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Esophageal Dysmotility and the Utility of Barium Swallow: an Opaque Diagnosis
Brendan M. Finnerty*1, Anna Aronova1, Cheguevara Afaneh1, Kamal S. Turkmany1, Thomas Ciecierega2, Carl V. Crawford2, Thomas J. Fahey1, Rasa Zarnegar1
1Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY; 2Gastroenterology, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY
Background: The gold standard for diagnosis of esophageal dysmotility is high-resolution manometry (HRM); however, barium swallow studies are routinely incorporated into the diagnostic algorithm. We aim to assess the sensitivity of barium swallow in diagnosing esophageal dysmotility, using HRM as the gold standard for comparison.
Methods: We retrospectively reviewed 198 consecutive patients who presented with complaints of esophageal dysmotility. Only patients with both barium swallow and HRM were included, while patients with a history of esophageal or proximal gastric surgery were excluded. Dysmotility diagnosed on barium swallow was graded as mild, moderate, or severe based on radiology interpretation. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for barium swallow were calculated for the overall cohort, including an achalasia and non-achalasia subset analysis. Lastly, we evaluated the concordance rates between HRM and barium swallow.
Results: One-hundred patients had both HRM and barium swallow studies performed. Using HRM as the gold standard, barium swallow had an overall sensitivity of 85%, specificity of 35%, PPV of 47%, and NPV of 78% for detection of esophageal dysmotility. Furthermore, it was able to detect dysmotility in achalasia patients (N=14) with 100% sensitivity and 32% specificity. Excluding patients with achalasia, barium swallow had 77% sensitivity and 35% specificity for detecting dysmotility; in other words, 65% of patients with normal HRM were misdiagnosed as having dysmotility on barium swallow. Furthermore, mild and moderate dysmotility diagnosed on barium swallow had concordance rates of 19% and 0% with HRM, respectively, which were significantly less accurate than the 82% concordance rate for severe dysmotility (p<0.001).
Conclusion: Compared to the gold standard, barium swallow accurately rules out patients with achalasia and is reliable in evaluating patients with severe dysmotility. However, it is a poor testing modality for the diagnosis of esophageal dysmotility in patients without achalasia, especially in mild or moderate disease. Therefore, a diagnosis of mild or moderate esophageal dysmotility on a barium swallow study should be further evaluated by high-resolution manometry.
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