S414 A Retrospective Review: Are We Under-Utilizing Barium Swallow Studies After a Normal EGD in Patients with Dysphagia?

Abstract

Introduction: Upper endoscopy (EGD) is an effective tool in the initial evaluation of patients >40 years old presenting with dysphagia and concomitant heartburn, odynophagia, and weight loss. However, it can miss subtle esophageal strictures, motility disorders, and extrinsic abnormalities which may be diagnosed with barium swallow study, or esophagram. In this study, we assessed the utility of barium swallow exam in patients presenting with dysphagia who had a grossly normal EGD. Methods: A retrospective analysis was conducted at a tertiary hospital from January 2018 through March 2019. Patients presenting with dysphagia who underwent both an EGD and barium swallow study with a 13mm pill (either before or after EGD) were included. Patients with an abnormal EGD were excluded. We analyzed esophagram results in patients who had a grossly normal EGD, and data was examined with univariate analysis. Results: 67 total patients underwent both an EGD and barium swallow study, of which 27 had a grossly normal EGD. The mean age (SD) of our study population (N=27) was 56.1 years (15.5), with 16 males. Of the 27 patients, 9 (33.3%) had a normal barium swallow exam while 18 (66.7%) patients had an abnormal exam. 7 patients had findings consistent with oropharyngeal dysphagia, 7 revealed structural issues manifested by difficulty of passage of a 13mm pill suggesting gastroesophageal junction obstruction, 2 showed esophageal dysmotility characterized by tertiary contractions, and 2 patients were found to have gastroesophageal reflux disease on esophagram. Of note, 8 out of 27 patients underwent esophageal biopsies, of which 6 showed normal histology, however 3 of those patients were found to have structural abnormalities on esophagram. Esophageal biopsies were not taken in 19/27 patients, of whom 14 had abnormal findings on barium swallow study. Conclusion: Per ASGE guidelines, EGD is considered first-line for evaluation of dysphagia unless contraindicated. Barium swallow with a 13mm pill is another valuable diagnostic modality especially in patients with a normal EGD. Our study showed that barium swallow identified potential etiologies of dysphagia in 66.7% of patients with grossly normal EGD, which led to further work-up and/or treatment. We discovered structural abnormalities on barium swallow in 50% of patients with grossly and histologically normal EGD. Esophagram proved to be a helpful adjunct to EGD with biopsy in evaluating dysphagic patients, emphasizing its importance as a part of the diagnostic algorithm.Table 1.: Patient Demographics and Barium Swallow Study Results (N=27)