|Year : 2015 | Volume
| Issue : 1 | Page : 6-11
Videofluoroscopy versus upper G.I. endoscopy: A comparative study as a diagnostic tool in patients presenting with dysphagia
Sharwak Ramlan, Sai Manohar, Gangadhara Somayaji
Department of Ear, Nose and Throat, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||13-Apr-2015|
Dr. Sai Manohar
Department of Ear, Nose and Throat, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objective: Dysphagia is a major symptom in many of the patients coming to the hospital. There can be various causes of dysphagia and its accurate diagnosis shows the way for the necessary treatment. Videofluoroscopy and upper gastrointestinal (GI) endoscopy are the two most commonly employed primary investigating modalities in assessing dysphagia. The objective of the study was to compare videofluoroscopy and upper GI endoscopy and establish a primary diagnostic tool for assessment of dysphagia. Materials and Methods: A prospective study was conducted on 20 patients presenting with dysphagia in a tertiary care hospital.They were evaluated both by videofluoroscopy and upper GI endoscopy. Patients were evaluated based on the accuracy of the findings obtained with both the tests and compared statistically. Results: Videofluoroscopy could successfully diagnose 83% of the cases with a positive cause of dysphagia whereas upper GI endoscopy could diagnose only 41% of the positive cases. Conclusion: This study shows that videofluoroscopy is an effective primary diagnostic tool for evaluating dysphagia.
Keywords: Dysphagia, upper GI endoscopy, videofluoroscopy
|How to cite this article:|
Ramlan S, Manohar S, Somayaji G. Videofluoroscopy versus upper G.I. endoscopy: A comparative study as a diagnostic tool in patients presenting with dysphagia. Arch Med Health Sci 2015;3:6-11
|How to cite this URL:|
Ramlan S, Manohar S, Somayaji G. Videofluoroscopy versus upper G.I. endoscopy: A comparative study as a diagnostic tool in patients presenting with dysphagia. Arch Med Health Sci [serial online] 2015 [cited 2020 Mar 31];3:6-11. Available from: http://www.amhsjournal.org/text.asp?2015/3/1/6/154918
| Introduction|| |
Swallowing is among the most primitive and vital of animal life functions.
Dysphagia is the medical term for the symptom of difficulty in swallowing. It is derived from the Greek dys meaning "bad" or "disordered", and phago meaning "eat".  Although classified under "symptoms and signs", the term is sometimes used as a condition in its own right. 
The two most common diagnostic procedures available are the videofluoroscopy and the upper gastrointestinal (GI) endoscopy. Both procedures have been validated and have evidence-based guidelines developed in accordance with the scientific evidence available for their performance and interpretation.
Causes of dysphagia can be divided into broadly oropharyngeal and esophageal causes. In oropharyngeal dysphagia patients have difficulty initiating a swallow, and they usually identify the cervical area as the area presenting a problem. Causes are mainly neurological causes like cerebrovascular accidents, Parkinson's disease, and rarely structural causes such as tumors, post cricoid webs. 
Esophageal dysphagia is due to difficulty in propagating food down the esophagus. It could be either due to a mechanical or a motility disturbance. Causes can be neuromuscular (motility) disorders like achalasia, diffuse esophageal spasm or mechanical causes like stricture, carcinoma esophagus, esophageal webs. ,
Hence investigation and diagnosis of the cause of dysphagia is vital. The modality should be effective and accurate in diagnosing the cause of Dysphagia-motility disorder, structural or functional, as well as to indicate the anatomical location, and to assess the exact if not, the possible etiology and pathology involved. It should help in rightly guiding us to the final diagnosis. The patient comfort and cost effectiveness of the procedure also matter.
The videofluoroscopy and upper GI endoscopy are the two most commonly used primary investigating modalities in patients with dysphagia. Literatures suggest that both are effective and commonly used investigating modalities, but there is a huge debate over the preference by the doctors of one procedure over the other.
The videofluoroscopy is known by several different names, such as the modified barium swallow (MBS), cookie swallow, or video pharyngogram. It involves the use of barium and fluoroscopy to assess the oral and pharyngeal phase of the swallow. The basic fluoroscopic unit required consists of a constant radiograph source, a radiograph detector, a monitor and recording system. The fluoroscopic images allow for the motion-picture radiograph of the dynamic swallow function and can be recorded for the availability of further review and analysis.  Videofluoroscopy gives a dynamic view of the swallowing mechanism, as well helps in identifying the location of the abnormality.
Advantages of videofluoroscopy are:
- All stages of the swallowing mechanism are seen.
- Estimates of volume, depth and clearance of aspiration can be made.
- Anatomical abnormalities can be detected (pouches, diverticulae, fistulae).
- Biofeedback to patients.
More cost effective when compared to upper GI endoscopy.
In a tertiary care hospital,there is a full-fledged radiology unit generally,who can do this procedure immediately without the patient having to wait for an appointment and immediate results are obtained.
- Radiation exposure to the patient.
- Properties of barium are designed to coat structures, so liquid and food containing barium does not behave in the same way as normal liquids or food.
- Limited or inferred information only is gained about mucosa and secretions, sensation, inter-bolus pressure, and details of glottic closure.
- Greater standardization of the procedure, with higher interjudge reliability between experienced clinicians, is required before it is truly a "gold standard" technique.
Endoscopy uses a fiber optic endoscope passed through the mouth into the stomach, with detailed visualization of the upper gastrointestinal tract. The examination requires a flexible endoscope with a halogen or xenon light source. The endoscopist can visualize the image directly through the eyepiece or by using a chip camera attached to the laryngoscope. When using a chip camera, the image can then be viewed on a monitor and recorded for further analysis. It also provides the provision for simultaneous biopsy.  While indirect imaging with barium swallow may suggest specific mucosal-based disease, definitive diagnosis and hence, directed therapy, comes only with direct endoscopic evaluation. This enables accurate visualization of abnormalities allowing options for biopsy for histological examination, and therapeutic intervention.
Advantages of upper GI endoscopy are:
- Provides direct view of anatomy to evaluate laryngeal and pharyngeal structures and pathology if present.
- Biopsy can be taken.
- No radiation exposure.
- In cases of lesion in certain areas of hypopharynx, where videofluoroscopy is negative, upper GI endoscopy can visualize the pathology.
- Costly when compared to videofluoroscopy.
- Invasive procedure.
- In obstructive conditions, where scope cannot me maneuvered beyond it, it is ineffective in diagnosing the exact pathology.
- Uncomfortable to the patient.
- Usually done by a medical gastroenterologist and the patient require a prior appointment and the procedure is subjected to the availability of the endoscopist.
To treat dysphagia, the doctor first needs to correctly identify the specific biomechanical aspects of the swallowing function through the appropriate use and interpretation of a diagnostic procedure to assess the type, cause and site involved. There is a great dilemma as to which should be the primary investigating modality to confirm the diagnosis among videofluoroscopy and upper GI endoscopy during initial presentation. ,,,,,
The aim of this study is to compare these two diagnostic tools and try to establish which is a better primary diagnostic tool in a patient coming to the OPD with complaints of dysphagia, upper GI endoscopy or videofluoroscopy?
| Materials and Methods|| |
A prospective, cross sectional study was conducted on 20 patients with complaints of dysphagia presenting to our tertiary care hospital for a period of one year from September 2012 to September 2013.
Inclusion criteria for the study was:
- Patients who present with dysphagia to the out-patient department (OPD).
Exclusion criteria were:
- Patient who are allergic to contrast material and patients with clinical evidence of aspiration are a contraindication for fluoroscopy.
- Patients with any recent episode of hematemesis or history of bleeding diathesis are a contraindication for upper GI endoscopy.
- Patients with obvious pharyngral pathology on otolaryngology evaluation.
Patients were clinically evaluated by detailed history and clinical examination.
Patients were then sent for videofluoroscopy.
The patients were explained regarding the procedure. The unit used was Allegro 500 MA.
In the supine position, patients were given 10ml of barium sulphate mixture (Baritop G 150% w/v 100 ml) mixed in water, for initial assessment of the upper aero digestive tract and to rule out any signs of aspiration. This was followed by a mouthful of barium (approx. 25 ml) and the patients were asked to hold the barium in the mouth till the fluoroscopic unit is ready for exposure. Continuous screening of the oropharynx, proximal and distal esophagus and gastroesophageal junction was done for free flow of the barium. Both single contrast and mucosal relief contrast films were taken and any pathology noted was documented.
Following the videofluoroscopy, the patients were asked to undergo upper GI endoscopy. The patients were kept NPO (Nil per os) that is, told not to eat, for at least 4 hours before the procedure. It was done under topical anesthesia. The procedure and the risks involved were explained to the patients and informed consent was obtained before the procedure .The patient lied on his/her left side with the head resting comfortably on a pillow. A mouth-guard was placed between the teeth to prevent the patient from biting on the endoscope. The endoscope used was Pentax EG-2990i Videogastroscope. The endoscope was then passed over the tongue and into the oropharynx. Quick and gentle manipulation under vision guides the endoscope into the esophagus. The endoscope was gradually advanced down the esophagus making note of any pathology. If required,biopsy was taken simultaneously with a pincer (biopsy forceps) which was passed through the scope and allows sampling of 1-3 mm pieces of tissue under direct vision.
The results of both the tests were tabulated on basis of whether the test was successful in accurately diagnosing the cause of dysphagia or not. Further investigations when necessary, where done to arrive at the final diagnosis. This was used to compare how either of the primary diagnostic tests done could diagnose the condition. Statistical test used was Mcnemar Chi Square test.
| Results|| |
Male to female ratio in our study was 3:2 [12 males (60%), eightfemales (40%)]. Age distribution of the patients ranged from 41-85 years.
Various causes of dysphagia were diagnosed among the 20 patients. Twelve patients had positive cause for dysphagia. Videofluoroscopy was diagnostic in ten of these patients (83.34%). Upper GI endoscopy was diagnostic in five patients (41%). Eight cases had no positive findings on videofluoroscopy or upper GI endoscopy [Table 1].
Among the diagnosed cases, five were malignant lesions (25%), two cases each of achalasia cardia and post cricoid web (Plummer Vinson syndrome, 10%), and one case each of stricture esophagus, diffuse esophageal spasm and Zenkers diverticulum (5%).
Videofluoroscopy showed a sensitivity of 60% and specificity of 53.3% on comparing with upper GI endoscopy. Positive predictive value (PPV) was 30% and negative predictive value (NPV) was 80% for videofluoroscopy [Table 2].
Chi square test showed a P value of 0.606 which suggests no significant difference between the two tests.
The lack of significance indicates that the two techniques are good enough to detect the condition satisfactorily. Keeping the endoscopy as the gold standard VFS shows a sensitivity of 60% and negative predictive value of 80%.
| Discussion|| |
Dysphagia is an important and interesting part of otolaryngology practice, and can sometimes be the indicator of a serious pathology inside.
In our study of 20 patients, ten cases were diagnosed effectively by a videofluoroscopy (50%). Upper GI endoscopy could diagnose five cases (25%). Eight cases had no abnormality both on videofluoroscopy or upper GI endoscopy. Two cases (malignancy hypopharynx) which showed a normal barium swallow were diagnosed by upper GI endoscopy [Figure 1]. Two cases of malignancy upper esophagus and one case of benign stricture of middle third of esophgus could be diagnosed by both upper GI endoscopy and videofluoroscopy.
|Figure 1: Upper GI endoscopy showing smooth swelling in the post cricoid region. Videofluoroscopy was normal in this patient. Rigid endoscopy with biopsy was done to confirm diagnosis of malignancy|
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Onecase of malignancyupper esophagus and two cases of post cricoid web [Figure 2] were diagnosed by videofluoroscopy, whereas upper GI endoscopy could see only a stricture beyond which it was not possible to pass the endoscope. One case of diffuse esophageal spasm could be diagnosed by videofluoroscopy where as endoscopy was normal. One case of Zenker's diverticulum was diagnosed by videofluoroscopy, where as upper GI endoscopy showed only a narrowing beyond which scope could not be passed with hold up of little food material. Two cases of achalasia cardia were diagnosed by videofluoroscopy, upper GI endoscopy could only say that there was dilatation of esophagus with narrow lumen at gastro-esophageal junction beyond which scope could not be passed.
|Figure 2: Videofluoroscopy showing shelf like filling defect in the cricopharyngeal junction with proximal hold up of barium, suggestive of post cricoid web|
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In a study, MG Rugiu  has mentioned the usefulness of videofluoroscopy in evaluating various conditions like globus pharyngeus, ageing, cerebrovascular accidents and other neurological conditions. He said that in comparison to videofluoroscopy, endoscopic evaluation has sensitivity range of 40-80% and specificity range of 59-91%. From a practical viewpoint, these data confirmed that if only the endoscopic examination is performed this may lead to an underestimation of the presence of swallowing disorders as well as the risk of inhalation, the latter, particularly when silent aspiration is present. Elliot JL  advocated for videofluoroscopy as the most useful modality for diagnosing swallowing disorders and determining appropriate interventions. He opined that, changes in dietary consistencies, changes in positioning, or by techniques to improve oral control and sensitivity to food in the mouth can improve swallowing. Bonnie Martin-Harris et al.,  reviewed a database containing a nonrandom sample of 608 swallowing studies. Results showed that only 10.4% of the studies were classified as normal examinations and aspiration occurred in 32.4%. However, swallowing abnormality without aspiration was recorded in 57.2% of the studies. The low percentage of normal studies coupled with the high percentage of change in measurable variables indicates high clinical utility for the videofluoroscopy study in diagnosing dysphagia. Jonathan E. Aviv  did a prospective study on 126 patients with dysphagia who were randomly assigned videofluoroscopy and endoscopic examination. The patients were assessed based on the outcomes. Seventy eight videofluoroscopy examinations were performed in 76 patients with 14 patients (18.4%) developing pneumonia; 61 endoscopic examinations were performed in 50 patients with 6 patients (12.0%) developing pneumonia. These differences were not statistically significant, showing that the outcomes of both studies were essentially same.
Some authors have opined that endoscopic examination is preferred in diagnosing dysphagia, (Wu Chih-Hsiu et al.,  Shyam Varadarajulu et al.,  Cornelius P. Dooley et al.  ).
Certain authors found no significant difference between modified barium swallow and endoscopy (Susan Brady, Joseph Donelli,  A. Al-Hussaini,  Robert W. Bastian,  Langmore S.E.  ) They have suggested that both investigations are valuable. It is likely that both will continue to be used and will be seen as complementary rather than competitors.
In our study we found that in comparison to upper GI endoscopy, videofluoroscopy was more effective in accurately diagnosing the cause for dysphagia. It was diagnostic in 83% of the cases. Also videofluoroscopy had a high NPV of 80%. This suggests that compared to upper GI endoscopy, videofluoroscopy is accurate in 80% of the cases. As a primary investigating modality, it was very effective in diagnosing majority of the functional and structural causes of dysphagia. Moreover endoscopy was not entirely confirmative and required further investigations to arrive at the final diagnosis.
| Conclusion|| |
Dysphagia is an increasingly common problem. This study shows that videofluoroscopy can accurately diagnose significant number of positive causes of dysphagia when compared to upper GI endoscopy. Videofluoroscopy has a high negative predictive value and can thus be used as a primary screening tool. Also videofluoroscopy was readily done with the availability of a radiology unit. It required no previous work up of the patient, also better tolerated by the patients and cost effective.
We would like to opine that videofluoroscopy should be the primary diagnostic tool for any patient presenting with dysphagia. However as the sample size is small, there is need for further study with a larger patient population.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]