Gastrointestinal Imaging

What Imaging Is Best for Epigastric Pain with Suspected Reflux, Gastritis, or Ulcer?

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What Imaging Is Best for Epigastric Pain with Suspected Reflux, Gastritis, or Ulcer?

A 48-year-old patient presents to your clinic with a three-month history of burning epigastric pain, worse after meals and when lying down at night. An empiric trial of a proton pump inhibitor (PPI) has provided only partial relief. You are considering gastroesophageal reflux disease (GERD), gastritis, or perhaps peptic ulcer disease (PUD), but you want to rule out an anatomic or significant mucosal abnormality before committing to long-term medical management or endoscopy. What is the most appropriate initial imaging study to order in this common clinical scenario? This article provides a step-by-step workflow based on the American College of Radiology (ACR) Appropriateness Criteria, which rates a Fluoroscopy biphasic esophagram as Usually Appropriate for this presentation.

Who Fits This Clinical Scenario?

This guidance applies to adult patients presenting with epigastric pain where the leading clinical suspicion is an inflammatory or ulcerative condition of the upper gastrointestinal (GI) tract. The classic symptom profile includes dyspepsia, heartburn, regurgitation, or a gnawing/burning pain localized to the epigastrium. These are patients for whom you are considering diagnoses like GERD, esophagitis, gastritis, or peptic/duodenal ulcers as the primary cause.

This workflow is intended for the initial imaging workup in patients without alarm features. It is crucial to distinguish this scenario from others that require a different diagnostic pathway. This guidance does not apply if:

  • Alarm features suggesting malignancy are present. Patients with significant unintentional weight loss, dysphagia (difficulty swallowing), odynophagia (painful swallowing), iron deficiency anemia, or hematemesis warrant a different workup, often proceeding directly to endoscopy. The ACR addresses this in a separate variant for suspected gastric cancer.
  • A large, symptomatic hiatal hernia is the primary suspicion. While an esophagram is excellent for identifying hiatal hernias, the clinical question and subsequent management may differ if this is the leading diagnosis from the outset.
  • The pain suggests a biliary or pancreatic source. Pain that is primarily in the right upper quadrant, radiates to the back, or is associated with jaundice would point toward a different set of differential diagnoses and imaging choices.

What Diagnoses Are You Working Up in This Scenario?

When ordering imaging for this presentation, you are primarily evaluating the structure and mucosal integrity of the esophagus, stomach, and duodenum. The goal is to identify or rule out several key conditions that produce overlapping symptoms.

Gastroesophageal Reflux Disease (GERD) and Reflux Esophagitis
This is often the most common cause of the patient’s symptoms. While GERD is a clinical diagnosis based on symptoms, imaging can identify its complications. A biphasic esophagram is highly effective at demonstrating spontaneous reflux of barium from the stomach into the esophagus. It can also reveal signs of chronic reflux-induced injury (esophagitis), such as mucosal irregularity, thickened folds, erosions, or the development of strictures.

Gastritis and Duodenitis
Inflammation of the lining of the stomach (gastritis) or duodenum (duodenitis) is another primary consideration. These conditions can be caused by H. pylori infection, NSAID use, or other irritants. Fluoroscopic studies can reveal indirect signs like thickened, irregular mucosal folds or erosions, providing evidence to support the diagnosis and guide further testing and treatment.

Peptic Ulcer Disease (PUD)
A critical diagnosis to identify is an ulcer in the stomach (gastric ulcer) or duodenum (duodenal ulcer). A biphasic, or double-contrast, study is particularly sensitive for detecting ulcers, which appear as a collection of barium in a mucosal crater, often with surrounding folds radiating toward it. Identifying an ulcer is a key finding that immediately directs management toward acid suppression and H. pylori eradication.

Why Is a Fluoroscopy Biphasic Esophagram the Recommended Study?

The ACR rates both Fluoroscopy biphasic esophagram and Fluoroscopy upper GI series as Usually Appropriate for this clinical scenario. The biphasic esophagram is often the starting point, focusing on esophageal motility and reflux, while the upper GI series extends the examination to include the stomach and duodenum. In practice, they are often performed together as a comprehensive upper GI study.

The rationale for this recommendation is based on the study’s high utility for evaluating the mucosal surface. The “biphasic” or “double-contrast” technique involves having the patient swallow a high-density barium suspension followed by an effervescent agent. This combination coats the mucosal lining with a thin layer of barium while the gas distends the lumen, providing a detailed, almost three-dimensional view of the mucosal relief. This is ideal for detecting subtle abnormalities like shallow ulcers, erosions, and inflammatory changes that define the differential diagnosis.

Let’s compare this to other modalities:

  • CT Abdomen and Pelvis with IV Contrast is rated as May be appropriate. While CT is excellent for evaluating the bowel wall, surrounding organs, and vasculature, it has lower sensitivity for superficial mucosal disease. It may detect a deeply penetrating ulcer or severe gastritis with significant wall thickening, but it will likely miss mild-to-moderate esophagitis or small ulcers. CT is a better choice if you suspect a complication like a perforation or abscess, but not for the initial evaluation of uncomplicated mucosal disease.
  • MRI Abdomen is rated Usually not appropriate. MRI offers no significant advantage over fluoroscopy for evaluating the mucosal lining of the upper GI tract and is more costly and less available. Its strength lies in soft tissue characterization of solid organs, which is not the primary clinical question here.

From a safety perspective, both the biphasic esophagram and upper GI series involve a moderate radiation dose (ACR Relative Radiation Level ☢☢☢, corresponding to 1-10 mSv). This is a key consideration, especially in younger patients, but is generally considered acceptable given the diagnostic value of the study.

What’s Next After a Fluoroscopy Biphasic Esophagram? Downstream Workflow

The results of the fluoroscopic study will guide your next steps, creating a clear decision tree for patient management.

If the study is positive for a definitive finding:

  • Ulcer Identified: If a gastric or duodenal ulcer is found, the next step is medical management. This typically includes initiating high-dose PPI therapy and testing for and treating H. pylori infection. For gastric ulcers, follow-up imaging or endoscopy is often recommended after a course of treatment to ensure healing and to rule out an underlying malignancy, which can masquerade as a benign ulcer.
  • Severe Esophagitis or Stricture: Findings of significant inflammation, deep erosions, or esophageal narrowing (stricture) are strong indications for referral to a gastroenterologist for esophagogastroduodenoscopy (EGD). EGD allows for direct visualization, biopsy to assess for Barrett’s esophagus or dysplasia, and potential therapeutic intervention like dilation of a stricture.

If the study is negative or non-specific:
A negative or normal esophagram/upper GI series does not completely rule out mucosal disease, as endoscopy is more sensitive for subtle inflammation. If the patient’s symptoms persist despite the negative imaging and ongoing empiric medical therapy, the next logical step is referral for EGD. The imaging study has successfully ruled out major structural abnormalities like a large ulcer or complex stricture, refining the differential and justifying the more invasive endoscopic evaluation.

Pitfalls to Avoid (and When to Get Help)

Navigating the workup for epigastric pain requires careful attention to the clinical context to avoid common missteps.

  • Ignoring Alarm Features: The most critical pitfall is applying this workflow to a patient with alarm symptoms (e.g., weight loss, dysphagia, anemia). These patients may require direct referral for endoscopy as the first-line investigation to rule out malignancy.
  • Over-relying on a Negative Study: Do not interpret a normal barium study as definitive proof of no pathology. Mild gastritis or esophagitis can be below the threshold of detection for fluoroscopy. Persistent symptoms warrant further investigation, usually with EGD.
  • Forgetting Patient Contraindications: Barium studies are contraindicated in patients with suspected bowel perforation. If there is any clinical concern for a perforation, a water-soluble contrast agent (e.g., Gastrografin) should be used instead.

If the clinical picture is confusing, the imaging results are equivocal, or the patient fails to respond to initial therapy, consultation with a gastroenterologist is the appropriate next step.

Related ACR Topics and Tools

For a comprehensive overview of imaging for all types of epigastric pain, refer to our parent guide. For specific questions about imaging techniques or radiation safety, the following GigHz resources can provide detailed information and support clinical decision-making.

Frequently Asked Questions

Why not just order an endoscopy (EGD) for every patient with these symptoms?

While endoscopy is the gold standard for visualizing the upper GI mucosa, it is more invasive, requires sedation, and is more costly than a fluoroscopic study. For patients without alarm features, an esophagram or upper GI series is a less invasive first step that can effectively diagnose significant structural issues like large ulcers, strictures, or motility disorders, potentially avoiding the need for EGD in some cases.

What is the difference between a biphasic esophagram and an upper GI series?

A biphasic esophagram focuses primarily on the esophagus, using both thick barium and effervescent crystals (double-contrast) to evaluate mucosal detail and motility. An upper GI series extends this evaluation to include the stomach and the first part of the small intestine (duodenum). In many practices, they are combined into a single comprehensive examination when the clinical question involves potential pathology in any of these areas.

Is a CT scan ever the right first choice for this type of epigastric pain?

A CT scan is generally not the first choice for suspected uncomplicated mucosal disease like gastritis or a small ulcer because it is less sensitive for these findings. However, if the clinical suspicion shifts toward a complication—such as a perforated ulcer, abscess, pancreatitis, or bowel obstruction—then a CT scan with intravenous contrast becomes the preferred initial imaging modality.

How should I prepare my patient for a fluoroscopy biphasic esophagram?

Patients are typically instructed to have nothing to eat or drink (NPO) for about 6 to 8 hours before the procedure. This ensures the stomach is empty, allowing for optimal mucosal coating and visualization. Patients should also inform the radiology team of any allergies or if they might be pregnant.

If the esophagram shows a hiatal hernia, does that explain the patient’s reflux symptoms?

Often, yes. A hiatal hernia, where part of the stomach protrudes into the chest through the diaphragm, can impair the function of the lower esophageal sphincter and is a major contributor to GERD. Identifying a hiatal hernia on an esophagram provides a clear anatomic explanation for the patient’s reflux symptoms and helps guide management, which typically focuses on aggressive acid suppression.

Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 29, 2026