Timed

Barium
Swallow:
A Simple
Technique
for Evaluating Esophageal
Emptying in Patients with Achalasia
Jose Marcelo A. de Oliveira
Sigurbjorn Birgisson2
Cindy Doinoff1
David Einstein1
Brian Herts1
William Davros1
Nancy Obuchowski1
Robert E. Koehler3
Joel Richter2
Mark E. Bakeri

OBJECTIVE.
by

which

after minimally
tifying

Our purpose

was to define

a simple

can

esophageal

emptying

radiologists

therapy.

invasive

the degree

ofemptying

MATERIALS

AND

films

of the esophagus

(45%

weight

had

were

The

observers.

barium

change

width

surements

of the

barium

We

found

the area

A
I

Division of Radiology, The Cleveland Clinic Foundation,

9500 Euclid Ave., Cleveland, OH 44195. Address correspondence

to M. E. Baker.

2Department
The Cleveland

of Gastroenterology,
Clinic

Foundation,

Division of Medicine,
Cleveland,

OH 44195.

3Department of Radiology, University of Alabama Hospital,

619 S. 19th St., Birmingham, AL 35233-6830.
AJR 1997;169:473-479

Roentgen

AJR:169, August

Ray Society

by improving

botiiliiiiiii
invasive

toxin

1997

by patient

tolerance.

used,

Forty-

require

of incomplete

of patients
dilatation

divided

were

also independently
spot films.
difference

the percentinto

measured

The product

estimate

of height

fbr percentage
between

quintiles.

the height
times

of emptying.

the percentage

of

the height-times-width

and

by the fbur observers. Interobserver

as the height-times-width
mea-

as well

films

swallow
change

are accurate

of the
of abnormal

disorder

esophageal

the

perfect

(the correlation

coefficients

esophageal
are

emptying.

and Clostnidiiiin
the two

with

undergoing
of symptoms.

methods

and reproducible

of estimating

procedure

technique.

apy.

esophageal

esophageal

(i.e..

In addition

I I. 4].

perforation)

to symptomatic

objective

mea-

emptying.

changes

examination

of

dilatation

may be

after

patients

thertreated

Ifphysicians
had a nore objective
assessing
esophageal
emptying
after

[5-7J.

nlyot-

matic

dilatation.

intervention
long-temi

then

might
efficacy

be-

and up

require surgery
after failed
or a complication
from this

miore

occur,
Of

appropriate

means
pneufurther

the

improving

thereby

this procedure.

of this study was twofold:

The purpose

pneumatic

be-

important

cause clinical
improvement
can correlate
poorly
with the degree of physiologic
improvement
of

minimally

Hellers

is a simple

in area based on height-times-width

with pneumatic

esophageal
is to relieve

more than one procedure

relief

by tour other

Percentages

was almost

omy and esophagectomy

reserved for patients
who are refractory to these treatments. As many
of the patients

were then analyzed

estimated

as estimated

the digitized

barium

of

dilatation

injection

treatments

films.

and estimated

of treatment

pneumatic

pneumatic

spot

were retrospectively
reviewed.
follow-up
study after patients

by the two observers

ofemptying

timed

column

aperistalsis

symptoms

to 22%

frontal

ml of low-density

and qualitatively

significant

images

percentage

of the lower

Currently.

as 4(W/e

and

of quan-

respectively).

The

goal

spot

I - and 5-mm

the

on

estimates

of the barium

and

dilatation

upright

of 100-2(X)

determined

became the quantitative

emptying

assessment

[ I -3]. The

cause

0361-803X/97/1692-473
American

body

on

chalasia is a motility
esophagus
consisting

sphincter
revision

5-mm

films

evaluated

and 0.93.

relaxation

after

the best method

technique.

The spot films

no statistically

and qualitative

qualitative

surements

swallow
before

hotiilinii,n
toxin injection.
The spot films
around the column
of barium by two obof interest
on the I - and 5-mm films served as

subjectively.

on the digitized

or qualitative
for

in the region

column

CONCLUSION.
Both

of barium

ofemptying.

I- and

I - and 5-mm

0.99, 0.87.

being

swallow

each of these four observers

as nieasured

agreement

seen

the

occasion.

RESULTS.
calculations

(volume

a barium

achalasia

technique.

at I. 2. and S mm after ingestion

independently.

between

seen on the

emptying

with

was also to determine

In the barium

sulfate

in area

each of whom

On a separate
width

timed

for timing

in patients

done by 23 patients with achalasia

as a baseline study or as a 1-month

for percentage

age ofemptying

and

this

technique

pneumatic
dilatation
or Clostridiu,n
and a region of interest was drawn

the gold standard

25, 1996; accepted

using

are obtained

in volume)

undergone
digitized,

Our purpose

METHODS.

two of these barium swallows

The examination
served either

servers.

Received November
February 26, 1997.

assess

to de-

fine a simple, noninvasive,

and widely available
barium technique that could serve as an objective measure
therapy

of esophageal

emptying

baseline

in achalasia

and post-

patients

and

to

473

de Oliveira

determine

a simple qualitative or quan-

whether

titative measure

ageal emptying

Materials

can

esoph-

assess

accurately

on the basis of a gold standard.

and Methods

Patients

A timed hariuni swallow

was performed
on 23
paticnts rcterred tn)I1i our gastroenterology
departnient

allowing

November
the

basis

of

chest pain.
swallow

November

(dysphagia.

was performed
follow-up

study

after

lrangc.

15-77

A total
fonned:

and

The patients
were

included

an average

patients

had

one

threc

Westbury.

patients

irvine.

13 women

of 46 years

old

NY) over 3()-45

tO)

study and three follow-up

studies

and

2(8) ml).

Then.

In 1 1 patients.

baseline

left

posterior

oblique

only

the

films)

was available.

lowed

up by the referring

tutions

after

Two

(eight

sets of films.

study

of these

patients

physician

from

I I I sets

were
other

two had a Hellers

the therapy.

of
fol-

insti-

myotonly

drink

the amount

without

films
non

(Figs.

1-3).

be captured

the sets of films

Finally.

film

from

because

analysis

lbr anal)one

the column

in the

of barium

because

included

the films

collected

the 42 set.s of films.

was discontinuous

the study sample

were

were

of spasm.

41 sets

set was

of films.

retrospectively

I -mm

Therefore.
For the

when

state:
the bariuni

constant

scope

carriage

Ironi

flInts.

If bariuni

by

PUP5e

The
which

technique

for

is sumniarized
(Fig.

the

timed

I). While standing.

swallows

were

per-

to ingest a low-density

baseline

study

and

(45%

weight

barium

in the appendix.

in volume)

barium

the patient
sulfate

(E-Z-PAQUE:

the
the

patient

of the 2-mm
At all times

standing

Data

Interpretation

taken

rather
was

and could
Care

on the
film

was

fluoro-

three

spot

the esophagus
was

not

film was to assess

the patient

than

exposed

of the

cleared

at

inges-

were

lengthwise.

distance

completely

right.

films

was continuous
film

2-mimi filni, the 5-mm

the

eniptying.
Technique

column

spot
taken

of the barium

the film

on the entire

to keep

were

in a relaxed,

otherwise.

100

in a slightly

three-on-one

spot

was

told

tolerate

(between

esophagus

the start

taken

The

reviewed.

position.

were

could

patient

If possible.

ment when

spastic.

the

ofthe

after

when the esophagus

one had

treatment,

they

or aspiration
with

(35 x 35 cm)

I . 2. and 5 nun

see. All patients

of barium

regurgitation

perfbration of thc esophagus as a complication

of the pneumatic
dilatation and
underwent surgery. and six still had not received treata.s initial

lows

barium

( 14 sets of tilms.

injec-

Allergan.

years old).

of 42 timed

seven

dilata-

study

study and two follow-up studies

(nine sets of films). and two patients had one baseline

excluded

manometry.

pneumatic

follow-up

had one baseline

sis.

regurgitation.

intrasphincteral

of C botulii:um toxin (Botox:

It) men

to

on

swallow. The timed barium

either as a baseline study or

) or cndoscopic

CM Itwo patients.

1994

had achalasia

loss). esophageal

barium

tion ( 2 1 patients

and

from

23 patients

symptoms

as a I -month
tions

All

and weight

standard

and

center

1995.

one

et al.

taken.
interim

in the up-

was kept

position.

swallow.
was

as tol-

was asked
suspension
E-Z-EM.

The
tized
lution

41

sets

using
Ektron

and Analysis
of

1- and

a I 2-bit.
1412

5-mm

charged-coupled.
(Kodak.

films

were

digi-

high-resoRochester,

NY)

Fig. 1.-46-year-old
man with achalasia.
A-C, Timed barium swallow shows technique

of exposing three-on-one
spot film at 1 mm (A), 2 mm (B), and 5 mm (C) after patient has ingested 220 ml of low-density barium.
Qualitatively,
approximately
40% of barium has emptied by 5-mm film. Study also shows problem of barium-foam
level (arrow, B ) caused by retained secretions
in esophagus. For quantitative
assessment,
we measure superior extent of barium column where barium-foam
interface
is best defined (superiorhorizontalline,
A and C). Regardless of level chosen, upper extent of barium height must be consistently measured on both 1 - and 5-mm films to assess emptying. Inferior extent of barium column is generally
measured at level of lower esophageal sphincter (inferior horizontal/me,
A and C). We choose widest point of column to measure its width (oblique lines, A and C).

474

AJR:169, August 1997

Timed

digital

imaging

(Gordon

camera

source.

The

1024

gray

levels

films.

The

were

scanned
was

were

x 1280

itor )Silicon

Graphics.

this was only an interim

light

first evaluated

images

was

for each

set of

and

pix-

8tY?.

10 x

least

at 150 x 512

approximately

displayed

pixels.

on a high-reso-

24 bits)

Mountain

graphics

View,

mon-

ages.

sequence.

column

assess

separate

the

observers

analysis.

other

before

The

intrareader
and

films

were

order

from
Neither

in the qualitative

neither

fur
The

each

to

of these

communicated

with

in random

each

order

by

(separate

reader).

The

set were

available

to the observers

was

measured

in the esophagus

esophageal

1- and

not used.

5-mm
for

because

count.

shape.

height

width

mined

than
we

the gold
using

standard

height

considered

to be an estimate

of the esophageal

measurement

count

barium
with

of height

of area

and width
the

of the area of the

of change

column

confidence

intervals

width

for the median

mpling technique 181 in which

a patient. not a film.

estimate

correlation

coefficient

measurements

of emptying
oti the

to the variability

between

agreenient

reader

on

count.

Likewise.

tV.O

WaS

different

The

).

describes

made

pixel

:iieasurements.
the
anie

variability

patient

patients.
assessed

occasions

interobserver

and
intraclass
in

in relaThus.

for the
for

the

insanie
pixel

agreement

was

assessed

for the two observers

for the pixel count
and the four observers
for the height-times-width
measurements
and the qualitative
estimate
of
esophageal

emptying.

in

as deterand

by
by the

qualitative estimate. We computed the median differences and constructed distribution-free

approximately
95%

qualitative

19. 10J were

of nieasuretiient

for the 1- and

that as determined

times

as

prxluct

coefficients

method

height-times-width

traobserver

of esoph-

correlation
for each

count.

non

the area of the

banuiii

by the pixel

at

films.

independent

column. Therefore.
films we compared the percentage

5-mm

61-

of the barium

it assesses

was considered

times

I-

analysis.

and width

of barium

parameters.

esophageal

the

41-60%.

in the I - and 5-mm

Intraclass
computed

the first one. the same four oh-

because

Rather

between

In the second

in Achalasia

set was

emptying.

2l4OC/c

the height

column

measurement.

the

each

film

servers

film. Each

emptying

empty.

apart from

cOluflifi

the area

sessions.

therm analyzed

2-mm

im-

or quantita-

amid one gastrtnteroIogist

from each

comparison.

taken

or 81-l()0%

Emptying

for esophageal

films as 0-20%.

1 week

separate

by the two readers

agreement.

the reading

radiologists

random

were

im-

in a randomized

assessment

the esophageal

5-mm

ageal

Esophageal

qualitatively

The pixel

on the digitized

analyzed

occasions

participated

tive

three

were

Measurements

age on two

films

barium

All the images

classifying

CA).

observers (one a radiologist

and the other a
gastroenterologist)
traced a region of interest around
Two

the esophageal

to Evaluate

1417

the

optiniized

Swallow

NY)

a Plannar

Park.
of

of view

images

( 1024

range

and svts

images

The

ciii.

lution

and

Orchard

dynamic

els. amid the field

35

system

Instruments.

Barium

using

the sampling

a resaunit was

Results
Because the data do not have a nomial
distribution, we computed the median percentage of
change

in the esophageal

nieasured
tive

estimate

width)

by the subjective
and

measurement

as compared

with

column

of barium

as

methods (qualitaof height times

that as mieasured

by

Fig. 2.-40-year-old
man with achalasia.
A-C, Exposure at 1 mm (A), 2 mm (B), and 5 mm (C) shows no emptying of barium by 5 mm. Note how barium column height changes on 2-mm film because of contraction.
This change does not alter our ability to assess emptying. Change in pixel count between
1- and 5-mm films was -3% and -6%, respectively,
for both observers.
Change
in gross area calculation
was 0%, -7%, -7%, and -1 2% for four observers.
Qualitative
assessment
of emptying was 0% for all four observers.
Negative numbers for change
in pixel count and gross area calculation
resultfrom
apparent increase in height due to contraction
in lower esophageal
region. Further, superior extent of barium column
is better defined on 5-mm film.

AJR:169, August 1997

475

D
Fig. 3.-39.year-old
woman with achalasia before and after pneumatic dilatation.
A-C, Exposure at 1 mm (A), 2 mm (B), and 5 mm (C) before pneumatic dilatation shows

partial emptying of barium by 5 mm. Change in pixel count between

1- and 5-mm
films was 49% and 47%, respectively,
for both observers.
Change in gross area calculation
was 48%, 41%, 47%, and 43% for four observers.
Qualitative
assessment
of
emptying was 40% for each of two observers
and 60% for each of two other observers.
D-F, Exposure at 1 mm (Dl, 2 mm (El, and 5 mm (F) after pneumatic dilatation shows complete emptying of barium by 5 mm. On 2-mm film little barium remains in distal
esophagus.
On 5-mm film this barium has emptied. Change in pixel count, gross area calculation,
and qualitative
assessment
was 100% for all observers.
This follow-up
study was performed
with slightly different film-to-patient
distance when compared
with initial films (A-C). Nonetheless,
we can easily estimate esophageal
emptying on
both studies and show that definite improvement
has occurred.

Timed

stimates

Barium

Swallow

to Evaluate

sigmoid

and nonfunctional

shape.

patients

of treatment

should

esophageal
a mild
in parentheses

tive techniques

for estimating

gold standard

of change
the

by

(Table

between

pixel

qualitative

1 ). The

and

by

-7.0%

and

2.5%

dian

difference

contain

four observers.

for

the four

observ-

for the me-

value

zero

for

no significant

indicating

in the accuracy

ence

or

were small:

intervals
the

in area

quantitative

of either

all

differ-

method

as com-

pared with pixel count (Figs. 2 and 3).

For the pixel

server reliability

count,
the inter- and intraobwas almost perfect. and the in-

reliability

terobserver
qualitative

of height-times-width

assessments

was

almnost

and

perfect.

The end point in treating

sia is to relieve

emptying.

However.

is usually

alone.

patients with achala-

symptoms

to stop therapy
relief

This

symptomatic

clinical

and

achieve

esoph-

the clinical

decision

based on symptomatic
assumes

approach

improvement

or relief

that

is associ-

improvement.
have observed

tomatic

improvemlient

optimal

or complete

may not accurately reflect

esophageal emptying.
Pa-

with

interpret

chronic

symptoms

minimiial

often

improvement

However.
that symp-

subjectively

compared

a detailed

score

be satisfied

severely
with

may

apy.

Holloway

symptoms

Those

in achalasia

expectations

patients

but probably

reflect

the patients

Failure

and
of ther-

tolerance

and the degree

emptying
lower

AJR:169, August

1997

the

and

of lower

the

at

to

obstruction

sphincter relaxation.
to improve esophageal
obstructiomi

that

are not related

of esophageal

adaptations

patients

I 121 have suggested

et al.

degree

relieving

assessing

esophageal

C.

whether

1)Otllli!lU111

toxin

by

esoph-

mini-

Hellers

Because

emptying

means

or continue

the height

less than

1 cm above

film

the

after

suspension.

technique

after

weight

or relief

gain

these

studies

toms

were

used

alone

of esophageal

changes

that

in

timed

technique.

cedure

before

treatment

barium

treated

used in different

ume).

The consistency
of the meal may be
semisolid.
or liquid. The patient may be
the
may

supine

or

the

or may

not

be ingested

upright

I miionth

esophageal
et al.

C.

the pro-

emptying.

I 19] described

achalasia
toxin
six

botiiliiiuni

patient

of our

after

for evaluating

ofbarium

aliquots

postprocedural

assessing

with

pneumatic

interpretation

Pasricha

the

I I 7]

Cohen

edema and spasm

confuse

technique

sympmeasure

after

avoid

we wait

Recently.

or

consider-

may

with either

Further.

To

this

and ob-

is that

I day

of

After

in

used

We believe

conflict

emptyimig.

barium

of

as an objective

present.

be

lion.

Water

lJ

dilatation

the test only

tients

tion.

ml

of dysphagia.

the reason

Esophageal
scintigraphy
is a simple. estaband objective
parameter for evaluating
esophageal
emptying
[ I 1-16]. The technique

examined

240

pneumatic

was

in the 5-mm

et al.

when considerable

lished.

ably.
solid,

drank
Lee

may

dilatation

varies

patient

sulfate

columiin

the cardia

dilatation.

injection.

institutions

of the barium

in

clini-

is essential

as pneumatic

dilatation.

performed

inaccurate

an objective

to stop
such

ingests

painjec10-nil

sulfate (70% weight in volspot film is obtained.

The

single

of the barium
fluid
level
above
the
esophageal
sphincter
and the maximum

height
lower

posi-

width

after

Additionally.

of

the

barium

column

the diameter

are

measured.

of the open

lower

the combination
of radionuclide
and food is
swallowed.
Lastly.
the area of interest
mea-

esophageal

sured

cause the volume of barium

ingested
and the
method
of ingestion
are consistent.
However,

can change

technical

significantly
13].

variations.

is not widely

because

In addition

to these
scintigraphy

esophageal

available.

it is

even though

proach

sphincter

provides

because

it is rela-

only

a single

gree of barium

lion.

Many

of

other

physicians

tance

from

for follow-up

patients

and

live

are

referred

changes

the telephone,

Vantrappen

measure

was

initially

of persistent

dilatation.

These

timed

matic

dilatation.

However,

years later by Eckardt

esophageal

diameter

and good

long-term

toms.
latation

between

existed

correlation

Cohen
therapy

[17]

after

several

of our patients

used

by

ob-

suggested
was

of pneu-

described

successful

that

the reduction
based

study

the

after

pneumatic

response

this

pleting

to de-

a study

to perform

to

et al. [6] showed

ing

this

tions

examination

swal-

barium

emptying

because

return

as

the patients

the technique

This
cause

technique
both

is also

be assessed using

of

to the radiologists

in

simple

the height

times width

a qualitative

estimate

qualitative
as the

estimate
change

in gross

easily

to interpret
Emptying

the percent

to

becan

change

in

as defined

of the barium

ofemptying.
of emptying
area.

able

gastroenterologists

the gross area of the esophagus

dilatation

institu-

not conveniently

emptying.

either

us-

examined

A description

and

assess

comFurther.

in other

who) were

radiologists

accurately

been

could

the other institutions.

replicate the study.

supervision.

described.

center.

was fitxed

can

di-

have

to our medical

no

if. the day after

our

successfully

after therapy

technique

21

in

under

have had no difficulty

on symp-

that pneumatic

in

and can be used in any center with a fluoroscopic

unit. The technique we describe
is easy

close

patients

the results

in determining

the de-

one point

assess esophageal

They

served that the diameter

of the esophagus correlated well with the duration of the symptoms
and suggested
that such a parameter could be
important

believe

us-

researchers

be-

to perforni
and requires no special equipment.
We have now trained
three of our technologists

symptoms

et al. [7] in achalasia

the cause

pneumatic

dis-

can be assessed

an objective

swallow

Barium

by

a significant

the treating institution.

Returning
may not be easy for the patients.
symptom

Although

over

these

ap-

niethod

is assessed.

We

dilata-

This

is obtained.

that a simple

low can adequately

pneumatic

film

at only

up achalasia

after

measured.

retention

time

patients

is

a standardized

This problem is important for gastroenterologists

who are following
to perform.

easy

termine

investigators

improvement

the absolute

esophageal

symptoms

symptomatic

miinimal

have unrealistic

others

dietary

improvement.

methods

is potentially

assessing

with

with

then

be considered.

alone

with

If com-

scintigraphy
in medical
centers
the patient
may not be possible.

in esophageal

of clinical

after treatment.

and

found that some

may

should

deciding

be achieved

in Achalasia

served that the test did not correlate

of

in patients

esophagus.

therapies.

evaluation

degree

ing

drainage
as dramatic
[5. 7. 1 1 1. This phenornenon was observed by Eckardt et al. [6], who
before

niyotomy

esophageal
the

especially

cannot

treat-

that the end point

reduce

dilated

invasive

tively

ated with physiologic

we and others 15-7]

tients

dilatation.

operator-dependent

Discussion

ageal

mnally

experts

be complete
will

to moderately

plete emliptying

cal

differ-

of change

either

ers. The 95% comifidence

and the

percentage

mnedian

of emptying

assessment

between

(actual

images).

the percentage

count

or qualita.

emptying

that emptying

in pixel count on digitized

count

intervals.

quantitative

esophageal

of measuring

pixel

ences

are 9 Yoconfidence

between

and assumes

some

believe

[51- This

emptying

calculated

Therefore.

achalasia

ing

Note-Numbers

Emptying

ageal sphincter
can lead to further deterioration
to the point at which the esophagus
becomes

of Esophageal

noncompliant

aDifferences

Esophageal

by

column

or

Because

the

is as accurate

is simple.

and

can

477

de Oliveira

be dictated
ferred

quickly.

method

we now use this as the pre-

of interpretation.

ing an expensive
we used
practical

as

films is totally imWe used this tech-

digitized

in a clinical

only

nique
standard

such as the one

workstation

to analyze

setting.

a method

for emptying

us-

Obviously,

to

and

establish

the initial

and follow-up

baseline

study,

choose

the barium

tial experience
patient

again

we

barium

allowed

volume

on follow-up

often

gested

for the

ingested
from

baseline

study.

a constant

With

examination.

low-up.

as ingested

we have a consistent

provement
over baseline.
We occasionally
encounter
when
using this technique.
with achalasia
can have

on the film.

portion

locate

in-

tients,

However.

our

tertiary

column

nonpropulsive
occur.

the spot film

is continuous

when

problem.

As a re-

Indeed,

is difficult.

In these

cases,

we

we

attempt

vigorous

esophageal

keep-

on the timed barium

tematic,

detailed

clinical

swallow

number

because we

had

an insufficient

ated

before and after therapy ( 12 patients at the

time of this assessment).

tial to show the definitive
in complementing

the

evalu-

Such a study is essenrole of our technique

clinical

examination

of

this film

with a spot film centered

over
portion of the esophagus.
We then

eral years must pass before we know whether

following
objective
data gleaned
from the bar-

and follow

films.

film (usually
as a reference

For qualitative

are desired,

we measure

ofthe

the esophagus

entire

assess-

the barium

barium

contains

point
to es-

column.

retained

food

ium study after pneumatic

dilatation
will assist
us in determining
the choice of further therapy
further
pneumatic
dilatation
myotomy).
Therefore,
the purpose
munication
was to establish
nique
and determine
the
assessing

of the
a bar-

difference

ium-foam

the su-

tion,

forms,

we measure

is arbitrary-one

to qualitatively

of the reasons
assess emptying.

we

None-

the barium techbest method

of

on the barium study.

we have shown that the timed

barium swallow
is a simple technique
to evaluate esophageal emptying.
Currently
in our insti-

cases, objectively
measuring
the height
barium
column
may be difficult.
When
interface

emptying

In conclusion,

tution,
trained

perior aspect of the barium

column
at a point
where the margin is consistent
and reasonably
well defined
(Fig. 1). At times, this measure-

or Hellers
of this com-

(i.e.,

all these examinations

technologists.

we prefer
current

except

that

for both
nations

lieve

the faster,

technique

no

exists between

and the qualitative

titative

Our

in accuracy

are performed

Because

is the

methods

the quanof evalua-

qualitative
method.
same as described

volume of barium
and the follow-up
exami-

to serve
as an internal
that this simple technique

control.
should

S. Pneumatic

dilation

or

1738

J, DeloofW,
Valembois
of achalasia
with
pneumatic
dilation.
Gut 1971; 12:268-275
8. Efron B. The jackkimife,
the bootstrap
amd other
resanmplumg
plans.
Philadelphia:
Society
for Industrial and Applied Mathematics,
1982:29-35
9. Fleiss JL. Statistical
inetiiodsfor
rates and propartiOfls.
2nd ed. New York: Wiley. 1981:21 1-236
10.
Landis
JR. Koch GG. The measurement
of observer agreement
for categorical
data. Biometrics

G. Hellemans

We bebe used

J. Treatment

1977:33:159-174
1 1 . Robertson
CS, Hardy JG, Atkinson
M. Quantitative assessment
of the response
to therapy
in
achalasia of the cardia. Gut 1989:30:768-773
12. Holloway
RH, Krosion
0, Lange RC, Baue AE,
McCallurn
RW. Radionuclide
esophageal
emptying of a solid meal to quantitate
results of therapy
in achalasia.
Gasiroenterologv
1983:84:771-776
13. Fisher RS, Malmud
LS, Applegate
G. Rock E,
Lorber SH. Effect of bolus composition
on esophageal transit: concise communication.
J NucI Med
1982:23:878-882

14. Rozen P. Gelfond

M, Salzman
J, Baron J, Gilat 1.
Radionuclide
confirmation
of the therapeutic
value
of isosorbide
dinitrate in relieving the dysphagia
in
achalasia.
J Cliii Ga.strne,mterol
1982:4:17-22
I 5. McLean
RG, Sniart RC, de Carle D. Lau A. Large
bolus radionuclide
esophageal
transit may predict
response
to esophageal
dilation
in achalasia
(letter). J Noel Med 1992:33:2059
16. Levine ML Dorf BS, Moskowitz
G, Bank S. Pneumatic dilation in achalasia underendoscopic
guidance:
lire- and postdilation
by radionuclide scmtiscan. Am J Gastroenterol
1987:82:3 1 1-314
Cohen NN. An end point for pneumatic
dilation
connIation

by

significant

we use the same

the baseline

1732-

P. Vandembroucke

contrac-

of patients

and

6. Eckardt
VF, Aignherr
C. Bernhard
G. Predictors
of outcome
in patients with achalasia treated by
pneumatic
dilation.
Gas:roenterologv
1992; 103:
7. Vantrappen

with a sys-

evaluation

evaluation

esophagomyotomy
treatment
for idiopathic
achalasia: clinical outcomes
and cost analysis.
Dig Dis
Sci 1993:38:75-85
5. Birgisson
S. Richter JE. Achalasia:
whats new in
diagnosis
and treatment?
Dig Dis 1997:15(suppl

to

tions are uncommon

in achalasia
patients.
We did not correlate esophageal
emptying
based

current

1991:52:336-342

l):l-27

expose the film when the esophagus

is relaxed.
We can usually achieve this goal. In our experience. continuous,

Surg

D, Samana J. Clinical
aspects and mancriteria
in achalasia.
HepatogastroenterOlO,gV 1991:38:481-487
3. Cohen
S. Motor disorders
of the esophagus.
N
EngI J Med 1979:301
: I 84-192
4. Parkman
HP, Reynolds
JC, Ouyang A, Rosato EF.

the barium

of this

and secretions,
a barium-foam
interface forms
after the patient
ingests
the barium.
In these

478

continuous,
contractions

achalasia
patients
after minimally
invasive
treatments.
We are currently
following
up
more than 30 patients with this technique.
5ev-

the height

level

often

Thorac

Eisenberg JM, Cohen

is in patients
In these pa-

of im-

column
above or below that reference
on the respective
films and add the two

prefer

stud-

for fol-

we then judge the degree

of emptying
on that reference
point. If quantitative

ment

follow-up

measure

for both

When

study is irrelevant.
the same film-to-

Achalasia:

MK.
Ann

2. Couturier
ometnc

(Fig. 3).

esophageal

suIt, exposing

volume

ment.
based

timate

forceful,

on

had to exclude one patient in our series because

point

measures

material

empty-

References

for the baseline

In these cases,

a fixed point on each

body)
that serves

vertebral

retained

for subsequent

distance

patient

the volume

distance constant.
we
centered
over the lower

of the esophagus

immediately
the upper

of

The last problem

we encounter
with the vigorous
form of achalasia.

on a three-on-one
film, and
a two-on-one
spot film. When

ing the film-to-patient

expose
a spot film

absence

the

patients
ingest
more
than
200 ml of barium,
the height of the barium
column
may not fit
lengthwise

or

of esophageal

the

therapy.

ies is unnecessary

Some patients
a massively
dis-

patients.

I. Ferguson

to

some problems

measure

ing in achalasia

was to estimate
the degree of esophageal
emptying on the examination
date only. The pres-

mi-

a tolerable

as an objective

of the study

In our

tended
esophagus.
In these patients,
the
esophagus
is so dilated
that we cannot
fit the
barium
column
we use instead

the

for both

that the purpose

remember

current, prior, or subsequent

For this reason also, keeping

has evolved:
now. for all subsequent
examinations
the patient
consumes
the same
of barium

are used

on

technique

volume

height

patient

examinations,

different

column

is desired,

for estimating

ence

For the

ingested.

subjectively

volume,

the

barium

assessment

assumptions

the

volume

examinations.

and if the same

must

are not suggesting

of the ingested

significance

if a quantitative

theless,

1-mm and the 5-mm film, then the estimate

of emptying
should be accurate. The observer

a gold

that it become
routine.
In our current study, we did not analyze

et al.

l7.

of achalasia.
Gastrointest
Endosc
1975:22:29
18. Lee JD. Cecil BD, Brown
PE, Wright
RA. The
Cohen test does not predict outcome in achalasia
after
pneumatic
dilation.
Gastrointest
Endosc
1993:39:157-160
19.
Pasricha
PJ, Ravich
Wi, Hendrix
TR, Sostre
5,
Jones B, Kalloo AN. Intrasphincteric
botulinum
toxin for the treatment
of achalasia.
N Eimgl J Med
1995:322:774-778

AJR:169, August 1997

Timed

APPENDIX:

Summary

1 . The patient
2. The patient

stands.

3.

ingests

(The

tolerance.
Three-on-one

lOO-2()O

same volume
spot

films

(35

the state

is to determine

4. The degree
measuring

(Fig.

of Timed

of the fluoroscope

distance

of emliptying
the

height

Barium

Swallow

Barium

Swallow

ml of low-density
of barium
X 35 cm)

carriage

to Evaluate

Technique

barium

(45%

for Assessing

weight

is used for follow-up

are obtained

from

the patient

in volume)

Emptying

Esophageal

over

30-45

in Achalasia

Emptying

sec. with

in Patients

the volume

with

ingested

Achalasia

based on patient

studies.)

I, 2, and 5
is kept

Esophageal

mm after ingestion,

constant

with

for all spot films.

the patient
The 2-mm

in a left posterior
film

is optional.

oblique

position.

but fluoroscopy

The

at 2 mm

of emptying.
is estimated

and width

qualitatively

for both films.

by comparing
calculating

the 1- and 5-mm

the rough

films.

area for both,

The degree

and determining

of emptying

may also be estimated

the percentage

of change

by

in the area

I).

AJR:169, August 1997

479