Study Selection

Technique	Best For	Contrast
Single contrast	Dysphagia, motility disorders, post-op follow-up, globus, Schatzki ring	Thin (60% w/v) + thick barium (250% w/v)
Double contrast	Mucosal disease, Barrett's, early carcinoma, esophagitis, varices, webs	Effervescent granules + dense barium 250% w/v
Water-soluble (Omnipaque)	Suspected perforation, anastomotic leak, Boerhaave, post-procedure eval	Omnipaque 240–300

Contrast safety rules:

Never use barium if perforation is suspected — barium mediastinitis/peritonitis has >50% mortality
Never use Gastrografin (high-osmolar ionic) if there is any aspiration risk — causes fatal pulmonary edema/chemical pneumonitis
Default to Omnipaque (low-osmolar non-ionic) when perforation is possible — safe if aspirated

Single Contrast Esophagram — Step-by-Step Protocol

Equipment: Standard fluoroscopy table; tilt capability required; grid cassette or flat-panel detector.

Contrast: Thin barium (60% w/v) for motility assessment; thick barium (250% w/v) or barium tablet for Schatzki ring/stricture evaluation.

Step	Position	Action	What You're Evaluating
1	Upright AP	Have patient drink thin barium through a straw continuously	Pharyngeal phase, cervical esophagus, primary peristalsis
2	Upright RAO	Continue drinking; trace esophagus full length	Peristaltic wave, esophageal caliber, extrinsic impressions
3	Upright lateral	Spot images during swallowing	Posterior impressions, anterior wall (cardia), Zenker's diverticulum
4	Prone RAO (Trendelenburg)	Patient prone; inject thick barium; assess LES on fluoroscopy	LES opening, hiatal hernia, GEJ morphology, mucosal folds
5	Right lateral supine	Swallow thick barium; image LES in open state	Critical step — Schatzki ring, distal strictures visible only when LES open
6	Upright AP	Administer barium tablet (13 mm) if Schatzki ring suspected	Functional significance of ring; tablet lodges at ring if <13 mm lumen

Always capture the open LES. Missed distal esophageal strictures and Schatzki rings are the most common error in esophagram interpretation — the LES must be imaged in the open state on the right lateral supine view.

Single Contrast Dictation Template:

Single contrast esophagram was performed with thin and thick barium. The pharynx and cervical esophagus are normal in morphology with intact primary peristalsis. The thoracic esophagus is normal in caliber and course without extrinsic impression, mucosal abnormality, or filling defect. Primary peristalsis is intact and symmetric. There is no tertiary activity. The LES opens normally. [No / Small sliding / Large sliding] hiatal hernia is identified. [No Schatzki ring / A mucosal ring measuring ___ mm is identified at the GEJ, consistent with a Schatzki ring — the ring is / is not functionally significant based on barium tablet passage.] No evidence of motility disorder. No diverticulum.

Double Contrast Esophagram — Step-by-Step Protocol

Equipment: As above; higher density barium required for mucosal coating.

Contrast: Effervescent granules (CO2 distension) + dense barium 250% w/v.

Step	Position	Action	What You're Evaluating
1	Upright	Administer effervescent granules with minimal water	Gas distension of esophagus
2	Upright RAO	Immediately have patient drink dense barium in 1–2 gulps (not continuous)	Mucosal coating while esophagus is distended with gas
3	Upright AP	Spot images of esophagus in distended state	En face mucosal pattern — plaques, erosions, nodularity, webs
4	Upright lateral	Spot images	Posterior wall, anterior indentation, cardia mucosal pattern
5	Prone RAO	Additional views with remaining barium	Distal esophagus, GEJ, Barrett's reticular pattern
6	Upright (repeat)	Instruct patient not to belch; additional spots if distension lost	Repeat distension if needed

Timing is critical. Double contrast images must be captured immediately after barium ingestion while CO2 distension is maintained and barium coats the mucosa. Delayed imaging produces pooled barium without mucosal detail. Instruct patients to drink quickly (not sip).

Double Contrast Dictation Template:

Double contrast esophagram was performed with effervescent granules and high-density barium. The esophageal mucosa is smooth and well-distended throughout. No plaques, erosions, ulcers, or mucosal nodularity. No filling defects. [No reticular mucosal pattern in the distal esophagus. / A reticular mucosal pattern is identified in the distal esophagus above the GEJ, raising concern for Barrett's esophagus — endoscopy recommended for confirmation.] No esophageal varices. The GEJ is normal in appearance. No evidence of malignancy.

Water-Soluble Esophagram (Perforation Protocol) — Step-by-Step

Equipment: Standard fluoroscopy; tilting table; suction available.

Contrast: Omnipaque 240–300 (low-osmolar non-ionic iodinated contrast). Have suction at bedside. Do NOT use barium. Do NOT use Gastrografin.

Step	Position	Action	What You're Evaluating
1	Scout radiograph	AP chest before contrast	Pneumomediastinum, pleural effusion, subcutaneous air
2	Upright or semi-upright	Administer 30–60 mL Omnipaque by cup or via NG tube	Pharyngeal/cervical esophageal leak
3	Upright RAO then LAO	Spot images in multiple projections	Thoracic esophageal leak, anastomotic dehiscence
4	Supine RAO	Image distal esophagus and GEJ	Distal/GEJ tears, anastomotic leaks
5	Left lateral decubitus	Roll patient; coat posterior wall	Posterior perforation, missed small leaks
6	Prone	Posterior wall coating if tolerated	Complete posterior wall assessment

A negative water-soluble study does not exclude perforation — sensitivity is only ~50–75%. If clinical suspicion remains high, thin barium is required (sensitivity >90%). Communicate directly with the surgical/thoracic team before and after the study.

Perforation Protocol Dictation Template:

Water-soluble esophagram was performed using Omnipaque [240/300]. Scout radiograph demonstrates [no / moderate] pneumomediastinum. [No / Small / Large] pleural effusion is present bilaterally / on the left / on the right. Following oral administration of contrast, the esophagus is opacified to the level of the [GEJ / anastomosis]. [No extravasation of contrast is identified outside the esophageal lumen. / Extravasation of contrast is identified at the level of the [___] esophagus, consistent with perforation. The site of extravasation measures approximately ___ cm. [Mediastinal communication / pleural communication] is / is not present.] The study was communicated directly to [Dr. ___] at [time].

Key Findings — Single Contrast

Finding	Interpretation
Schatzki ring (B-ring)	Mucosal ring ≥2 cm above diaphragm. <13 mm = typically symptomatic. Distinguish from A-ring (muscular, dynamic, normal)
Hiatal hernia	Gastric folds herniating above the diaphragm; document size and reducibility
Zenker's diverticulum	Posterior pharyngeal pouch at Killian's triangle; barium pooling on lateral view
Esophageal dysmotility	Tertiary contractions (non-peristaltic), aperistalsis (achalasia), corkscrew esophagus (diffuse esophageal spasm)
Achalasia	Bird-beak tapering at GEJ; dilated esophagus; absent primary peristalsis; retained food/debris
Extrinsic impression	Vascular ring, enlarged lymph nodes, mediastinal mass

Key Findings — Double Contrast

Double contrast provides superior mucosal detail — CO2 distends the lumen while dense barium coats the mucosa.

Mucosal Pattern	Diagnosis
Discrete white plaques; parallel longitudinal lines; "shaggy" esophagus (severe)	Candida esophagitis
Reticular mucosal pattern in distal esophagus above GEJ	Barrett's esophagus (sensitivity limited — endoscopy is gold standard)
Longitudinal serpiginous filling defects; change with respiration and position	Esophageal varices
Filling defect with shouldering; irregular or destroyed mucosal pattern	Esophageal carcinoma
Superficial erosions; mucosal nodularity without discrete plaques	Reflux esophagitis

Key Findings — Suspected Perforation

Finding	Significance
Extravasation of contrast outside esophageal lumen	Perforation confirmed — document site, extent, mediastinal involvement, pleural communication
Pneumomediastinum on scout	Strongly suggests perforation even before contrast — proceed with Omnipaque
Pleural effusion (left > right)	Associated with thoracic perforation (Boerhaave); right-sided effusion with distal/GEJ tears
"Beaking" at GEJ with no flow distally	May represent impacted foreign body or complete obstruction rather than perforation

Pediatric Esophagram — Key Differences

No double contrast (no effervescent granules) · Lateral view first · Fluoroscopy grabs only (no full-exposure spots) · No barium tablet

Pediatric Technique:

Step	Position	Action
1	True lateral	First view — inject thin barium via NG or have infant suck from bottle; document pharynx and cervical esophagus
2	AP	Document thoracic esophagus and GEJ; assess for extrinsic impressions
3	Right posterior oblique	Assess posterior esophageal impressions (vascular ring)
4	AP with gastric filling	Document DJJ position — mandatory in every pediatric UGI-equivalent study

Finding	Significance
DJJ right of midline or below duodenal bulb	Malrotation until proven otherwise — never end a pediatric esophagram without documenting the DJJ position
Posterior esophageal impression (lateral view)	Vascular ring — bilateral impressions (anterior + posterior) = double aortic arch; posterior only = aberrant right subclavian artery
H-type TEF	Fistula fills only under gentle injection pressure; easily missed — low threshold to repeat in multiple obliquities
High reflux (above carina)	Aspiration risk — clinically significant even if physiologic reflux is common in infants

Esophagram — Interpretation and Findings