Esophageal Dysmotility and the Utility of Barium Swallow: An Opaque Diagnosis

Background: The gold standard for diagnosis of esophageal dysmotility is high-resolution manometry (HRM); however, barium swallow studies are still routinely incorporated in the diagnostic algorithm by clinicians. We aim to assess the sensitivity of barium swallow to diagnose esophageal dysmotility using HRM for comparison. Methods: We retrospectively reviewed 100 consecutive patients evaluated for esophageal dysmotility by both barium swallow and HRM. Dysmotility on barium swallow was graded as mild, moderate or severe. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated, including an achalasia subset analysis. Results: Compared to HRM, barium swallow had an overall sensitivity, specificity, NPV, and PPV of 88%, 35%, 80%, and 51%, respectively, for detecting esophageal dysmotility. In achalasia patients (N=17), it detected dysmotility with 100% sensitivity and 30% specificity. Excluding achalasia patients, barium swallow had 81% sensitivity and 35% specificity; in other words, 65% of patients with normal HRM were misdiagnosed with dysmotility on barium swallow. For patients who exhibited normal, mild, moderate, and severe dysmotility as diagnosed on barium swallow, the concordance rates compared with HRM were 80%, 22%, 27%, and 89%, respectively. Conclusion: Compared to the gold standard using high-resolution manometry, 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 diagnosis of esophageal dysmotility in patients without achalasia, especially in mild or moderate disease. As such, careful consideration of the diagnosis of esophageal dysmotility should be taken when using this technique.