The Horizontal Phase

1. The patient lies in right anterior oblique (RAO) position on horizontal x-ray table and holds a cup of "thin barium" with the left hand.  
   
   
2. Have patient drink barium through a straw. Watch several individual swallows from the hypopharynx to the GE junction. Look for abnormal motility as well as for anatomic lesions. 
   
   
3. Take one single contrast (SC) spot of the barium-distended lower esophagus and gastric cardia during breath-holding. Take one SC spot of the same region during breath-holding and Valsalva maneuver to demonstrate a possible sliding hiatal hernia.
   
   
4. After bariuim clears from the esophagus, either spontaneously or by giving the patient sips of water from a straw, evaluate for gastroesophageal reflux. While you observe with the fluoroscope, have the patient turn from the RAO position to the supine position. Then have the patient turn into the RPO position while you look for spontaneous reflux. Gastroesophageal reflux induced by provocative maneuvers, such as straight-leg raising, coughing, and sipping water while lying supine is not considered as significant as spontaneous reflux.