Technology & Innovation Are Fluoroscopic Exams Still Relevant? A Review in the Age of Endoscopy and Cross-Sectional Imaging April 08, 2026 - Sharla Lester

This is an AHRA Quick Credit article. The corresponding post-test in the AHRA Online Institute is coming soon.

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Abstract

Fluoroscopic examinations have declined over the last several decades. This review investigates the benefits and limitations of fluoroscopy and the procedures and modalities that have led to their decline. The literature suggests multiple limitations with fluoroscopy were identified, with few benefits. Furthermore, this review discusses fluoroscopic procedures in conjunction with other modalities, and what led to the decline in fluoroscopy examinations.

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Baduku, Ballard et al., and Shalom et al. observed fluoroscopic procedures, like barium swallows and barium enemas, have greatly decreased over the last several decades. The authors continued observing the advent of cross-sectional imaging and endoscopy contributed to the decline. Other modalities and procedures were more beneficial than some fluoroscopic procedures, as they provided more detail and no radiation exposure to the patient; however, relevance still exists in other fluoroscopic examinations.^1-3

The purpose of this literature review is to discuss the relevance of fluoroscopic examinations, the alternative modalities for exploration in conjunction with fluoroscopic examinations, and future research that may present other imaging such as modified barium swallows, urethrocystography, needle procedures, tube placement, and infertility procedures. Collaborative research between other procedures and modalities would add value in fluoroscopic examinations.

Methods

Electronic databases included in Midwestern State University’s Moffett Library were searched to locate literature about fluoroscopy barium studies compared with cross-sectional imaging and other replacement procedures: CINAHL Complete, Medline Complete, and PubMed Electronic. Google Scholar search engine was also utilized.

Restrictions were placed on publication years from 2019 through 2026 of full-text, peer-reviewed articles. A keyword search was performed using the following terms:

• Fluoroscopy
• Cross-sectional imaging
• Endoscopy,
• Barium enemas
• Esophageal
• Small bowel

Multiple articles were reviewed and then narrowed down to 18 and grouped into various themes after being analyzed:

• A decrease in fluoroscopy.
• The benefits and limitations with fluoroscopy.
• Fluoroscopy in conjunction with other modalities.
• Modalities replacing fluoroscopic examinations.

Articles related to surgery were dismissed, as the topic is primarily related to barium procedures and other examinations that may be replacing them. Additionally, articles older than five years were omitted to ensure recent research was reviewed.

Decrease in Fluoroscopy

With the development in the endoscope in the early 1960s, a large decline in gastrointestinal (GI) procedures in fluoroscopy followed.¹ Fluoroscopy contributed to long-term health risks, adding cumulative radiation exposure to patients.⁴ The availability in computed tomography (CT), magnetic resonance (MR), and ultrasonic imaging further played a role in the decline with fluoroscopy, as these studies allowed better visualization of normal and abnormal anatomy.^1-3 Insurance reimbursement had been a factor as well. Fluoroscopy reimbursements were increasingly lower than other newer technologies.^1-3

Fluoroscopic examinations have decreased in the United States. For example, Ballard et al.² reported that double-contrast, barium enemas decreased by 95%; single-contrast, barium enemas decreased by 89%; double-contrast, upper GI examinations decreased by 77%; and single-contrast, upper GI examinations decreased by 65%.

Researchers identified various reasons for these decreases.^1-3 One example was the increasing availability of endoscopy.¹ Endoscopy quickly replaced contrast fluoroscopic examinations because it did not use ionizing radiation, which presented risks for patients.^1-2 Baduku¹ found within the last 50 years, fiberoptic endoscopy’s use grew rapidly, reducing the traditional contrast examinations in evaluation of disorders in the upper GI tract.

Baduku¹ continued to state the primary diagnostic modality continued being endoscopy, making endoscopy an initial upper GI tract procedure. The author found endoscopy allowed direct visualization in the pharynx and esophagus’s mucosa and the sensitivity in evaluating small mucosa lesions over fluoroscopy. Baduku¹ further indicated esophageal manometry further contributed to the decrease in contrast imaging.

In cases with regurgitation, manometry assesses the esophageal pressure.¹ Gastroenterologists have continued advocating endoscopies over contrast fluoroscopy.¹ The evaluation in non-neoplastic conditions, such as inflammatory bowel disease, was also diagnosed with endoscopy, in part, due to lack of radiation.⁵

With the increase in endoscopic examinations, residents also experienced fewer fluoroscopic examinations.⁶ According to Shalom et al.,³ not enough emphasis had been placed on the importance in fluoroscopy procedures in radiology resident programs, which resulted in the lack of knowledge. Faculty and fellow reading assignments of imaging examinations frequently included abdominal imaging, ultrasound, and CT, with few assignments in GI fluoroscopy. Shalom et al.³ reported only several weeks during the first-year residency were dedicated to fluoroscopy training, resulting in insufficiently trained residents who subsequently trained the next group of residents inadequately.

Shalom et al.³ continued to report that these insufficiently trained residents became responsible for the increased radiation dose patients received from longer fluoroscopy times. Baduku¹ and Galgano et al.⁶ also found radiology residents experienced less fluoroscopy from the decreased examinations; therefore, residents reported unfamiliarity with the relevant findings visualized during these examinations. Ballard et al.² further disclosed that interpretive skills suffered as fewer studies were being performed with newer technologies available. Based on the relative value unit (RVU), CT and MRI had higher insurance reimbursement rates than fluoroscopic examinations.³

In some parts of the world, some less experienced radiologists lacked interest and skill in performing fluoroscopy studies; they perceived contrast studies as dirty, laborious, more taxing, and requiring special skills.¹ Some radiology departments no longer performed contrast studies in fluoroscopy but performed them on inpatient floors such as gastrografin challenge studies in evaluating small bowel obstruction and therapeutic contrast enemas in patients suffering from constipation.²

Fluoroscopic imaging continued to be inferior compared to cross-sectional imaging. Cross-sectional imaging from CT and MRI was increasingly used in GI tract imaging in the past 45 years.^1-2 CT and MRI had the capability in detecting diseases outside the tubular GI tract compared with fluoroscopy examinations.¹

Limitations in Fluoroscopy

While low-dose fluoroscopic equipment makes fluoroscopy procedures attractive, there are several limitations noted in the literature for the primary use of fluoroscopy in imaging; beyond this advancement, there is little current literature regarding advancements in the equipment. For example, fluoroscopy’s limitation remained in ionizing radiation compared with some modalities.^1,3-4,7

Hamdoun et al.⁴ found when comparing barium follow-through (BFT) with magnetic resonance enterography (MRE), BFT utilized ionizing radiation, whereas MRE employed MRI technology, which offered better soft tissue contrast in multiple planes without radiation. With BFT’s long-term health risks from cumulative radiation exposure in the pediatric and reproductive age groups, MREs remained the preferred study in the radiation-sensitive population.⁴

According to Baduku,¹ endoscopy was the initial screening tool in evaluating upper GI tract disorders since endoscopy did not require ionizing radiation, like contrast fluoroscopy required. Shalom et al.³ further noted radiation dose parameters and examination times must remain within safety limits.

Fluoroscopy examinations required patient compliance.^3,8 Biscaldi et al. asserted that a patient must be on a low-residue diet at least one day and follow drug administration in emptying the colon before barium administration for a double-contrast barium enema (DCBE). ⁷ Some procedures, such as barium swallows and upper GI exams, required fasting before ingesting barium (Hamdoun et al., 2024).⁴

Ingesting barium and changing positions during the procedure had been challenging in some patients.^3-4,8 Some inpatients had difficulty changing positions and required ancillary staff to monitor their equipment.³ Complication risks in the acutely unwell patient included aspiration risk with pulmonary edema, as well as the patient’s swallowing reflex being compromised in those without appropriate consciousness levels.⁸

Using barium sulfate posed more limitations.^4,7 Some patients had discomfort in ingesting barium because of the taste and texture. Consuming barium could cause constipation or barium impaction.⁴ Hamdoun et al. reported barium did not provide detailed images in the bowel wall during BFTs and had the potential in masking pathologies. ⁴ Barium failed to identify an esophageal perforation 10%–12% of the time during barium esophageal fluoroscopy.⁸ Baduku found fiber-optic endoscopy did not use contrast medium, thus reducing the risk in adverse patient contrast reaction. ¹  

Baduku established fluoroscopic examinations lacked sensitivity and specificity compared with endoscopy and cross-sectional imaging. Contrast fluoroscopy studies have been known to over-diagnose benign lesions, such as strictures. The evaluation in small mucosa lesions showed more specificity and sensitivity with endoscopy than with fluoroscopy. Diseases outside the GI tract demonstrated better with CT and MRI.¹

Computed tomographic colonography (CTC) accurately diagnosed colorectal neoplasia over fluoroscopy barium enemas. CTC demonstrated higher-quality evidence, with multiplanar images, in colorectal cancer and advanced polyps. Endoscopic and cross-sectional imaging techniques more accurately evaluated non-neoplastic conditions such as inflammatory bowel disease.⁵ Biscaldi et al.⁷ found double-contrast, barium enemas had low specificity and did not identify the reason in the mass effect.

Benefits in Fluoroscopy

Barium Esophageal Studies

Esophageal fluoroscopy studies demonstrated structural and functional anatomy in the esophagus.^2-4 Baduku and Shalom et al. stated the evaluation in esophageal motility visualized during esophageal fluoroscopy examinations could not be determined in endoscopy.^1,3  

The authors further stated an esophageal fluoroscopy study included visualization during the swallowing process and identifying the motility rate and normal esophageal indentations. Fluoroscopy in the esophagus identified esophageal intramural and submural masses and morphologic abnormalities, whereas endoscopy failed.^1,3 Fluoroscopy showed findings from submucosal and extrinsic mass lesions (i.e., diverticula and tumors) better than endoscopy.¹

Mechanical and functional esophageal abnormalities presented as dysphagia, regurgitation, chest pain, vomiting, choking episodes, and coughing when swallowing. Furthermore, dysmotility, such as achalasia, foreign bodies, Schatzki’s rings, and strictures showed up more with fluoroscopic esophageal contrast studies than with manometry.¹ Images under fluoroscopy better demonstrated dysphagia from achalasia, strictures, esophageal webs, Schatzki’s rings, and foreign bodies.³

Shalom et al. stated benefits in real-time imaging with contrast administration allowed patients to vary their position permitting different views and obtaining additional information as needed. For example, a radiologist missed an anterior fistulous communication during a CT scan with the patient supine but discovered it later with fluoroscopy and patient positioning.³

Water Soluble Esophageal Studies

Ballard et al. and Rumhumha et al. reported that the American College of Radiology (ACR) recommended fluoroscopic esophagography in the evaluation with suspected esophageal perforation under the ACR appropriateness criteria. ^2,8  Fluoroscopic esophagography had a high specificity and low sensitivity in diagnosing esophageal injury, with a false negative rate of less than 10%.⁸ Fluoroscopic examinations with water-soluble contrast provided invaluable information and showed leakage locations in post-operative patients of thoracic-esophageal surgery who were suspected of having an esophageal perforation.¹

Water-soluble oral contrast and radiographs helped locate perforations caused by ingestion of corrosive agents.³ The GI tract required a three-week wait after ingesting corrosive agents before barium contrast administration.⁹ Fluoroscopy barium swallows determined the length in strictures, short-segment versus long-segment, site, severity, stenosis, filling defects, and the number of strictures in the upper GI tract in subacute and chronic stages.^1,3,9

Modified Barium Swallow Study

Dysphagia was reported in an estimated 8% of the world’s population.^10,11 Martin-Harris et al. stated dysphagia represented a physiologic impairment which occurred along the spectrum of the swallowing from the mouth to the stomach. ¹¹ Fynes et al. and Martin-Harris et al.¹¹ agreed the elderly are at risk for dysphagia. ^10,11

Modified Barium Swallow Study (MBSS) is a diagnostic, real-time fluoroscopic examination study to assess functional anatomy and physiology of the oral pharyngeal swallowing mechanism.^11-13 The study is performed with the combined expertise of a speech language pathologist (SLP) and radiologist, and assisted by a radiologic technologist.^11,13

Under fluoroscopy, the identification and assessment of the type and severity of physiological swallowing impairments are noted.^10,12-13 The safety of the patient’s swallowing function is also observed.^10-11,13 Barium sulfate containing liquids and solid boluses are administered to assess swallowing physiology, airway protection, and efficiency. ¹¹

Martin-Harris et al. continued to state boluses of various consistencies and different volumes are administered under fluoroscopy, as different volumes and consistencies impact swallowing physiology and airway protection. ¹¹ When penetration or aspiration are observed, the SLP will test the effectiveness of therapeutic swallowing strategies to minimize or improve the amount of penetration or aspiration ^10-13 Compensatory strategies include chin tuck, turning or tilting the patient’s head, breath hold, or changing the volume/consistency of the swallowed liquids to enhance swallowing efficiency and or reduce risk.^10-11,13  

Bonilha et al. and Martin-Harris et al. stated MBSS in adults is considered a low dose radiation study and very low associated cancer risks. ^{11, 12} MBSS allowed for strategies to be evaluated that improve the swallowing function, safety, and quality of life in dysphagia patients.^10-11

Barium Contrast Enemas

Hirschsprung disease (HD) was diagnosed with a full-thickness rectal biopsy; however, fluoroscopic barium contrast enemas (BCE) diagnosed HD as well.^14-15 Anwar et al. reported risks with rectal biopsies, which included bleeding, perforation, sepsis, and anesthetic-related risks. Anwar et al. further reported BCE sensitivities as high as 80%–88% in excluding HD.¹⁴ Hailemariam et al. found the diagnostic accuracy in BCE compared with rectal biopsies accurate at 95%.¹⁵ Both Anwar et al. and Hailemariam et al. agreed with the high accuracy in the diagnosis in HD. ^{14, 15} BCE was confirmed as the primary diagnostic modality without a rectal biopsy. Anwar et al. suggested BCE be used routinely in diagnosing HD, thus reducing complications from a rectal biopsy. ¹⁴ Hailemariam et al. reported BCE diagnoses should inform surgical management in populations lacking pathology services.¹⁵

Biscaldi et al. stated DCBE aided in diagnosing bowel endometriosis and accurately estimated the size in the endometriotic nodules. Biscaldi et al. continued to state DCBE had a low specificity but had good sensitivity in bowel endometriosis diagnosis. DCBE, compared with MRI, showed better precision in estimating the largest diameter with the intestinal nodule.⁷

Biscaldi et al. and Guerriero et al. found retrograde distention during DCBE allowed a complete overview with the entire colon, making retrograde distention a primary advantage in DCBE. Both authors agreed DCBE also diagnosed endometriotic cecal lesions. Benefits included easy performance and cost effectiveness.^7,16 DCBE examinations had nearly 90% accuracy with a 97% positive predictive value in sensitivity and specificity.¹⁷

Fluoroscopy Studies in Conjunction With Other Modalities and Procedures

CT and fluoroscopy imaging demonstrated post-operative GI leaks.³ Extra-luminal gas, a sign in perforation, showed well on CT, whereas the leakage location demonstrated better under fluoroscopy.¹ Shalom et al. discovered a negative read on an initial CT with intravenous contrast showed discrepancies when a leak under fluoroscopy was discovered. The patient was placed in a steep oblique position and delayed imaging discovered contrast extravasation in the GI tract under fluoroscopy.³

Risks from gastric bypass included forming gastro-gastric (GG) fistulas. Diagnosis in GG fistulas on CT depended on oral contrast administration and the correct bolus timing; if the study was insufficient, fluoroscopy would be a quick and accurate alternative.³

In evaluating caustic ingestion, upper GI endoscopy assessed the severity in the acute phase.^3,9 CT and fluoroscopy demonstrated distinctive radiologic patterns as well, such as esophageal strictures, luminal narrowing, and stenosis.³

Kamat et al. identified using water-soluble oral contrast during fluoroscopy detected perforations within the GI tract. Kamat et al. continued to identify that in corrosive injuries, CT scanning had several advantages: CT was noninvasive, cost-effective, and measured the length of involvement with the structured sections in the esophagus and stomach. ⁹  

Kamat et al. also found CT had a sensitivity at 96% and specificity at 57% in detecting esophageal damage. CT measured the maximum esophageal wall thickness, which helped predict the patient’s response in endoscopic dilation.⁹

Anwar et al. and Hailemariam et al. agreed that barium contrast enemas (BCE) adequately diagnosed HD along with full-thickness rectal biopsy. ^{14, 15} Hailemariam et al. found in settings where confirmatory biopsies lacked, BCE would be acceptable in diagnosis in surgical management. ¹⁵ Anwar et al. found the accuracy to be high with BCE in diagnosing HD and should be used in remote settings ruling out HD. BCE would decrease morbidity and mortality, leading in early and prompt intervention.¹⁴

Better Alternatives Compared to Fluoroscopy

Baduku and Ballard et al. deduced endoscopy, esophageal manometry, and PH monitoring led to the decline in esophageal fluoroscopy examinations. ^{1, 2} Baduku found endoscopy diagnosed luminal abnormalities within the esophageal tract and provided direct visualization with the mucosa in the pharynx and the esophagus. Baduku continued to state endoscopy was noted as more sensitive and specific in detecting small mucosal lesions over contrast esophageal studies. Manometry assessed esophageal pressure in cases with regurgitation.¹

MRI provided better spatial resolution and tissue contrast with multiplanar imaging than barium follow-through studies in diagnosing GI disorders. MRE accurately demonstrated small tumors and inflammatory bowel disease.^4,18 MRE further showed luminal and extraluminal intestinal structures and functional capabilities in the bowel. MRE evaluated mucosal inflammation, ulceration, and inflammatory bowel disease. MRE’s superior soft tissue contrast, lack in radiation, and detailed visualization within the bowel wall made MRE the preferred study.⁴

Computed tomography enterography (CTE) further demonstrated mural, extraluminal, and extraintestinal Crohn’s disease better than barium follow-through studies. MRE was the preferred study in evaluating inflammatory conditions and assessing vascularity and fibrosis.⁴

Computed tomography colonoscopy (CTC) became the preferred method over barium enema examinations in investigating the entire bowel.^5,7 Spada et al. recommended CTC in colorectal cancer screening, evaluation in colorectal neoplasia, cases with positive fecal occult blood test, colonoscopy contraindications in surveillance in colorectal cancer resections, and patients with high-risk polyps after polypectomy.⁵ Biscaldi et al. found CTC studies performed well in diagnosing rectosigmoid endometriosis. CTC estimated the degree in intestinal stenosis and the distance between intestinal endometriotic nodules and the anal verge. Double-contrast barium enemas provided a complete overview of the entire colon and detected cecal nodules.⁷

Conclusion

A marked decline in fluoroscopic imaging had occurred with the advent in fiberoptic endoscopy and cross-sectional imaging. The decline had further affected the training of radiology residents, making them uncertain about performing examinations and diagnoses, passing their uncertainty onto the newer residents. Future residents should focus on the upper GI tract as those studies had not been completely taken over by endoscopy and cross-sectional imaging.

In some instances, fluoroscopy offers some benefits along with other imaging modalities and procedures. In evaluation of the esophagus post-caustic ingestion and post-operative patients, fluoroscopic esophagography and CT imaging are best used together. In discovering Hirschsprung's disease, barium contrast enemas along with rectal biopsy have high diagnostic accuracy.

Future considerations would include other imaging performed with fluoroscopy, such as urethrocystography, needle procedures, tube placement, and infertility procedures. Additional collaborative research with other procedures and modalities, such as interventional radiology, would add value in fluoroscopy examinations.

From a management standpoint, workflow should be reexamined to determine if changes in full-time employees (FTEs) are needed based on the numbers of fluoroscopic examinations per quarter (or other metric, depending on the type of institution).

References

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