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Paper text:
barium as a positive radiographic contrast medium for evaluation of gastrointestinal disorders has historically been associated with the first application of x - rays in medicine .
it formed the mainstay as a primary diagnostic modality to investigate disorders of the gastrointestinal tract .
various improvisations in the composition of barium and its techniques ( high density , double contrast ) allowed accurate anatomical depiction .
technical innovations in the form of image intensification , automatic exposure , automatic film processor systems , etc . , provided ease in performing such tedious procedures .
there were , however , concerns regarding the excessive exposure of ionizing radiation to both , the radiologist and the patient . the advent of ultrasonography , endoscopy , capsule endoscopy , physiological monitoring , and axial imaging ( computed tomography [ ct ] and magnetic resonance [ mr ] scanning ) relegated the superiority of barium examinations . over the last 30 years , there has been a steady decline in requests for barium studies due to the above reasons .
now , barium meal evaluation of stomach and small bowel is performed only in teaching institutions and in mofussil areas , where there is dearth of modern imaging facilities .
this art comes with practice and with dwindling number of investigations asked for ; there is no time to master the same .
being operator depended , the clinicians would not trust the studies performed by juniors and would thus seek their answers from the gamut of other investigations available .
mastering the art of barium examination is time consuming and in the present economic trends , is not cost - effective .
with passage time , there will be nobody who would be able to perform an appropriate and optimal barium examination .
furthermore , the present generation of clinicians and radiologists rely more on endoscopy and axial imaging , and would not like to spend more time in the time - consuming barium examinations .
this decline of barium investigations has had negative repercussions on the residency training programs as they are not aware of the proper techniques , advantages , and limitations of the study . in odd cases where
one is forced to perform such an investigation , they would be on tender hooks to go about it and perform a shoddy study .
there are areas where endoscopy , axial imaging , and physiologic monitoring are inadequate ; they are invasive , time consuming , expensive , and not without their shortfallings , ambiguity , and complications .
it is primarily the financially driven initiatives that have propagated the use of other complementary modalities as a primary modality(s ) of choice over the conventional barium examination .
barium studies , till date , remains the safest , fastest , and cheapest diagnostic investigation to evaluate vague abdominal symptoms and the art has to be revived .
motility disorders of the gastrointestinal tract from pharynx to anus and submucosal lesions are best and quickly evaluated by barium studies .
no other modality can be as faster , safer , and more accurate than this age - old barium evaluation .
it is useful for both , diagnostic as well as for follow - up to evaluate response to therapy .
other specialties such as speech therapy and the ear - nose and throat , also require barium studies for accurate anatomic depiction by barium studies for the detection of vocal cord movements , artificial voice box evaluation , and other benign conditions such as diverticulum .
the real - time evaluation of the upper digestive tract by barium is a boon for them as it resolves many ambiguous disorders .
however , for staging purposes in esophageal cancers , almost all esophageal disorders can be diagnosed by barium swallow examination .
barium study is a quick investigation to evaluate response to treatment and to evaluate the postoperative status and their complications in gastroenterology , being a faster and cheaper investigation . in our institution
, we perform a large number of loopogram ( distal and proximal ) using barium before closure to external bowel diversion .
to perform even a simple and easy study such as loopogram , one needs to be aware of basics and basis of the use of barium studies in tubular structures such as mucosal coating , distension , the barium pool , projections , and compression to optimize visualization of abnormalities at single- and double - contrast studies .
at tata memorial hospital , we evaluated the audit data over 10 years from january 2006 to december 2015 .
the data were divided into three groups , namely , barium swallows , barium meals , and enemas and others ( enteroclysis , loopogram , and cologram ) .
being a tertiary cancer center and with the availability of most of the latest imaging technologies , we were seldom performing barium studies for the primary evaluation of the stomach and colon .
there has been a slow but steady decline in the number of barium studies performed in our hospital over the past 10 years . in our institute
, we found a trend of overall decrease in the number of barium studies from 2989 to 672 in 10 years with 76% regression . out of all the barium studies ,
the major decline was seen in the number of barium swallows which went down from 2801 to 471 in 10 years with an approximately 83% decrease over interval period [ figure 1 ] .
overall , 76% regression in the number of barium studies with a major decline seen in the number of barium swallows being performed having 83% decrease the decline is probably due to the fact that ours is a tertiary cancer center where most of the cases are already worked by basic imaging investigations outside .
similar trends are seen in the united states . in the data published by medicare , during a 3-year period ( 19992001 ) ,
there was approximately 33% decrease in the number of double - contrast barium enema ( dcbe ) for colorectal cancer screening , and in 2008 , the u.s .
preventive services task force recommendations for colorectal cancer screening guidelines the use of dcbe is omitted .
one of the many postulated reasons for the decline of use of dcbe , the most important are ( 1 ) wider availability and increasing use of cross - sectional imaging tests , such as abdominal ct and mr imaging ( mri ) , ( 2 ) higher sensitivity and specificity of ct and mri in detecting polyps , ( 3 ) alternatives such as ct- and mri - based virtual colonoscopy , and ( 4 ) very few trained radiologist who can perform and interpret this technique and teach radiology trainee for performing such procedures .
not surprisingly , there was a slight increase in the number of loopogram , reflecting the increase in surgical intervention .
the decline of barium evaluation of esophagus , stomach , and small bowel is attributed to diverse factors including the ever - increasing accessibility of endoscopy and sophisticated cross - sectional imaging modalities such as ct and mri . at our institution ,
barium studies are now used primarily to evaluate the pharynx , larynx , and cervical anastomosis and to evaluate the external bowel diversion loop before closure . for accurate anatomic delineation of the lesion
, our radiotherapy department still uses the lateral barium study for the neck at six feet distance , for the larynx and pharynx .
similarly , many centers across the world still use contrast swallow studies for the assessment of anastomotic leaks , and in a recent study by price et al . showed that barium swallow is a specific test for detecting anastomotic leaks after esophagectomy .
rarely , we have had to resort to enteroclysis ; for the odd cases , a routine barium follows through examination sufficed .
tata memorial centre ( tmc ) grant in aid under dae is one of the largest comprehensive cancer centers in asian subcontinent .
tmc  rural outreach program  ( tmcrop ) in southern maharashtra districts ( approximate population 3 million ) in the western part of india in 2002 . from 2008 ,
we introduced barium swallow examination , a faster and cheaper investigation for early esophageal cancer detection , as a primary tool for screening program in our tmcrop .
besides , being a primary diagnostic tool for many upper gastrointestinal disorders , these barium fluoroscopic examinations also have an important role in the evaluation of patients after gastrointestinal surgery ( including postesophagectomy and anastomosis surgery ) and in the diagnosis of a host of postoperative complications ( e.g. , perforation and obstruction ) .
hence , in the era of personalised cancer medicine and molecular functional imaging there is a need to revitalize barium studies that have been ignored for a long time .
importantly , there is a need to interact proactively with the clinicians who are our feeders .
joint discussions should be held , and it must be emphasized to them that other imaging modalities are complementary to barium studies and that there are many instances whereby , this cheaper and faster investigation would be beneficial to the patient . they must be coerced , and we should demonstrate a good study to encourage them to look our way . another problem that needs to be resolved is that of the available literature .
newer books on imaging do not lay sufficient stress on the various techniques of performing barium studies ; whatever little they may add , is insufficient .
it is not that barium examination can be mastered by reading books or through the internet .
it is the older editions on the subject that describe in depth the nuances in the performance of barium studies .
hence , it is the need to preserve older textbooks that describe these procedures in depth .
they also contain more illustrations than the newer ones , as other modalities were not in vogue then .
the institution also plays an important role in regard with sanctioning of grants for fluoroscopic equipment .
they too must be made aware of the fact that fluoroscopic equipment for barium studies is a must in the armamentarium of the radiodiagnosis department .
money should be spent not only on such equipment but also for the other modern and latest equipment . finally , to gather experience ,
junior doctors need to weed out frank cases to perform barium examination on diagnosed cases for applying and learning the art of barium studies , and importantly , the art of fluoroscopy . unlike vascular and interventional studies , fluoroscopy is an art in barium examination where one does not try to diagnose lesions on fluoroscopy .
fluoroscopy is performed to see adequacy of contrast coating , its passage , and to record images of lesions ( suspicious or obvious ) in orthogonal views .
our aim to preserve the age - old technique of barium studies not only to keep it going on but also for the betterment and appropriate management of the patient .
our goal is not to  save  barium studies simply to keep this technology alive , per se , but rather to preserve barium radiology for the quality in patient care .
with the advent of the modern imaging technologies , the present era of oncology is seeing steady decline in requests for barium studies due to the many reasons . 
 it is prudent to mention here , that , barium examinations can not be made obsolete ! 
 our aim to preserve the age old technique of barium studies not only to keep it going on but also for the betterment and appropriate management of the patient . 
 our goal is not to  save  barium studies simply to keep this technology alive , per se , but rather to preserve barium radiology for the quality in patient care .