A 34-year-old woman’s esophageal cancer was missed by two separate barium swallows.

Why is it that this test can miss the presence of a tumor?

The patient, who died several months later, says in her YouTube video that the barium swallows came back “clear” even though she’d been having symptoms, namely, trouble with getting food down (dysphagia).

A barium swallow is performed for many reasons including to check for a suspected esophageal cancer.

How is a barium swallow done?

• The patient lies on an X-ray table.

• X-rays of their chest and stomach may then be taken.

• The patient then swallows a thick barium drink.

• The radiologist will view the barium via imaging as it moves about in the patient’s mouth and throat.

• The patient may be asked to hold their breath at times.

• The process is repeated with a thinner barium drink.

• The patient might also be given a barium tablet.

You’d think that a tumor would clearly show up during this test.

But that is not always the case.

“Yes, a barium swallow can certainly miss esophageal cancer,” says Santosh Sanagapalli, MD, a consultant gastroenterologist, endoscopist and specialist in esophageal disorders.

“It should not be used to rule out cancer.

“While a barium swallow performed properly should be able to diagnose large cancers, the problem is that there is significant variability in protocols used, and the quality of barium swallow performed in many community radiology practices is poor.

“Further, even when the test is performed properly under supervision of an experienced radiologist, it can still miss small cancers.

“Therefore, if there is ever concern about esophageal cancer, the test of choice to definitively tell us whether this is the case (or rule it out) is upper GI endoscopy.”

Can an esophageal cancer small enough to be missed still cause symptoms?

Nobody knows how small the woman’s tumor was when she developed her first symptom, which was pain when swallowing.

And nobody knows how much bigger it had gotten by the time a new symptom arose: difficulty swallowing (dysphagia).

“Firstly, a tumor does not need to be particularly big to cause dysphagia,” says Dr. Sanagapalli.

“The normal diameter of the esophagus is approximately 20mm, so even a tumor that is only 5mm in size can cause a significant narrowing of the esophageal lumen, which may be appreciated by the patient as dysphagia to solid foods.

“Secondly, barium swallow is not a perfect test. The barium swallow provides only a two-dimensional representation of a three-dimensional organ.

“Because of this, depending on its location around the circumference of the esophageal wall, a small tumor of 5-10mm could easily be missed.

“When the esophagus is collapsed (its resting state), a small tumor of 5-10mm diameter may easily be lost amongst the floppy wall.

“Maximizing distension of the esophagus during the barium swallow by adjusting the amount of barium ingested and patient position can help, but ultimately it cannot match the view obtained at endoscopy, where the esophagus can be fully distended with gas and a direct visual inspection of the entire lining of the esophagus made.”

Trouble Swallowing Food, Barium Test Comes Back Normal

If you’ve had this experience, such as the young woman in the YouTube video, your next step should be to request an upper endoscopy.

Do not let your doctor convince you that your difficulty swallowing is being caused by anxiety.

Unfortunately, in the 21st century, there remain too many physicians who are more likely to dismiss this complaint in a young woman as anxiety or stress, when compared to a man over 50 presenting with the same complaint.

It is NEVER normal to experience the sensation that food is struggling to get down your esophagus and into your stomach – despite eating slowly and taking small bites.

The barium swallow may be the first test recommended since the upper endoscopy is more complex and requires sedation.

But don’t let that stop you.

The woman’s message in her YouTube video is that she felt confident nothing was seriously wrong because the barium swallow showed no cancer.

At that time, she did not have an upper endoscopy. This procedure was delayed because the negative barium swallow and diagnosis of anxiety-induced swallowing difficulties made her feel reassured.

But the issue with swallowing kept getting worse until food began coming back up. Even water came back up.

The Barium Swallow for Other Evaluations

“Barium swallow is still a useful test in evaluating the esophagus,” says Dr. Sanagapalli.

“It is best used in the evaluation of esophageal motility disorders, where it can evaluate the quality of peristalsis and the ability of the esophagus to properly empty its contents into the stomach.

“These are both things that endoscopy cannot do.

“While barium swallow can also assess for structural abnormalities, in most cases, it has now been superseded by endoscopy for this purpose.”

For more on the gold standard for esophageal cancer detection, go here.

Here is the link to the video.

Dr. Sanagapalli is a gastroenterologist and director of the Esophageal Disorders Center at St Vincent’s Hospital, Darlinghurst. He performs diagnostic and therapeutic endoscopic procedures, and enjoys providing comprehensive and holistic care to patients with a wide variety of disorders affecting the gastrointestinal tract.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.