What is acid reflux?

Barium Esophagram
The barium esophagram is an inexpensive, readily available, and noninvasive esophageal test. It is most useful in demonstrating structural narrowing of the esophagus and in assessing the presence and reducibility of a hiatal hernia. Subtle findings such as Schatzki rings, webs, or minimally narrowed peptic strictures are often seen only with an esophagram; they are missed by endoscopy, which may not adequately distend the esophagus. This test, which involves consuming a 13-mm radiopaque pill or marshmallow along with the barium liquid, is the most sensitive for detecting esophageal narrowing, with values reported between 95% and 100%. By giving the patient in the prone oblique position swallows of barium, the barium esophagram also allows good assessment of peristalsis and is helpful preoperatively in identifying a weak esophageal pump.

The ability of the barium esophagram to detect esophagitis varies considerably. Although sensitivities of 79% to 100% have been reported with moderate to severe esophagitis, mild esophagitis is usually missed. Barium testing also falls short when addressing the presence of Barrett esophagus. Barium studies can identify GER when contrast moves in a retrograde fashion from the stomach into the esophagus. If this occurs spontaneously, repeatedly, or to a significant degree into the middle or proximal esophagus, the test is positive, but it has a sensitivity of only about 40% for defining GERD. Provocative maneuvers such as leg lifting, coughing, the Valsalva maneuver, or the water-siphon test can be used to elicit stress reflux. Although these tests can improve the sensitivity of the barium esophagram, some argue that they also decrease its specificity.

The barium esophagram is primarily used in evaluating the patient with GERD with new-onset dysphagia because it can define subtle strictures and rings as well as assess motility. Conversely, endoscopy is preferred in the patient with recurrent dysphagia known to have a stricture or for the assessment of esophagitis or Barrett esophagus.