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Information ⬇

Synonym/Acronym

Esophagram, video swallow, esophagus x-ray, swallowing function, esophagography.

Rationale

To assist in diagnosing disease of the esophagus such as stricture or tumor.

Patient Preparation

There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. The Canadian Anesthesiologists’ Society has fasting guidelines for preprocedural fasting. Related information can be located at https://www.cas.ca/English/Page/Files/97_Appendix%206.pdf.

Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.

Pediatric Considerations: The fasting period prior to the time of the examination depends on the child’s age. General guidelines are as follows: birth to 6 mo, 3 hr; 7 months to 2 yr, 4 hr; 3 yr and older, 6 hr.

Normal Findings

  • Normal peristalsis through the esophagus into the stomach with normal size, filling, patency, and shape of the esophagus.

Critical Findings and Potential Interventions ⬆ ⬇

N/A

Overview ⬆ ⬇

Study type: X-ray Contrast/Special; related body system: Digestive system.

This radiological examination of the esophagus evaluates motion and anatomic structures of the esophageal lumen by recording images of the lumen while the patient swallows a barium solution of milkshake consistency and a chalky taste. The procedure is a dynamic study and uses fluoroscopic and cineradiographic techniques. A dynamic study is one in which there is continuous monitoring of the motion being studied as opposed to a static study in which the patient and equipment are held in one position until the image has been taken. The barium swallow is often performed as part of an upper GI series or cardiac series and is indicated for patients with a history of dysphagia and gastric reflux.

The standard barium swallow study focuses on the esophageal structures of the GI tract and may identify reflux of the barium from the stomach back into the esophagus. Muscular abnormalities such as achalasia, as well as diffuse esophageal spasm, can be easily detected with this procedure. Gastroesophageal reflux disease (GERD) is a disorder of the GI system commonly seen in older adults. Because of the physiological changes associated with the aging process, numerous factors may negatively impact quality of life and contribute to the development of significant complications in older adult patients as a result of GERD.

Themodified (video) barium swallow focuses on the oropharyngeal structures and is also used to evaluate dysphagia, or difficulty swallowing. The test may be performed and observed in the presence of a radiologist and radiology technician with or without a feeding specialist or speech pathologist, depending on the reason for the examination. Nurses will encounter patients who struggle with swallowing disorders in different settings, such as intensive care units, nurseries, rehabilitative units, and skilled nursing care units. Situations that might indicate a modified barium swallow include the evaluation of a patient’s ability to swallow food after a stroke or the inability of a child to swallow food of varying consistencies without gagging and choking during feeding.

Indications ⬆ ⬇

Interfering Factors ⬆ ⬇

Contraindications

Pregnancy is a general contraindication to procedures involving radiation.

Patients with an obstruction, ulcer, esophageal perforation, or suspected esophageal rupture, unless water-soluble iodinated contrast medium is used; barium is not used because leakage of the dye could worsen any existing infection.

Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.

Patients with severe constipation or bowel obstruction, as barium may make the condition worse.

Patients with a severe swallowing disorder to the extent that aspiration might occur.

Factors That May Alter the Results of the Study

  • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
  • Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.

Potential Medical Diagnosis: Clinical Significance of Results ⬆ ⬇

Abnormal Findings Related to

Nursing Implications, Nursing Process, Clinical Judgement ⬆

Potential Nursing Problems: Assessment & Nursing Diagnosis

ProblemsSigns and Symptoms
Bleeding (related to inflammation, infection, ulceration, trauma, alcohol misuse, cancer)Dark stools, tarry stools; foul-smelling stools; fatigue; dizziness; pallor; shortness of breath; bloody or coffee ground emesis; tachycardia; hypotension
Fluid volume (deficit—related to gastrointestinal bleeding secondary to ulceration, inflammation, infection, trauma, cancer, substance use disorder [alcohol])Bloody or coffee ground emesis; tachycardia; orthostatic hypotension; altered level of consciousness; weakness; poor skin turgor; dry mucous membranes
Nutrition(insufficient—related to pain, inflammation, infection, dysphagia, trauma, substance use disorder [alcohol])Weight loss; documented insufficient caloric intake; skin that is dry, brittle, and pale; refusal or no interest in eating; hair comes out easily

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

  • Discuss how this procedure can assist in assessing esophageal structure and function.
  • Explain that the procedure takes about 15 to 30 min and is performed in a radiology department.
  • Review the procedure with the patient.
  • Explain that pregnancy testing may be required.
  • Explain that no pain should be experienced during the test.
  • Advise that barium contrast medium will need to be swallowed.
  • Advise that baseline vital signs will be recorded and monitored throughout the procedure.

Procedural Information

  • Positioning for this procedure is to stand in front of the x-ray fluoroscopy screen.
  • Those who are unable to stand for the procedure are placed supine on the radiographic table.
  • As the procedure begins, an initial image is taken, and the patient is asked to swallow a barium solution with or without a straw.
  • Multiple images at different angles may be taken.
  • Explain that it may be necessary to drink additional barium to complete the study.
  • Swallowing the additional barium evaluates the passage of barium from the esophagus into the stomach.

Potential Nursing Actions

Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

After the Study: Implementation & Evaluation Potential Nursing Actions

Avoiding Complications

  • Monitor the patient for complications related to the procedure.
  • Complications are rare but may include:
    • Allergic reaction (related to contrast reaction)
    • Aspiration of barium (related to extreme swallowing disorders)
    • Constipation, impaction, or bowel obstruction (related to retained barium)

Treatment Considerations

  • Follow post-procedure vital sign and assessment protocol.

General

  • Explain that stool color will be white or light in color for 2 to 3 days following the study.
  • Advise the patient to notify the requesting health-care provider (HCP) if unable to eliminate the barium, or if stools do not return to normal color.
  • Resume the usual diet, fluids, medications, and activity, after completion of the barium swallow as directed by the HCP.

Bleeding

  • Trend and increase frequency of vital signs assessment.
  • Administer ordered blood or blood products.
  • Administer ordered stool softeners.
  • Encourage intake of foods rich in vitamin K and avoidance of foods that may irritate the esophagus.
  • Monitor stools for color consistency, odor, and amount.
  • Carefully monitor the patient for fatigue and fluid and electrolyte imbalance.

Fluid Volume

  • Facilitate management of fluid volume deficit.
  • Monitor and trend Hgb, Hct, and PT/INR.
  • Assess sensorium frequently.
  • Monitor heart rate (HR) and blood pressure (BP), including orthostatic.
  • Administer ordered fluid replacement therapy (crystalloids, blood, platelets).
  • Facilitate procedures to identify causes of bleeding.
  • Administer vitamin K to assist coagulation.
  • Provide information for an alcohol support group.
  • Advise taking a mild laxative and increase fluid intake (four 8-oz glasses) to aid in elimination of barium, unless contraindicated.

Nutrition

  • Facilitate management of insufficient nutrition.
  • Record calorie count, daily weight, and consider a dietary consult.
  • Support cultural or ethnic food choices.
  • Perform swallowing evaluation as appropriate.
  • Promote easy-to-swallow foods.
  • Discourage alcohol use.
  • Pediatric Considerations: Ensure parents understand to hydrate children with electrolyte fluids post barium swallow.
  • Considerations for Older Adults: Note that chronic dehydration can also result in frequent bouts of constipation.
  • Encourage older adult patients to use a mild laxative daily after the procedure until the stool is back to normal color.

Clinical Judgement

  • Consider how food choice is an important part of an individual’s cultural identity. How do you support that identity and create a diet plan that the individual will adhere to?

Follow-Up and Desired Outcomes

  • Tracks and reports bloody or coffee ground emesis to the HCP.
  • States signs and symptoms of GI bleeding with corresponding actions that can be taken to decrease bleeding risk.
  • States the rationale to avoid taking substances (NSAIDs, aspirin, steroids, alcohol) that can cause gastric irritation and result in bleeding.
  • Agrees to nutritional evaluation with adherence to a balanced diet.
  • Ensures fluid intake is commensurate with body needs for dehydration prevention.