Barium Swallow: MedlinePlus Medical Test

What is a barium swallow?

A barium swallow, also called an esophagogram, is an imaging test that checks for problems in your upper GI tract. Your upper GI tract includes your mouth, back of the throat, esophagus, stomach, and first part of your small intestine. The test uses a special type of x-ray called fluoroscopy. Fluoroscopy shows internal organs moving in real time. The test also involves drinking a chalky-tasting liquid that contains barium. Barium is a substance that makes parts of your body show up more clearly on an x-ray.

Other names: esophagogram, esophagram, upper GI series, swallowing study

What is it used for?

A barium swallow is used to help diagnose conditions that affect the throat, esophagus, stomach, and first part the small intestine. These include:

• Ulcers
• Hiatal hernia, a condition in which part of your stomach pushes into the diaphragm. The diaphragm is the muscle between your stomach and chest.
• GERD (gastroesophageal reflux disease), a condition in which contents of the stomach leak backward into the esophagus
• Structural problems in the GI tract, such as polyps (abnormal growths) and diverticula (pouches in the intestinal wall)
• Tumors

Why do I need a barium swallow?

You may need this test if you have symptoms of an upper GI disorder. These include:

• Trouble swallowing
• Abdominal pain
• Vomiting
• Bloating

What happens during a barium swallow?

A barium swallow is most often done by a radiologist or radiology technician. A radiologist is a doctor who specializes in using imaging tests to diagnose and treat diseases and injuries.

A barium swallow usually includes the following steps:

• You may need to remove your clothing. If so, you will be given a hospital gown.
• You will be given a lead shield or apron to wear over your pelvic area. This protects the area from unnecessary radiation.
• You will stand, sit, or lie down on an x-ray table. You may be asked to change positions during the test.
• You will swallow a drink that contains barium. The drink is thick and chalky. It’s usually flavored with chocolate or strawberry to make it easier to swallow.
• While you swallow, the radiologist will watch images of the barium traveling down your throat to your upper GI tract.
• You may be asked to hold your breath at certain times.
• The images will be recorded so they can be reviewed at a later time.

Will I need to do anything to prepare for the test?

You will probably be asked to fast (not eat or drink) after midnight on the night before the test.

Are there any risks to the test?

You should not have this test if you are pregnant or think you may be pregnant. Radiation can be harmful to an unborn baby.

For others, there is little risk to having this test. The dose of radiation is very low and not considered harmful for most people. But talk to your provider about all the x-rays you’ve had in the past. The risks from radiation exposure may be linked to the number of x-ray treatments you’ve had over time.

What do the results mean?

A normal result means that no abnormalities in size, shape, and movement were found in your throat, esophagus, stomach, or first part of the small intestine.

If your results were not normal, it may mean you have one of the following conditions:

• Hiatal hernia
• Ulcers
• Tumors
• Polyps
• Diverticula, a condition in which small sacs form in the inner wall of the intestine
• Esophageal stricture, a narrowing of the esophagus that can make it hard to swallow

If you have questions about your results, talk to your health care provider.

Is there anything else I need to know about a barium swallow?

Your results may also show signs of esophageal cancer. If your provider thinks you may have this type of cancer, he or she may do a procedure called an esophagoscopy. During an esophagoscopy, a thin, flexible tube is inserted through the mouth or nose and down into the esophagus. The tube has a video camera so a provider can view the area. The tube may also have a tool attached that can be used to remove tissue samples for testing (biopsy).

References

1. ACR: American College of Radiology [Internet]. Reston (VA): American College of Radiology; What Is a Radiologist?; [cited 2020 Jun 26]; [about 4 screens]. Available from: https://www.acr.org/Practice-Management-Quality-Informatics/Practice-Toolkit/Patient-Resources/About-Radiology
2. Cancer.Net [Internet]. Alexandria (VA): American Society of Clinical Oncology; 2005–2020. Esophageal Cancer: Diagnosis; 2019 Oct [cited 2020 Jun 26]; [about 3 screens]. Available from: https://www.cancer.net/cancer-types/esophageal-cancer/diagnosis
3. Hinkle J, Cheever K. Brunner & Suddarth’s Handbook of Laboratory and Diagnostic Tests. 2nd Ed, Kindle. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins; c2014. Barium Swallow; p. 79.
4. Johns Hopkins Medicine [Internet]. Baltimore: The Johns Hopkins University; c2020. Health: Barium Swallow; [cited 2020 Jun 26]; [about 3 screens]. Available from: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/barium-swallow
5. RadiologyInfo.org [Internet]. Radiological Society of North America, Inc.; c2020. Esophageal Cancer; [cited 2020 Jun 26]; [about 3 screens]. Available from: https://www.radiologyinfo.org/en/info.cfm?pg=esophageal-cancer
6. RadiologyInfo.org [Internet]. Radiological Society of North America, Inc.; c2020. X-ray (Radiography) – Upper GI Tract; [cited 2020 Jun 26]; [about 3 screens]. Available from: https://www.radiologyinfo.org/en/info.cfm?pg=uppergi
7. UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2020. Gastroesophageal reflux disease: Overview; [updated 2020 Jun 26; cited 2020 Jun 26]; [about 2 screens]. Available from: https://ufhealth.org/gastroesophageal-reflux-disease
8. UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2020. Hiatal hernia: Overview; [updated 2020 Jun 26; cited 2020 Jun 26]; [about 2 screens]. Available from: https://ufhealth.org/hiatal-hernia
9. UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2020. Upper GI and small bowel series: Overview; [updated 2020 Jun 26; cited 2020 Jun 26]; [about 2 screens]. Available from: https://ufhealth.org/upper-gi-and-small-bowel-series
10. University of Rochester Medical Center [Internet]. Rochester (NY): University of Rochester Medical Center; c2020. Health Encyclopedia: Barium Swallow; [cited 2020 Jun 26]; [about 2 screens]. Available from: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=92&contentid=P07688
11. UW Health [Internet]. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2021. Swallowing Study; [cited 2021 Aug 29]; [about 3 screens]. Available from: https://patient.uwhealth. org/healthwise/article/abr2463
12. Very Well Health [Internet]. New York: About, Inc.; c2020. Barium Swallow and Small Bowel Follow Through; [updated 2020 Mar 11; cited 2020 Jun 26]; [about 3 screens]. Available from: https://www.verywellhealth.com/barium-x-rays-1742250

What to Expect, Side Effects, and Cost

Barium Swallow: What to Expect, Side Effects, and Cost

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Medically reviewed by Graham Rogers, M. D. — By Erica Cirino — Updated on April 22, 2017

What is a barium swallow?

A barium swallow is a special type of X-ray test that helps your doctor take a close look at the back of your mouth and throat, known as the pharynx, and the tube that extends from the back of the tongue down to the stomach, known as the esophagus.

Your doctor may ask you to do a barium swallow to help diagnose any conditions that make it difficult for you to swallow or if they suspect that you have a disorder of the upper gastrointestinal (GI) tract. Your upper GI tract includes:

• the esophagus
• the stomach
• the first part of the small intestine, called the duodenum

To do a barium swallow, you swallow a chalky white substance known as barium. It’s often mixed with water to make a thick drink that looks like a milkshake. When it’s swallowed, this liquid coats the inside of your upper GI.

Barium absorbs X-rays and looks white on X-ray film. This helps highlight these organs, as well as their inside linings and the motion of your swallowing, on the X-ray image. These images help your doctor diagnose any disorders of the GI tract.

Your doctor may order a barium swallow to help diagnose a possible structural or functional problem with your upper GI tract. Some common problems that a barium swallow may help diagnose include:

• hiatal hernia
• inflammation
• blockages
• muscle disorders that could lead to difficulty swallowing or spasms
• gastroesophageal reflux disease (GERD)
• ulcers
• both cancerous and noncancerous tumors

Sometimes a barium swallow is done as part of a series of X-rays that look at the whole upper GI tract. A continuous X-ray beam, called a fluoroscopy, is often used during a barium swallow to capture movement through your GI tract.

A common test that accompanies the barium swallow is the upper GI endoscopy, also known as an esophagogastroduodenoscopy, or EGD. Barium swallows are also often done as part of an upper GI and small bowel series of tests.

It’s important to follow the dietary guidelines your doctor gives you before your procedure. You are not supposed to eat or drink anything for six hours before your procedure. You may take small sips of water up until two hours before your procedure.

If you are getting additional tests done or have any existing medical conditions, the directions your doctor gives you may be slightly different. You should notify your doctor before your procedure if you have or have had any of the following conditions:

• an esophageal or bowel perforation
• bowel obstruction
• difficulty swallowing
• severe constipation

These conditions may disqualify you from doing a barium swallow, as they increase the risk of complications.

Your doctor will direct you to your local radiology facility for your barium swallow. A trained radiology technician will perform the procedure. From start to finish, a barium swallow takes about 30 minutes. You will get your results within several days of your procedure.

Once you’re at the radiology facility, you will be asked to remove your clothing and jewelry and secure your belongings in a locker. You’ll change into a medical gown provided by your doctor.

Your technician will position you on an X-ray table. They may ask you to move your body position as they take standard X-rays of your heart, lungs, and abdomen.

Then, your technician will give you a barium drink to swallow. They will take single X-rays, a series of X-rays, or a fluoroscopy to watch how the barium moves through your pharynx. You might have to hold your breath at certain times to prevent any movement from disrupting the X-ray images.

Next, the technician will give you a thinner barium drink to swallow. They will again take X-rays or a fluoroscopy to watch how the barium moves down the esophagus.

When all X-rays are complete, you can gather your things and leave. You can go back to your normal diet and daily activities after your barium swallow procedure unless your doctor advises otherwise.

Your doctor’s office will be in touch within a few days to go over the results of your test and to schedule any follow-ups that may be needed.

Here is an example of a normal barium swallow study, in which the barium (the dark liquid) is seen moving down the esophagus without any leakage or regurgitation (reflux):

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Photo: Anka Friedrich / commons.wikimedia.org

The barium you swallow is artificially flavored and sweetened. However, many people report that it tastes bitter or chalky.

If you have health insurance, a barium swallow may be fully or partially covered. If you don’t have insurance, the procedure may cost between $300 and $450. This covers the costs of your doctor’s time interpreting the X-rays as well as the cost of the technicians who perform the procedure.

If the barium is not completely expelled from your body after the procedure, it can sometimes cause constipation or fecal impaction. You should drink lots of fluids and eat high-fiber foods to help move the barium through your digestive tract and out of your body. If that doesn’t help, your doctor might give you a laxative to help move it through.

After your procedure, you might notice that your bowel movements are lighter in color. This happens because your body doesn’t absorb the barium. Your stool will return to its normal color once all the barium has been expelled.

Be sure to contact your doctor right away if:

• You have trouble having a bowel movement or can’t have a bowel movement.
• You have pain or bloating in your abdomen.
• You have stools that are smaller in diameter than usual.

Also, barium swallows involve exposure to radiation, like all X-ray procedures. The risks of complications related to radiation exposure accumulate over time and are linked to the number of X-ray exams and treatments a person receives in their life. It can be helpful to share a record of past radiation procedures with your doctor before your barium swallow.

Exposure to radiation during pregnancy can cause birth defects in unborn fetuses. Because of this, pregnant women should not undergo barium swallow procedures.

The barium swallow is a less invasive way to look at the upper GI tract than an endoscopy. Barium swallows are a useful diagnostic tool for checking for upper GI tract disorders that can be easily diagnosed with X-ray alone. More complex disorders require endoscopy.

Here’s how to stay comfortable before, during, and after a barium swallow:

Tips

• Wear loose-fitting clothing that’s easy to remove and put back on.
• Remove all jewelry at home before you go in for your procedure.
• Be sure to eat and drink enough the night before your procedure before starting your fast at midnight. It may help to schedule your barium swallow for first thing in the morning so you don’t have to avoid food or drink for too long.
• Be prepared for the barium to taste unpleasant.
• Bring something to eat and drink after your procedure. Foods that are high in fiber — including fruits like apples, bananas, and raspberries — can help prevent constipation as well as get rid of the taste.
• Make sure you drink eight 8-ounce glasses of water a day after your procedure.

Was this helpful?

Last medically reviewed on April 10, 2017

How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

• Barium swallow. (n.d.).Retrieved from
  hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/barium_swallow_92,P07688/
• Barium swallow (upper gastrointestinal series or “upper GI series”). (2014, June)
  health.harvard.edu/digestive-health/barium-swallow-upper-gastrointestinal-series-or-quotupper-gi-seriesquot
• Barium swallow study (esophagram). (2017, January)
  nationaljewish.org/programs/tests/imaging/barium-swallow-study/
• Mayo Clinic Staff. (2015, October 8). Chart of high-fiber foods
  mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/high-fiber-foods/art-20050948
• Upper GI endoscopy. (n.d.)
  hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/esophagogastroduodenoscopy_92,p07717/

Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available.

Current Version

Apr 22, 2017

Written By

Erica Cirino

Apr 10, 2017

Medically Reviewed By

Graham Rogers, MD

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Medically reviewed by Graham Rogers, M.D. — By Erica Cirino — Updated on April 22, 2017

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Zenker diverticulum. What is Zenker’s diverticulum?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Zenker’s diverticulum is a pouch-like protrusion of the esophagus at the pharyngoesophageal junction. The disease is manifested by bad breath, belching, dysphagia, dry cough. As the pathology progresses, a rounded soft formation appears on the neck, which increases during meals. To establish the diagnosis, a physical examination, radiopaque examination of the esophagus, and esophagoscopy are performed. All patients are prescribed fractional dietary nutrition, rinsing the mouth with antiseptic solutions after meals. In the later stages, endoscopic or open diverticulectomy is performed.

ICD-10

Q39.6 Q38.7

• Causes
• Pathogenesis
• Classification
• Symptoms of Zenker’s diverticulum
• Complications
• Diagnostics
• Treatment of Zenker’s diverticulum
• Prognosis and prevention
• Prices for treatment

General

Zenker’s diverticulum (pharyngeal-esophageal, hypopharyngeal diverticulum) is a rare pathology of the digestive tract, manifested by bulging of the wall of the pharyngeal end of the esophagus. The disease may be accompanied by impaired swallowing function, difficulty moving food through the esophagus and esophagitis.

The disease was first described by the German pathologist Friedrich Zenker in 1877. The prevalence is 1.5-5% of all esophageal diverticula. The disease often affects elderly and senile people, which is associated with an age-related decrease in the elasticity and elasticity of the muscles of the esophagus. In men, pathology occurs 2-3 times more often than in women. The dimensions of the diverticulum can be different and vary from 1 to 20 or more cm in diameter.

Zenker diverticulum

Causes

The etiology of Zenker’s diverticulum is not fully understood. The occurrence of a hypopharyngeal diverticulum may be associated with congenital malformations of the esophagus (stenosis, partial doubling), hereditary muscular dystrophies. The disease develops against the background of the already existing pathology of the organ (GERD, esophagitis), calcification of the cartilage of the larynx, constant injury to the mucous membrane with coarse food.

In addition to the main causes, in modern gastroenterology there are predisposing factors, the presence of which leads to a frequent or constant increase in intraesophageal pressure and increases the risk of developing a diverticulum. Intraesophageal hypertension is observed with foreign bodies, tumors of the pharynx and esophagus, enlargement of the thyroid gland, esophageal achalasia, and adhesive processes in the mediastinum.

Pathogenesis

The most common localization of Zenker’s diverticulum is the posterior wall of the pharyngeal-esophageal region. This is due to the presence of anatomical pharyngeal narrowing in the area of ​​​​the transition of the pharynx into the esophagus and a weak point of the esophagus – the Killian’s triangle. The triangle is localized between the thyroid-pharyngeal and cricopharyngeal muscles passing in an oblique direction. Normally, during the act of swallowing, the muscles of the pharynx contract, the cricopharyngeal muscle relaxes, the mouth of the esophagus opens, and food enters the stomach under the influence of wave-like contractions of the esophageal muscles.

With myodystrophy and diseases of the esophagus, weakness of the posterior wall of the pharyngeal-esophageal zone occurs, intraesophageal pressure increases, the contractility of the cricopharyngeal muscle is disturbed, which entails incomplete relaxation of the upper esophageal sphincter. As a result, against the background of inferiority of the connective tissue apparatus of the muscles of the pharynx and premature contraction of the upper sphincter, intraluminal pressure increases even more, protrusion of the mucous and submucosal membranes of the Killian’s triangle occurs and a diverticulum is formed.

Classification

According to the mechanism of formation, Zenker’s diverticulum belongs to pulsion ones, i.e. occurs due to the bulging of the organ wall under the influence of high intraesophageal pressure. By origin, pathology is congenital and acquired. Depending on the size of the formation and the intensity of clinical manifestations, 3 stages of the disease are distinguished:

Functional. Small diverticulum (up to 2-3 cm). Clinical manifestations may be absent or non-specific. The disease is often an incidental finding on radiography of the stomach or esophagus for other pathology.

Symptoms of Zenker’s diverticulum

The clinical manifestations of the disease depend on the size of the protrusion and increase as the formation increases. In the initial stages, there is a sore throat, profuse salivation, bad breath, a rare dry cough, or difficulty swallowing solid foods. At the stage of diverticulitis, mucus, food, air accumulate in the sac, which is accompanied by constant cacosmia, belching. Patients may experience a lump in the throat while eating (the “dumpling sign”).

In this period, there is dysphagia, shortness of breath, food regurgitation with symptoms of nocturnal cough. On examination, an asymmetric formation in the neck is determined, the size of which is reduced by palpation. With a large size of the diverticulum, frequent regurgitation of stagnant mucus or food occurs, a seething noise is noted when pressure is applied to the throat, pain in the cervical spine, nausea, dysphagia, and a constant unpleasant odor from the oral cavity.

Education, increasing in size, compresses the surrounding tissues and can cause pneumonia, mediastinitis, obstruction of venous outflow from the neck and head. Patients complain of worsening general condition, a sharp decrease in body weight, hoarseness.

Complications

At stages 2 and 3 of the disease, inflammation of the diverticular sac may occur with the formation of an abscess. Prolonged purulent process can lead to perforation of Zenker’s diverticulum, development of mediastinitis and bleeding. Regurgitation of the contents of the sac causes aspiration of food or mucus, accompanied by pneumonia. In patients, the process of swallowing is disturbed up to aphagia. Regular trauma to the mucosa or a constant inflammatory process in the area of ​​the protrusion contribute to the growth of atypical epithelium and malignant degeneration of the tissues of the esophagus.

Diagnostics

At the functional stage, in the absence of a specific picture of the disease, the disease is rarely diagnosed. Patients turn to specialists with the development of severe symptoms. In this case, the diagnosis most often does not cause difficulties. The main methods to establish an accurate diagnosis are:

• Gastroenterologist examination. During the collection of anamnesis, the patient’s complaints about the constant smell from the oral cavity, food regurgitation, and the duration of symptoms deserve special attention. On palpation of the neck, the formation of a soft consistency is determined, which changes size when touched.
• Contrast X-ray of the esophagus. It is the main method for diagnosing the disease, it is carried out in a standing position in frontal and lateral projections using a barium suspension. Allows you to determine the location, size, shape of the diverticulum, motor disorders of the organ and the state of the anatomical structures surrounding it.
• Esophagoscopy. Endoscopic diagnostics is an additional research method used for diagnostic difficulties and suspicion of cancer, esophageal fistula due to the high risk of diverticulum perforation. It allows you to accurately determine the size and shape of the formation, the state of the mucous membrane of the organ.

Differential diagnosis in the early period of the disease is carried out with chronic pharyngitis, gastroesophageal reflux disease. At subsequent stages, Zenker’s diverticulum is differentiated from benign and malignant formations, cicatricial narrowing of the esophagus, esophagitis.

Frame from X-ray examination of the esophagus with barium suspension. Zenker diverticulum.

Treatment of Zenker’s diverticulum

Tactics of treatment depends on the stage of the disease and the presence of complications. At the initial stages of the disease, conservative treatment is carried out. Patients are prescribed a sparing diet, fractional meals 5-6 times a day. Food is recommended to be taken in an upright position and chewed thoroughly. Before eating, it is advisable to drink 1-2 teaspoons of olive or sunflower oil, after eating – rinse your mouth with warm water or a weak antiseptic solution.

At 2, 3 stages of the disease and in the presence of complications, surgical treatment is indicated. Two days before surgery, a special diet is prescribed and the diverticulum is thoroughly washed with a probe or catheter. To date, several types of surgical interventions have been proposed for the treatment of the disease:

• Open operations. With a small size of the formation, the diverticulum is invaginated into the lumen of the esophagus and the esophageal wall is sutured. In some cases, for a better outflow of contents, the diverticular sac is fixed to the periosteum of the hyoid bone (diverticulopexy). A radical method of treatment is a one-stage diverticulectomy, which consists in the imposition of U-shaped sutures on the neck of the diverticulum and cutting off the sac.
• Endoscopic technique. A “bridge” between the esophagus and the diverticulum is cut through the esophagoscope under visual control and the resulting defect is clipped. The advantage of this operation is a shorter rehabilitation period and the absence of a scar on the skin.

Prognosis and prevention

The prognosis of Zenker’s diverticulum depends on the severity of the pathology, the size of the formation, and the presence of complications. With the timely appointment of a diet or surgery, the prognosis is favorable. A significant increase in education, the development of complications can cause serious consequences (mediastinitis, asphyxia) up to death. Prevention consists in the competent treatment of acute and chronic diseases of the esophagus, adherence to the basics of rational nutrition, and careful chewing of food. In the presence of the first symptoms of the disease (cacosmia, belching, difficulty swallowing), an examination by a gastroenterologist is recommended.

You can share your medical history, what helped you in the treatment of Zenker’s diverticulum.

Sources

1. self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

   Difficulty swallowing, dysphagia – causes, examination and treatment | Symptoms

   Stroke
   Signs: Usually a previously diagnosed stroke. Weakness or paralysis on one side of the body, difficulty speaking, difficulty walking, or a combination of these symptoms.

   Parkinson’s disease
   
   Signs: Rigidity of the muscles and fewer conscious movements compared to the norm. Involuntary, rhythmic, trembling movements (tremor), coordination disorder (ataxia) and balance disorder.

   Multiple sclerosis
   Signs: Transient symptoms related to various parts of the body, including visual disturbances, muscle weakness and/or abnormal sensations. Sometimes weak, clumsy movements.

   Certain motor neuron diseases:

   • Amyotrophic lateral sclerosis
   • Progressive bulbar palsy
   • Pseudobulbar palsy

   Signs: Muscle twitching, degeneration and weakness. Progressive difficulty in chewing, swallowing and speaking.

   Myasthenia gravis
   Symptoms: Weak, droopy eyelids and weak eye muscles. Excessive weakness of the muscles after working them.

   Dermatomyositis
   Signs: Muscle weakness. Fever, fatigue and weight loss. Sometimes pain and/or swelling of the joints, dark or red rash.

   Muscular dystrophy
   Signs: Muscle weakness that began in childhood.

   Achalasia (rhythmic contractions of the esophagus are greatly reduced and the lower esophageal muscle does not relax normally).
   Symptoms: Difficulty swallowing (dysphagia) of solid foods and liquids that worsens over months or years. Sometimes regurgitation (regurgitation) of undigested food during sleep. Feeling of discomfort in the chest. Feeling of fullness in the stomach after eating a small amount of food, nausea, vomiting, bloating, and symptoms that worsen when eating.

   Diffuse esophageal spasm
   Signs: Chest pain. Transient difficulty swallowing.

   Systemic sclerosis (scleroderma)
   Signs: Raynaud’s phenomenon. Pain and/or swelling of the joints. Swelling, thickening and tension of the skin of the fingers, and sometimes of the face and other areas. Intermittent heartburn, difficulty swallowing and shortness of breath.