Unfortunately, most patients with malignant esophageal obstruction have significant dysphagia for 3 to 6 months before diagnosis. Video fluoroscopic recording permits slow motion and stop-frame analysis of the oropharyngeal stage of swallowing. It is important to recognize that esophageal examination by either liquid barium or endoscopy is not sufficient to diagnose either neuromotor disorders or esophageal obstruction in all patients. Both of these methods of objective evaluation may miss significant degrees of esophageal stenosis unless the examiner is particularly cautious and objective in the examination. After a thorough history and physical examination, barium contrast studies are the first step for the diagnosis of esophageal obstruction.
Proper technique is imperative for success.
When small amounts of liquid barium are given in the upright position to a patient with early stenosis, the esophageal lumen proximal to the stenosis is not sufficiently challenged by stretching to make the stenotic segment apparent to the examiner. It seems somewhat illogical for the patient to be examined only with liquid barium, especially if the complaint to the physician has been solid food dysphagia. The patient clearly tells us in the history that liquids have caused no problem but that swallowing a solid bolus causes dysphagia. Therefore in patients in whom an esophagram with liquid barium does not clearly define the cause of dysphagia, a bolus challenge study must be conducted. The best method for evaluating patients with a history of dysphagia is to first use an adequate volume of liquid barium in the upright and recumbent positions.