Reflux Seen on a Barium Swallow is Not a Substitute For Ambulatory Reflux Monitoring in Symptomatic Patients

Objective: Gastroesophageal reflux (GER) is often reported in barium studies (GERB). We aimed to evaluate whether GERB associates with parameters defining conclusive reflux using Lyon criteria on esophageal physiological testing (GERpH). Methods: Adults who underwent both ambulatory reflux monitoring off antisecretory therapy and barium esophagogram between 2018 and 2023 were eligible for inclusion in this retrospective study. All reflux monitoring studies were independently reviewed to extract acid exposure time (AET) and number of reflux episodes. GERpH was diagnosed based on Lyon consensus criteria, and compared with GERB reported on barium esophagogram. Performance characteristics of GERB in predicting AET >6% and GERpH by Lyon criteria were calculated. Results: Of 182 patients (median age: 55.0 y, 69.8% females, median body mass index: 29.8 kg/m²), 61 had GERB and 101 had GERpH, whereas 58 had neither GERB nor GERpH. AET >6% was seen in 39.3% with GERB, and never with GERB without GERpH. The sensitivity and specificity of GERB in predicting AET >6% were 31.6% and 65.1%; corresponding values in predicting conclusive gastroesophageal reflux disease were 37.6% and 71.6%, respectively. A hiatus hernia (HH) was seen in 46.8% with GERB and was associated with higher median AET (6.0% vs 3.8% without HH, P = 0.003) and higher frequency of AET >6% (50.6% vs 32.5%, P = 0.032), but not higher reflux episodes (P ≥ 0.51). Conclusions: In patients with symptoms suspicious of reflux disease, reflux seen on a barium esophagogram has suboptimal performance characteristics in predicting conclusive gastroesophageal reflux disease. HH identified on barium esophagography is associated with a higher reflux burden on reflux monitoring.