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E. Adams and A. Ibele
esophageal stricture, achalasia, hiatal and paraesophageal hernias,
post-bariatric surgical pathology, and other conditions in which
the surgeon wishes to illuminate the patient’s precise upper GI
anatomy. There is typically no role for this study in preoperative
workup or routine postoperative evaluation of a bariatric patient.
Although upper GI X-ray is often effective in diagnosing most
anastomotic leaks, the CT scan has a higher sensitivity and specicity for this condition. This test has been most useful at our institution as an initial rst study to guide further management of
patients presenting with dysphagia and reux or to evaluate postsurgical anatomy in patients presenting with complications of
prior gastric surgery.
References
1. American College of Radiology. Practice parameter for the performance
of esophograms and upper gastrointestinal examinations in adults. 2019.
2. Johnston BT, Troshinsky MB, Castell JA, Castell DO.Comparison of
barium radiology with esophageal pH monitoring in the diagnosis of gastroesophageal reux disease. Am J Gastroenterol. 1996;91(6):1181–5.
3. Dempsey DT.Barium upper GI series in adults: a surgeon’s perspective.
Abdom Radiol. 2018;43(6):1323–8.
4. Jobe BA, Richter JE, Hoppo T, et al. Preoperative diagnostic workup
before antireux surgery: an evidence and experience-based consensus of
the esophageal diagnostic advisory panel. J Am Coll Surg.
2013;217(4):586–97.
5. Fornari F, Gurski RR, Navarini D, Thiesen V, Mestriner LHB, Madalosso
CAS.Clinical utility of endoscopy and barium swallow X-ray in the diagnosis of sliding hiatal hernia in morbidly obese patients: a study before
and after gastric bypass. Obes Surg. 2009;20(6):702–8.
6. Ghassemian AJ, MacDonald K, Cunningham PG, etal. The workup for
bariatric surgery does not require a routine upper gastrointestinal series.
Obes Surg. 1997;7(1):16–8.
7. Sharaf RN, Weinshel EH, Bini EJ, Rosenberg J, Ren CJ. Radiologic
assessment of the upper gastrointestinal tract: does it play an important
preoperative role in bariatric surgery? Obes Surg. 2004;14(3):313–7.
8. Mizrahi I, Abubeih A, Rachmuth J, etal. Routine upper gastrointestinal
uoroscopy before laparoscopic sleeve gastrectomy: is it necessary?
Obes Surg. 2019;29(6):1704–8.
5 The Upper GI Series
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9. Dallal RM, Bailey L, Nahmias N.Back to basics– clinical diagnosis in
bariatric surgery. Routine drains and upper GI series are unnecessary.
Surg Endosc. 2007;21(12):2268–71.
10. Singh R, Fisher BL.Sensitivity and specicity of postoperative upper GI
series following gastric bypass. Obes Surg. 2003;13(1):73–5.
11. Brockmeyer JR, Simon T, Jacob RK, Husain F, Choi Y.Upper gastrointestinal swallow study following bariatric surgery: institutional review
and review of the literature. Obes Surg. 2012;22(7):1039–43.
12. Csendes A, Burgos A, Braghetto I. Classication and management of
leaks after gastric bypass for patients with morbid obesity: a prospective
study of 60 patients. Obes Surg. 2012;22(6):855–62.
13. Quartararo G, Facchiano E, Scaringi S, Liscia G, Lucchese M. Upper
gastrointestinal series after Roux-en-Y gastric bypass for morbid obesity:
effectiveness in leakage detection. A systematic review of the literature.
Obes Surg. 2014;24(7):1096–101.
14. Bingham J, Shawhan R, Parker R, Wigboldy J, Sohn V.Computed tomography scan versus upper gastrointestinal uoroscopy for diagnosis of
staple line leak following bariatric surgery. Am J Surg. 2015;209(5):810–
4.
15. Arteaga-González I, Martín-Malagón A, Martín-Pérez J, Carrillo-Pallarés
A.Usefulness of clinical signs and diagnostic tests for suspected leaks in
bariatric surgery. Obes Surg. 2015;25(9):1680–4.
16. Carrodeguas L, Szomstein S, Soto F, etal. Management of gastrogastric
stulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1292 consecutive patients and review of literature. Surg
Obes Relat Dis. 2005;1(5):467–74.
17. Brethauer SA, Nfonsam V, Sherman V, Udomsawaengsup S, Schauer PR,
Chand B.Endoscopy and upper gastrointestinal contrast studies are complementary in evaluation of weight regain after bariatric surgery. Surg
Obes Relat Dis. 2006;2(6):643–8.
18. Gumbs A, Duffy A, Bell R. Management of gastrogastric stula after
laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis.
2006;2(2):117–21.
19. Bhalla S, Yu JX, Varban OA, et al. Upper gastrointestinal series after
sleeve gastrectomy is unnecessary to evaluate for gastric sleeve stenosis.
Surg Endosc. 2021;35(2):631–5.
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Timed Barium Swallow
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inForegut Disease
JosephSujka, JoelRichter,
andChristopherDuCoin
Case Presentation
A 50-year-old male presents to the ofce with progressive dysphagia to solids. His symptoms began 3 months ago and have
worsened over time. Foods that exacerbate his symptoms the most
are bread and steak. He reports a 15-pound weight loss in the past
3 months. His primary care physician ordered a timed barium
swallow (TBS) that showed the normal passage of contrast at 1
and 5min (Image 6.1). The 13mm barium tablet failed to pass
and remained lodged above the gastroesophageal junction. What
is the differential diagnosis? What is the next step in the workup
of this patient?
6
J. Sujka (*)
Department of Surgery, University of South Florida Morsani College of
Medicine, Tampa, FL, USA
e-mail: josephsujka@usf.edu
C. DuCoin · J. Richter
Division of Gastrointestinal Surgery, Department of Surgery, University
of South Florida Morsani College of Medicine, Tampa, FL, USA
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_6
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J. Sujka et al.
Image 6.1 Timed Barium Swallow showing classic Type 2 Achalasia with
a large column of retained barium and “bird’s beak” sign at the distal esophagus
Introduction
Timed barium swallow (TBS) was described in the late 1990s by
de Oliveira at the Cleveland Clinic. It was developed as an inexpensive test that was easy to perform while additionally having
the benet of being noninvasive, well-tolerated, and utilizing minimal radiation. It is applied in the diagnosis and evaluation of
esophageal pathology while also having a value in the postoperative period to assess the success of therapy [1].
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TBS and barium swallow can aid in the diagnosis of upper
gastrointestinal pathology, such as; achalasia and other esophageal motility disorders, esophageal strictures, gastroesophageal
reux disease (GERD), hiatal hernias, and esophageal cancer [2].
TBS originally started as a modication to existing methods of
documenting esophageal emptying in patients with achalasia after
treatment. Various volumes of barium were tried in an effort to
create a protocol [3]. TBS has now been standardized and consists
of administering 8oz. of low-density barium in the upright position and obtaining a spot lm at 1 and 5min to assess for evacuation of the barium from the esophagus. After this initial evaluation,
the esophagus is rinsed with a drink of water, and subsequently, a
13mm barium pill is administered. Another lm is obtained to
assess the passage of the tablet out of the esophagus at 5 min.
Results are considered abnormal when the initial barium column
at 1 and 5min is greater than 5cm and 2cm, respectively. Failure
to clear the barium tablet at 5min is also considered an abnormal
result [1, 4].
The 13mm barium tablet is a key component of a TBS because
it can increase the test’s diagnostic accuracy. The 13mm size is
used in TBS specically because it has been shown to be the
threshold of dysphagia and discomfort in patients with esophageal strictures smaller than 13mm. On the other hand, strictures
that are larger than 13mm will likely be asymptomatic [3]. The
barium tablet helps delineate strictures in the esophagus that are
not evident with liquid barium alone. These strictures are typically not tight and will allow passage of the liquid barium, but the
pill will get trapped in the area of narrowing, which is usually the
esophagogastric junction [3].
There are limitations to TBS, such as if a patient has retained
food or liquid in the esophagus, this can lead to misinterpretation
of the barium column [3]. Another limitation is in patients with
type III or vigorous achalasia, powerful esophageal contractions
can make interpreting the lms difcult. When obtaining a TBS in
patients with high-amplitude esophageal spasms, the imaging
must be taken once esophageal spasms resolve [3].
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J. Sujka et al.
Use asaDiagnostic Tool
TBS was initially used for the diagnosis of achalasia and the
assessment of treatment. However, it can be used to delineate the
anatomy of the esophagus and other spastic esophageal motility
disorders and esophageal strictures. It can also be used in the
diagnosis and preoperative workup of other benign and malignant
esophageal disorders, such as hiatal hernias and cancer [1].
Achalasia
Achalasia is an uncommon esophageal motility disorder where
the ability of the lower esophageal sphincter (LES) to relax is
impaired. In addition, there is a component of aperistalsis in the
body of the esophagus. The most common presentation is dysphagia; however, chest pain, regurgitation, weight loss, and aspiration
are also part of the clinical picture. The diagnosis of achalasia is
made with a combination of endoscopy, high-resolution manometry (HRM), and TBS [5]. HRM can be challenging to obtain
because it is invasive and at times not tolerated by the patient.
However, HRM is 93% accurate in making the diagnosis of achalasia [6].
TBS can be helpful in delineating esophageal anatomy and
function as part of the workup for achalasia. Retention of contrast
on TBS correlates closely to the distensibility of the esophagogastric Junction (EGJ) [6]. However, approximately 20% of the
patients with achalasia can have a non-diagnostic liquid barium
test. Hold up of the 13mm tablet improves the diagnostic accuracy to 100% [1]. In the case scenario above, TBS and HRM are
used together in making the diagnosis of achalasia [1]. TBS can
also function as a substitute for HRM in patients that are not able
to tolerate the catheter or where there is no access to manometry.
Despite its usefulness, TBS does not always present a uniform
picture of achalasia and can at times have different image results.
For example, type I achalasia has a dilated esophagus that is frequently distorted with a tapering at the end of the GE junction
6 Timed Barium Swallow inForegut Disease
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creating the classic “birds’ beak” appearance. On the other hand,
type II achalasia will have a dilated esophagus as seen in type I;
however, the esophagus remains straight. The classic single point
of obstruction at the GE junction is again seen in type II.Type III
achalasia, also called vigorous achalasia, can have a characteristic
image on TBS with multiple areas of narrowing in a normaldiameter esophagus with multiple tertiary contractions along the
length of the esophagus. All of these images are affected by the
skill of the proceduralist to both perform and interpret the results.
Due to this difference in achalasia presentation, TBS has been
examined for reproducibility and inter-observer reliability. Kostic
etal. compared the TBS studies of healthy individuals, achalasia
patients pretreatment, and achalasia patients post-treatment. They
found that healthy patients uniformly emptied their esophagus by
2min; however, achalasia patients had variable ndings depending on the severity of their disease state. More importantly, the
TBS studies had excellent intra- and inter-observer reliability
with good reproducibility [7]. This suggests that even with the
variable presentation of achalasia TBS represents a consistent and
repeatable study to monitor patients.
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The Use ofTBS inNon-achalasia
Esophagogastric junction outlet obstruction (EGJOO) is similar
to achalasia and is dened as an elevated LES pressure with failure of the relaxation mechanism, with normal body peristalsis on
HRM. What differentiates EGJOO from achalasia is that the
esophagus has normal body peristalsis, while in achalasia there is
aperistalsis. Like with achalasia, the highest yield in making the
diagnosis of EGJOO is when TBS is used in combination with
HRM [8]. In situations where esophageal peristalsis is maintained, the TBS can have varying results. The most common pattern is barium retention at 1min with complete emptying by 5min
due to generally intact peristalsis. Often, the columns of barium
are within normal limits at 1 and 5min. This is believed to be the
result of the maintained contractile force of the esophagus that
can push the food bolus; in this case, liquid barium down past the
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strictured or pathologic area. However, the 13mm barium tablet
will fail to pass 50% of the time in EGJOO [1]. While TBS can
help suggest EGJOO along with HRM, it is unable to differentiate
between anatomic obstruction and functional EGJOO [9].
TBS is a valuable tool for both the foregut and bariatric surgeon. The foregut surgeon can use the TBS for the perioperative
workup of a hiatal hernia. A barium study will provide important
information regarding the type of hernia, its size, and the approximate length of the esophagus, thus helping the surgeon plan the
procedure. In the postoperative period, barium studies can be used
to assess for appropriate hernia repair and function of the fundoplication. TBS can also evaluate patients with postoperative complications like recurrence, slipped Nissen, or a crura repair that is
too tight.
For the bariatric surgeon, TBS may be used preoperatively to
delineate the anatomy before surgical intervention and in certain
instances can replace preoperative endoscopy. TBS can also be
used in the immediate postoperative period to rule out complications such as a leak in Bariatric surgery. In the late postoperative
period, TBS can be used to evaluate patient anatomy or help diagnose a marginal ulcer or anastomotic strictures [2]. Finally, barium studies can evaluate patients with a slipped gastric band.
J. Sujka et al.
TBS Uses inEvaluating Treatment Ecacy
TBS is not only diagnostic for various esophageal pathologies but
can also be used in the postoperative period as an objective measure to evaluate the effectiveness of various treatments. In the
reported series on patients with achalasia undergoing pneumatic
dilation, there is a 73% correlation between a postoperative resolution of symptoms and clearance of barium on TBS.When performing a post-dilation TBS evaluation, there can be concordant
or discordant ndings between symptomatic relief and improvement of TBS.Vaezi etal. dened improvement of TBS after pneumatic dilation when there was an objective decrease in at least
50% of the barium column length compared to pre-procedure
images. In this study, they found that 77% of patients that had
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concordant ndings, meaning improvement in both TBS and
symptoms, will remain symptom-free at 6 years. On the other
hand, 90% of patients with discordant ndings, in this case symptomatic improvement with a change less signicant than 50% on
TBS, had a recurrence of symptoms before 12 months [10].
Longer- term follow-up corroborated these ndings showing
patients with concordant ndings have better long-term outcomes
and symptom relief [11].
Another study by Kostic etal. examined the success of surgical
myotomy with TBS.The study evaluated 45 patients both preand post-myotomy with a TBS.They examined the height and
width of the barium columns and compared these changes to
related symptoms. The authors found a decrease in barium height
after myotomy, correlated with symptom improvement. Prior to
treatment, patients with a higher column had more regurgitation
and those with little change in height over 5min had more dysphagia [12].
Andersson etal. also examined whether or not TBS could be
used to monitor treatment efcacy in the context of a randomized
controlled trial. They randomized patients into two groups, pneumatic dilation or laparoscopic myotomy with TBS performed
both before and after treatment. There was a median interval of
6 months between the TBS in both groups with follow-up for
18months. Comparing the TBS from both groups, there was no
signicant difference in TBS ndings. However, the height of the
barium column at 1 min and symptom scores had a signicant
correlation with dysphagia for liquids, chest pain, and dysphagia.
Patient’s with less than 50% improvement in their height at 1min
had a 40% risk of treatment failure in follow-up [13]. This study
lends additional data that TBS can be used both in a diagnostic
setting but also to check for treatment efcacy.
Some have questioned whether or not other measures besides
barium column height may better dene success after achalasia
treatment. Blonski et al. identied 81 consecutive patients who
were treatment naïve for achalasia that underwent either pneumatic dilation, Heller myotomy, or POEM between 1/2012 and
7/2017. They assessed the accuracy of percent change in pre- and
post-myotomy barium height at 5min versus an absolute <5cm
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cutoff for assessing treatment response. They concluded that a 3%
improvement in barium height at 5min was more accurate than an
absolute cutoff value of <5 cm on post-treatment TBS [14].
Similarly, Sangapalli etal. examined a single cohort of 24 patients
who underwent treatment for achalasia and their TBS ndings.
They compared post-therapy residual barium absolute height,
residual height, and surface area. They also found that other measures, in this case change in barium surface area, were superior to
the conventional barium height in dening objective response to
achalasia therapy [15].
Achalasia and other esophageal motility disorders are lifelong diseases that have no definitive cure. Treatment is geared
toward the improvement of symptoms, and this must be clear
when discussing both the diagnosis and treatment options.
TBS is often used in the workup of patients that had treatment
and present with persistent or recurrence of symptoms of
these conditions. Ideally, patients will have a postoperative
TBS, which can be used to objectively compare it with the
symptoms [16].
J. Sujka et al.
Conclusion
TBS is a low-cost and easily reproducible test that can aid in the
diagnosis of achalasia and other foregut diseases. It can be interpreted with ease by radiologists, gastroenterologists, and surgeons
with similar results. It can be used as a standalone diagnostic tool,
or in combination with HRM, for the diagnosis of achalasia. It can
similarly be used in the early postoperative period to assess for
successful treatment, as well as in the late postoperative period
and during follow-up. Lastly, it is useful in the evaluation and
workup of patients that have postoperative recurrence of symptoms after either endoscopic or surgical treatment of foregut
disorders.
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