscle contractions that propel food. Gastroesophageal Reflux Disease (GERD) can be visualized directly when stomach contents mixed with barium flow backward into the lower esophagus.
A more complex disorder called achalasia, characterized by the failure of the lower esophageal sphincter (LES) muscle to relax, is clearly demonstrated. The lack of LES relaxation and effective peristalsis causes the esophagus to retain barium, leading to a classic “bird-beak” appearance at the junction with the stomach. The Timed Barium Esophagram (TBE) is a specific technique used to quantitatively measure the height of the retained barium column over a set period. This measurement helps assess the severity of the obstruction and the effectiveness of treatment.
Other motility issues involve disorganized or hyperactive contractions, such as diffuse esophageal spasm. In this condition, the esophagram reveals uncoordinated, non-propulsive muscle activity that gives the esophagus a characteristic “corkscrew” or “rosary bead” appearance. By capturing the entire swallowing sequence on video fluoroscopy, the esophagram can also identify less severe forms of dysphagia (difficulty swallowing). These forms may be caused by ineffective or weak esophageal contractions.