Barium X-ray and Cancer Diagnosis

Barium X-ray Cancer Diagnosis

Reviewed By:
Mark Oren, M.D., FACP


Barium x-rays can refer to a number of tests of the gastrointestinal (digestive) system. The tests examine the gastrointestinal (GI) tract, the region of the body from the esophagus to the rectum. These x-rays can detect cancers that occur in any portion of the GI tract.

Diagnostic tools that use barium x-rays are divided into two main categories:

  • Upper GI tests (mouth, esophagus, stomach and small intestine), including barium swallow, barium meal and small-bowel series
  • Lower GI tests (large intestine [colon and rectum]), including barium enemas (the administration of barium into the patient’s rectum through a tube)

Barium is used in radiology tests because its contrast properties outline internal organs and they appear white on the x-ray images.    It helps to visualize problem areas and can indicate difficulties with swallowing (dysphagia) or digestion, ulcerations, malignancy or structural abnormalities.

About barium x-rays

Barium x-rays include a variety of radiographic tests in which a barium compound is swallowed or delivered by enema (the administration of a substance, such as barium, into the patient’s rectum through a tube). The barium coats various internal organs, such as the esophagus and the inner lining of the gastrointestinal (GI) tract. This highlights abnormalities – including potentially cancerous growths – and allows a physician to view them on x-ray images.

Barium reveals tumors and ulcers because it collects in abnormal areas or around growths. Barium also reveals problems with swallowing or digestion because it can be filmed passing through the mouth, throat and intestines.

Barium x-rays can help diagnose several types of gastrointestinal system cancers, including:

  • Colorectal cancer. Cancer of the colon and recturm, the two organs that comprise the large intestine.
  • Small intestine cancer. Cancer of the long tube that connects the stomach to the large intestine. Types of small intestine cancer include:

    • Gastrointestinal stromal tumors
    • Gastrointestinal carcinoid tumors
    • Adenocarcinoma
    • Sarcoma
    • Lymphoma

  • Esophageal cancer. Cancer of the esophagus, the muscular tube that carries food from the mouth to the stomach.

  • Stomach cancer. Also known as gastric cancer, it affects the sac-like organ that holds food and secretes gastric juice to start the digestive process.

  • Laryngeal and hypopharyngeal cancer. Cancers that start in or around the larynx, commonly known as the voice box.

In some cases, barium x-ray tests are ordered to look for the spread of a cancer from one area of the body into the gastrointestinal tract. Such cancers include:

  • Ovarian cancer. Overgrowth of malignant, abnormal cells in one or both of a woman’s ovaries. The ovaries are female reproductive organs that produce eggs called ova and hormones called estrogen and progesterone.

  • Oral cavity and oropharyngeal cancers. Oral cancer is cancer that starts in the mouth, also called the oral cavity. Oropharyngeal cancer develops in the part of the throat just behind the mouth, called the oropharynx.

In addition, barium x-ray tests are used to diagnose conditions that may or may not be related to cancer, such as:

  • Dysphagia. Difficulty swallowing, which can be caused by a number of medical conditions.
  • Gastroesophageal reflux disease (GERD). A disorder in which stomach acid moves upward from the stomach into the esophagus.

  • Peptic ulcers. Ulcers in the stomach or upper part of the small intestine.

  • Hernias. Opening or weakness in the wall of a muscle, tissue or membrane that normally holds an organ in place.

  • Diverticulosis. Bulging pouches in the digestive tract.

Barium is a soft metallic element. The type commonly used in medical tests is the compound barium sulfate, which is usually referred to simply as barium. It is not radioactive but radiopaque. Since radiation will not pass through barium, it shows up on x-rays as a light area, making it a type of contrast medium.

Barium tests can use standard x-rays, fluoroscopy, cineradiography or a combination of these machines. Fluoroscopy uses a video monitor and an x-ray tube that makes an element brighter and easier to see (an image intensifier). Cineradiography (also called videofluoroscopy) uses a movie camera to turn images produced by standard x-rays or fluoroscopy into a record of movement. Videofluoroscopy is used to examine the passage of food through the mouth, throat or stomach.

Definitions of the types of barium x-ray vary according to physician and facility.  It is important for patients to ask the physician or facility for clarification of the specific procedure.

Types and differences of barium x-rays

There are two primary kinds of barium x-rays:

  • Upper GI barium tests. There are four primary types of upper GI tests:
    • Upper GI barium x-ray. This term is generally used to refer to a liquid barium x-ray of the stomach along with the esophagus (tube connecting the mouth to the stomach), duodenum (upper part of the small intestine) or both.

      It has also been used to describe a liquid barium x-ray of the esophagus only (esophagram). The esophageal wall is normally smooth, but a barium swallow can help reveal any potentially cancerous bumps that are present. A barium swallow is often the first test recommended for patients who are having trouble swallowing (dysphagia). This condition is a main symptom of  esophageal cancer and can be associated with cancers of the head, neck and oral cavity. Dysphagia may result from chemotherapyand radiation treatments as well. Barium swallows can also highlight tracheoesophageal fistulas, holes created when tumors destroy the tissue between the esophagus and the trachea (windpipe).

      A radiologist conducts this test to look for physical or functional problems in the upper digestive tract.
    • Modified barium swallow (MBS).  This term generally refers to barium testing of the uppermost parts of the digestive tract including the mouth, pharynx, larynx and esophagus. The test also may be called a videofluoroscopic swallow study (VFSS). In this test, barium can be presented in a liquid form or in a paste that can be mixed with foods, such as pudding. In some instances, the barium used to coat a cookie prior to eating. This test is most often used with geriatric individuals, people with Parkinson’s disease, stroke patients or people with other neurological disorders. MBS is used to diagnose dysphagia and aspiration (food or liquids that enter the  airway and lungs) – common concerns among these populations. An MBS also may be used to evaluate swallowing problems as the result of certain cancers or cancer treatments.
    • Barium meal (also called a barium beefsteak meal). This term generally refers to a test in which the patient digests food containing or coated with barium. The test determines whether the stomach can adequately process food. The term “barium meal” also may refer to a liquid test assessing the esophagus, stomach and/or duodenum.
    • Small-bowel series. This term refers to a liquid barium x-ray of the small intestine. A small-bowel series is often done after a barium swallow assessing the esophagus and stomach.
  • Lower GI barium tests. There are two types of lower gastrointestinal barium tests (lower GI series):
    • Single-contrast barium enema (commonly referred to simply as a barium enema). An enema is the administration of a substance, such as barium, into the patient’s rectum through a tube. In a barium enema, a barium compound can be administered before a conventional x-ray of the large intestine. It may also be used with a fluoroscopy, an x-ray method that highlights internal structures as shadowy images on a fluorescent screen.
    • Double-contrast barium enema. X-rays are taken after barium is administered into the patient’s rectum through a tube. The barium helps the x-rays outline the colon and rectum better and helps reveal abnormalities such as polyps. The night before the test, patients take a laxative and a regular enema is completed the morning of the test. Air is puffed into the rectum to enlarge the bowel.  A double-contrast enema is effective in revealing problems in the large intestine. However, research has shown that it sometimes fails to detect small polyps.

      The double-contrast technique may be used to diagnose stomach cancer. In this procedure, the patient swallows a thin tube and air is pumped into the stomach. This thins out the barium coating, allowing even small abnormalities to be revealed.

Before the barium x-ray

Patients should follow their physician’s advice about the preparatory steps that may be necessary before a barium x-ray. These may include dietary restrictions and modifications to a patient’s regimen for taking over-the-counter and prescription medications.  

Before an upper GI barium x-ray, patients may receive special instructions such as how long to fast prior to testing. Prior to a lower GI barium test, the lower gastrointestinal tract must be emptied of its contents. These steps may include:

  • Minimum-residue diet, restricted to low-fiber foods allowing only minimal solids in the intestines, such as lean meat, refined cereals, pasta and liquids. Typically this diet starts two or three days before the test.
  • Clear liquids only. This stricter diet may be required up to three days before testing, or the patient may be started on a minimum-residue diet and then limited to clear liquids a day or two before testing.
  • Abstention from medications. The physician may have the patient stop taking some or all medications starting 12 to 24 hours before testing.
  • Fasting. Typically, fasting begins 12 hours before testing.
  • Laxatives, enemas, suppositories. Any combination of these may be recommended the evening before and/or the morning of the test.

Patients should also inform their physician about any previous allergic reactions to barium sulfate or allergies to foods, preservatives or dyes. Other conditions that may affect the use of barium sulfate include:

  • Asthma.
  • Hay fever.
  • Cystic fibrosis. Risk of small-bowel blockage is increased.
  • Dehydration. Barium sulfate my cause severe constipation.
  • Intestinal blockage or perforation. Barium sulfate can exacerbate this condition.

Women who are pregnant are discouraged from having barium x-rays due to the potential for radiation exposure to the fetus.

During the barium x-ray

Barium x-rays are usually performed in a physician’s office, hospital or outpatient clinic. A mild sedative may be given. Barium is chalky but has flavoring added and does not taste bad to most people. Depending on the test, it can be in the form of a thin liquid, thick liquid, paste or solid. The type of test determines the exact nature of the procedure. Details that apply to specific tests include:

  • Barium swallow: Typically, the patient will be instructed not to eat or drink after midnight the day before the test. The patient may be instructed to consume baking soda along with the liquid barium because the resulting gas improves the appearance of the barium on x-rays. Tests may be done with the patient standing or lying on a tilt table or both. When standing behind a fluoroscope patients may be asked to change positions and hold their breath while x-rays are taken. Patients may be strapped to a table that is tilted to allow pictures from various angles. The abdomen may be compressed by a belt or the examiner’s lead-gloved hand during testing. The test can take one to two hours to complete.
  • Modified barium swallow (MBS). This test also may be called a videofluoroscopic swallow study (VFSS). The patient sits in a special chair during the exam, which uses fluoroscopy with or without cineradiography (video images). The patient ingests small amounts of thin or thickened liquid barium. The patient may drink a small amount of barium or eat a soft substance (e.g., pudding, applesauce) mixed with barium. Depending on the condition, the patient also may ingest a cookie or cracker coated with barium.

    This test is used when dysphagia (difficulty swallowing) or aspiration (food or liquids entering into the airway)  is suspected. Fasting is not required. A speech-language pathologist and radiologist conduct this test jointly to diagnose swallowing problems and evidence of aspiration. An MBS can help determine the most appropriate diet for a patient and suggest techniques to reduce the risk of choking and aspiration. The test, usually performed in a hospital, can take up to an hour to complete.
  • Barium meal. Typically, the patient will be instructed not to eat or drink after midnight the day before the test. The patient digests a meal containing barium. The radiologist uses fluoroscopy to watch how long the stomach takes to digest the meal. If the barium meal is performed within a few days of a barium enema, a cleansing enema and laxative may be required first to clear all barium from the intestines. The procedure can take anywhere from 20 minutes to several hours, depending on the number and nature of x-rays required.
  • Small-bowel series. A small-bowel series is typically done in conjunction with a barium swallow. The patient will drink additional barium and more x-rays will be taken every half hour until the barium reaches the large intestine. The barium swallow and small-bowel series can take up to six hours to complete because of waiting time between the tests.
  • Barium enemas. The patient lies down sideways, and a lubricated enema tube is inserted into the rectum. The barium contrast agent is slowly administered through the tube into the colon.  The entire procedure takes from 20 to 45 minutes and may cause discomfort or minor cramping. To allow different views of the lower GI tract during x-rays, the table can be tilted and the patient instructed to change position. After filming, the tube is removed and the patient uses a bedpan or toilet to begin expelling the barium. Following expulsion of the barium, more x-rays are taken. When a double-contrast barium enema is used, the entire process is repeated. In the second procedure, air is supplied through the enema tube. The air helps outline the colon better for better viewing by the physician.

After the barium x-ray

Following the test, patients should be sure to drink plenty of liquids to avoid severe constipation brought on by barium sulfate. Patients are likely to have stools that are white, pink or gray for several days following the procedure. This will last until the barium is completely expelled from the system. In some cases, patients will be given a cleansing enema or asked to take a laxative that will flush out the remaining barium.

Patients should report any of the following symptoms to a physician:

  • Discolored stools that continue more than three days after the test
  • Inability to experience bowel movements or pass gas three days after the test
  • Bloating
  • Severe, continuing constipation
  • Severe cramping
  • Nausea or vomiting
  • Stomach or lower abdominal pain
  • Tightness in the chest or breathing difficulties

Potential risks of barium x-rays

Risks of barium x-rays may include:

  • Radiation. Low levels of radiation are emitted during radiographic tests. Fluoroscopy and cineradiography can emit more radiation than standard x-rays. Kidney damage can be worsened by contrast agents such as barium, according to the National Institutes of Health (NIH). The physician may recommend that kidney patients protect their kidneys by drinking water before and after x-rays. The test also may be ordered without the use of a contrast agent.
  • Infection. This occurs infrequently during upper or lower GI barium tests. A common symptom of infection is fever. Infection should be treated promptly.
  • Cramping. This is common during both types of barium enemas but eases after the procedure.
  • Tearing of the colon. This is a rare risk of the lower GI tests. Surgery may be necessary if the intestine is perforated.
  • Constipation. Often patients will be advised to expel the barium and avoid constipation by eating high-fiber foods, using laxatives or drinking more water.
  • Intestinal obstruction. If the barium is not defecated it can harden in the intestine. A white stool is normal for up to three days after barium x-rays. The patient should notify the physician if there is no white stool or if there are other bowel problems. Intestinal obstruction could lead to potentially fatal barium poisoning.
  • Poisoning. Normally the body cannot absorb barium sulfate because this compound is not water soluble. Poisoning can occur in the rare cases in which water-soluble barium compounds are accidentally used instead of insoluble forms, or in which intestinal blockage prevents the body from expelling barium sulfate. Symptoms of barium poisoning include diarrhea, nausea, vomiting and stomach pain. In severe cases the body can lose so much potassium that paralysis or death can result.

    In most cases, however, barium x–rays are administered with no difficulty or lasting complications.

Follow-up testing

If abnormalities appear on a barium x-ray, the physician may order follow up tests to diagnose problems with the gastrointestinal (digestive) system. Depending on symptoms, a physician may order one or more of the following tests of the upper GI tract:

  • Endoscopy. The physician guides a fiber-optic viewing tube (endoscope) with a miniature camera on the end through the patient’s mouth to examine the esophagus or stomach for lesions, blockage or other problems. The camera sends back pictures of abnormalities that are viewed on a monitor. The physician can also use the endoscope to obtain tissue samples (biopsies) for analysis.
  • Ultrasound.  A test that uses harmless sound wave to creates pictures that outline organs and tissues.  However, an ultrasound does not detail the lining of the GI system.  An abdominal ultrasound can show excess formation of fluid or abnormal size or shape of an organ. In addition, an ultrasound probe may be used during an endoscopy to determine the presence of and depth of penetration of cancer. The probe sends out very sensitive sound waves that penetrate deep into the tissues to reveal close-up images of the esophagus and nearby tissues.
  • Esophageal pH test. This test measures the acidity in the throat. It can indicate acid reflux, the abnormal presence of stomach acid in the esophagus.
  • Manometry. A manometer (tube lined with pressure gauges) guided down the throat measures the contractions of the esophagus (esophageal manometry) and/or stomach (gastric manometry). It may be used in suspected cases of gastroparesis or other conditions involving the nerves or muscles of the upper digestive system.
  • Bernstein test (esophageal acid perfusion test). This test for esophagitis introduces a small quantity of acid in the esophagus through a nasogastric tube.
  • Gastric emptying scan (GES). The patient eats food containing a tracer (a radioisotope, with a low, safe level of radiation). With the patient lying down, a scanning machine is placed above the abdomen for several hours. The tracer allows the machine to track the radioactivity in the stomach and show how fast the food exits the organ.
  • Antroduodenal motility study. The patient is sedated or has the throat numbed. A tube is passed down the throat and through the stomach into the duodenum. Sensors in the tube measure the contractions of the digestive tract at rest and after a meal and reveal whether emptying of the stomach is delayed.

Other ways of testing for lower GI problems such as colon cancer include:

  • Digital rectal exam. The physician carefully inserts a gloved, lubricated finger several inches into the rectum to feel for abnormalities.
  • Flexible sigmoidoscopy. The physician inspects the interior of the rectum and the lower colon (the sigmoid) with a flexible, lighted tube called a sigmoidoscope. Deaths from cancer of the rectum and sigmoid colon are more than 50 percent lower among people who have had sigmoidoscopy, according to the CDC.
  • Colonoscopy. A longer flexible, lighted tube with a camera lens called a colonoscope that allows a physician to inspect the rectum and entire colon. The device is connected to a video camera and monitor. The physician may pass a wire through the colonoscope to remove polyps with an electric current. Tissue samples can be taken for microscopic examination in a biopsy. For more information, see Colonoscopy.

A physician will be able to provide more details about the many types and definitions of barium x-ray tests, when they are needed, how they are performed and their risks and benefits.

Questions for your doctor about barium x-rays

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about barium x-rays:

  1. Which type of barium test do I need?
  2. How and where will the test be administered?
  3. What are the risks associated with the test?
  4. Will I need any special preparation for the test?
  5. How long will the test take to complete?
  6. What do you hope to learn from the test?
  7. When and from whom will I receive the results of the test?
  8. What can I expect in the recovery process?
  9. Do I have any conditions that make create difficulties with the test?
  10. How often will I need to have a barium x-ray?
  11. What additional tests might be necessary?
  12. What will likely follow if you find cancer?
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