Timed Barium Esophagography in Esophagogastric Junction Outflow Obstruction: A Retrospective Radiologic Assessment

Introduction: Esophagogastric junction outflow obstruction (EGJOO) is a heterogeneous manometric pattern requiring symptoms and supportive evidence to establish clinical relevance. Timed barium esophagography (TBE) provides functional radiologic assessment of esophageal emptying through timed imaging, quantitative barium column measurements, and morphologic evaluation. Methods: This single-center retrospective study included 42 patients referred for TBE for suspected EGJOO between June 2024 and December 2025. TBE was performed upright after ingestion of low-density barium suspension. Positivity required a continuous residual esophageal barium column with craniocaudal height ≥ 2 mm at 1′ after bolus ingestion. Minimal mucosal coating, non-columnar traces, and contrast confined to a hiatal hernia were recorded qualitatively but not considered positive. Quantitative measurements, clearance patterns, morphology, interobserver reliability, and exploratory concordance with Chicago Classification v4.0-adjudicated categories were assessed. Results: TBE was positive in 12/42 patients (28.6%). Mean age was 58.0 ± 13.9 years; 26/42 patients were female. In positive studies, mean column height and width were 122.9 ± 65.4 mm and 31.1 ± 17.8 mm at 1 min, and 89.0 ± 54.6 mm and 28.2 ± 18.2 mm at 2 min. Persistent 5 min retention occurred in two patients. Interobserver reliability was excellent (ICC 0.90). Morphologic abnormalities were frequent in positive examinations, supporting overall radiologic phenotype-based interpretation. In the EGJOO-focused subset, exploratory concordance metrics were 41.7%, 100%, 100%, and 46.2% for sensitivity-like, specificity-like, positive predictive, and negative predictive concordance, respectively. Conclusions: In this small exploratory cohort, standardized TBE provided functional and morphologic information on esophageal bolus transit. Positive TBE findings showed exploratory concordance with clinically relevant EGJOO, whereas a negative study did not exclude it. These findings require validation in larger prospective cohorts.