The future of barium imaging

Barium sulphate has been used as a gastrointestinal (GI) contrast agent for over 100 years. Since the first report of single contrast barium radiography in 1910, barium techniques have evolved in parallel with technical developments such as fluoroscopic image intensification. Double contrast techniques were first described in the 1920s but did not become mainstream until the 1960s and 1970s when double contrast techniques were refined. This development facilitated high quality examination of bowel segments inaccessible to compression. Rectal tube insufflation for barium enema was followed by nasogastric tube insufflation for upper GI barium studies, eventually superceded by gastric insufflation using carbon dioxide producing oral preparations. Barium techniques to examine the GI tract extend all the way from the mouth to the anal canal. They are wellestablished and widely practised. However, barium imaging faces stiff competition from other technical innovations that have occurred over its long history. It has become evident that the indications for which barium imaging remains the investigation of choice have diminished considerably. Evidence of better diagnostic performance has seen several barium applications supplanted by emerging radiographic techniques. This to the dismay of “traditionalist” radiologists who appreciate and enjoy the skill required to produce high quality barium examinations, and because barium images often have an aesthetic quality independent of their subject matter or clinical utility. When endoscopy was limited to diagnosis only, the battle lines were fairly drawn but the pendulum started to swing irrevocably with the development of endoscopic techniques to biopsy and treat lesions. This article describes the current and predicted future role of barium imaging from top to bottom (pun intended) and discusses the alternative, competing investigations in each anatomical area.