1751 Digestive System Exams Upper

How is the Alimentary Canal imaged?

Fluoroscopy or a combination of fluoroscopy and radiography

Fluoroscopy makes it possible to what?

Observe the canal in motion and determine the subsequent procedures for a complete examination

What is the radiographer’s role in fluoro

To assist the patient before and after contrast administration while assisting the radiologist during the procedure. If images are required after fluoroscopy the radiograph will acquire these also

Why is contrast media necessary for visualization of the alimentary canal?

Because it doesn’t have sufficient density to be seen through surrounding structures

Radiolucent - Negative contrast

• Air, gas producing tablets crystals or carbon dioxide (soda water)

• Anatomic area fill with negative contrast appears dark/black on image

Radiopaque - Positive Contrast

• Elements with higher atomic number Ex. Barium

• Anatomic area fill with this contrast appears light/white on image

Negative + Positive contrast = double contrast

Common Double Contrast studies

• Stomach - Barium sulfate + carbon dioxide (crystals)

• Small intestine (SBFT) Barium sulfate + methylcellulose (laxative that produces gas)

• Large intestine - Barium sulfate + air

• Enteroclysis (small intestine) Barium sulfate + Air

Definition of enteroclysis

An exam of the small intestines that is much more invasive than the SBFT and is reserved for certain pathologies. A tube is placed down the patient’s throat to the end of the duodenum and barium is injected. Air may also be injected for a double contrast exam

What does ROCM stand for

Radiopaque Contrast Media

What is ROCM

High-density pharmacologic agents used to visualize low-contrast tissues in the body

Common tissues visualized with ROCM

• Vasculature

• Kidneys

• Gastrointestinal (GI) Tract

• Biliary Tree

2 most commonly prescribed ROCM

Water Insoluble - Non-Iondinated

Water Soluble - Iondinated

Barium atomic #

56

Iodine atomic #

53

Barium Sulfate chemical abbreviation

BaSO₄

Barium Sulfate Facts

• Water insoluble - salt of the metallic element barium

• Most commonly used

• Dry powder, paste, or liquid

• Powdered barium has different concentrations and is mixed with plain water (Concentration depends on the part to be examined and the radiologist)

Possible Barium Complications

• Patient rarely have allergic reactions to barium sulfate. They may react to the preservatives or additives, but not the barium itself

• Complications are rare as long as barium sulfate remains in the GI tract

• If barium is retained in the large bowel for a prolonged period of time “impaction” may occur

  • It may form a mass which occludes the lumen of bowel causing constipation or complete obstruction

  • Patients at risk of impaction are inactive geriatric patients, dehydrated or neonatal patients

  • Encourage patient to drink plenty of fluids following procedure and doctor may prescribe a laxative

Barium complications 2

• Aspiration may be a problem if the patient experiences nausea and vomiting following ingestion of barium

  • Aspiration of large amounts of barium may lead to pneumonia

  • Most barium can be cleared by coughing

  • Safer to aspirate barium than gastrografin/omnipaque

Barium complications 3

• Peritonitis (inflammation of the peritoneum) may occur when barium spills into the abdomen from perforations or tears

  • Most rectal perforations are due to barium tip insertion or over-inflation of the balloon

  • The body cannot absorb barium outside GI tract

  • Free barium is mostly inert (chemically inactive) but the dyes, flavoring may cause inflammation

  • Bacteria and partially digested food matter will also be dumped into the peritoneum with the barium

  • 50% morality rate from peritoneal barium spills

  • May be surgically removed or aspirated from the cavity

  • If perforation is suspected radiographer should use water-soluble iodine based contrast media

BE Perforation - Free barium in the peritoneal cavity

Speed with which the barium passes through the alimentary canal depends on

• Suspending medium

• Temperature of the medium

• Motility function of the alimentary canal

Normal transit time to reach the ileocecal valve

2-3 hours

Barium reaches the rectum within

24 hours

Contraindication to using barium

• Perforated viscus

• Obstruction

• Surgery following procedure

Water soluble - Iodination contrast media characteristics

• Outlines esophagus but doesn’t adhere to mucosa as well as barium

• Strong, bitter taste

• Satisfactory exam of stomach and duodenum, but not clear detail for small intestine

• Moves more quickly than barium suspensions

• Easily removed by aspiration either before or during surgery

• If escaped into peritoneum through perforation, no ill effects occur

• Absorbed from peritoneal cavity and excreted by kidneys

• If aspirated gastrografin is hypertonic enough to cause pulmonary edema

• Taken orally for rapid large intestine exam if patient cannot receive enema

• Contraindication: Pt allergic to iodine

Pulmonary edema due to aspiration of gastrografin

kVp for scout

85

kVp for barium

120

kVp for double contrast

90-100

kVp for water soluble

80-90

Post instructions for barium studies

• Alert pt stool may be white for next few days. Barium being evacuated

• Resume regular diet following exam, unless otherwise instructed

• Drink plenty of fluid to wash out barium (if not may cause constipation)

• If constipation occurs, contact dr. may suggest laxative

Fluoro Equipment

• Image intensification systems connected to accessory units, such as cine film recorders, television systems, spot-film cameras, digital cameras, and video recorders

• Remote control fluoro room can be controlled from adjacent room

Devices used for compression and palpation of abdomen

• Compression cone on fluoro unit

• Pneumatic compression paddle inflated to put pressure on abdomen

• Radiologist hand - with leaded glove

Prep for digestive exams

• Check orders (any other exams contrast would interfere with)

• Footboard on table

• Lead curtain on tower

• Bucky tray moved down

• Storage for exam

• Input pt and dr info

• Select data on control panel

• Appropriate frames per second

• Mix contrast and prepare supplies

• Have shield for pt

Devices used for radiation protection

• Leaded tower drape

• Lead apron

• Lead gloves

• Bucky slot shield

• Protective eyewear

• Thyroid shield

• Compression paddle

Clinical indications for modified barium swallow study

• Oral and pharyngeal dysphagia

• food sticking in oropharynx

• laryngeal abnormalities

• odynophagia (painful swallow)

• CVA (Cerebrovascular accident, stroke)

• Questionable aspiration

• Recent recurrent pneumonia and right lower lobe infiltrates

• Progressive neurological diseases

Modified Barium Swallow Study facts

• Food tray - Various solid and liquid consistencies inpregnated with barium contrast

• Performed by speech pathology and radiology

• No prep

• Evaluated the oral and pharyngeal stages of swallowing

Clinical indications for esophagram

• Food sticking below the collarbone

• Hiatal hernia

• Zenkers diverticulum

• Possible esophageal stricture

• Possible esophageal dismotility

• Questionable perforation

• Possible mass

• Reflux/laryngopharyngeal reflux

• Screen for esophageal CA

Esophagram facts

• Liquid barium

• Radiology only

• No prep

• Evaluates entire esophagus

Are esophagrams performed single or double contrast

Can be single or double

What are carbon dioxide crystals

Effervescent granules, powder or tablets that release carbon dioxide on contact with stomach fluid. Causes gastric distention and smoothing of rugae. Similar to alka seltzer

What is commonly saturated with barium during esophagram

cotton or marshmallows

Is preliminary prep required for esophagram

no

What is valsalva maneuver

Patient takes in breath and is asked to bear down as if trying to move bowels

Why is the valsalva maneuver performed

To rule out hiatal hernia and reflux

What does patient have to remove for esophagram

Clothing from waist up and replace with a gown as well as eyeglasses necklaces and long earrings

What position would you begin an esophagram in

Patient and table erect with barium cup in left hand

What are the routine overhead images for esophagram

• AP or PA

• RAO or LPO

• Right Lateral

AP/PA Esophagus (CR and Positioning)

• Patient supine or prone with arms above head

• Center the MSP to the grid

• Turn head slightly, to assist drinking the barium

• Shield Patient

• Place IR at the top of the mouth

• CR around T5-T6

• Instruct patient to take big swallows and expose while esophagus is full of barium

AP/PA Oblique (RAO or LPO) Esophagus (CR and Positioning)

• Oblique patient 35 to 40 degrees. This obtains a wider space and unobstructed view of the esophagus between the vertebrae and the heart

• RAO - Side down arm at the side and side up arm by the head

• Shield patient

• Place IR at the top of the mouth

• CR - at the level of T5-T6 and 2 inches from the spine to the elevated side

• Instruct patient ot take big swallows and expose while esophagus is full of barium

Lateral Esophagus (Right or Left (CR and Positioning)

• Recumbent lateral position - preferably right lateral and facing radiographer

• Arms forward

• MCP centered

• Shield patient

• Place IR at the top of the mouth

• CR at the level of T5-T6

• Instruct patient to take big swallows and expose while esophagus is full of barium

Esophagram Eval Criteria (For all 3 positions)

• Collimation

• Esophagus from lower part of neck to the stomach entrance

• Esophagus filled with barium

• Penetration of the barium

AP or PA Esophagram Eval Criteria

• No rotation of patient

• Visualize esophagus through the superimposed thoracic vertabrae

AP or PA Oblique Esophagram Eval Criteria

• Esophagus between the vertebrae and the heart

Lateral Esophagram Eval Criteria

• Arm not interfering with esophagus

• Ribs posterior to the vertebrae superimposed with no rotation

PA Esophagus with Proper positioning

PA Esophagus with Left shoulder rolled up

RAO Esophagus with proper positioning

RAO Esophagus with superior and inferior no barium

RAO Esophagus with rotation less than 35-40 degrees

Lateral esophagus with proper positioning

Lateral esophagus with superior and middle no barium

Upper Gastrointestinal Series (UGI) Facts

• Try to schedule in AM

• Patient should be NPO from midnight until exam (8-9 hours)

  • No gum chewing or smoking

  • Brush Teeth but do not swallow water

• Mix thick and thin barium if no contraindications and have crystals ready

  • History of bowel obstruction

  • Perforation or laceration

  • Viscus Rupture

• Remove clothing from waist up and replace with gown, including glasses necklaces and long earrings

• Footboard on table

• Lead apron on tower

• Control panel ready

UGI Facts 2

• May include scout radiograph to rule out contraindications

• Patients normally begin with table erect (if unable to stand begin in RAO)

• Patient hold barium in left hand

• Radiologist has patient drink and fluoro

• Have pillow ready for when table is lowered

UGI Routine Projections

• AP or PA

• RAO or LPO

• Right Lateral

Indications for UGI Exam

• Bezoar - solid mass of indigestible material that accumulates in the digestive tract that can cause blockage

  • Phytobezoar - Indigestible plant material such as fibers, skins, and seeds

  • Trichobezoar - Hair and fingernails usually in patients with mental or anxiety disorders that consume them

• Diverticula - small bulging pouches in the digestive system that can become inflamed or infected and lead to blockage of fistula (things connect that shouldn’t connect) (Diverticulosis = disease of having diverticula) (Diverticulitits = inflamed diverticule)

• Emesis

• Gastritis

• Gastric Carcinoma

• Ulcers - Sore in the lining of the stomach

• Hiatal Hernia - Upper part of stomach pushes through an opening in the diaphragm into the chest cavity

AP Stomach and Duodenum (CR and Positioning)

• Supine or trendelenburg for hiatal hernia

• 14×17 IR

• MSP at the level midway between the xiphoid process and the lower rib margin (1-2 inches above lower rib margin L1-L2)

• If using 11×14 center between MSP and left lateral abdomen border at the level of L1-L2

• Mark left side

• Suspend respiration at the end of expiration

• Shield gonads

PA Stomach and Duodenum (CR and Positioning)

• Recumbent or erect

• 14×17 IR

• CR Recumbent - MSP at the level midway between the xiphoid process and the lower rib margin (1-2 inches above lower rib margin at L1-L2)

• CR Erect - Center 3-6 inches lower than recumbent due to visceral movement

• Mark left side

• Suspend Respiration at the end of expiration

• Shield Gonads

PA Oblique Stomach and Duodenum (CR and Positioning)

• Recumbent RAO - Visualized the pyloric canal and duodenal bulb. No superimposition of pylorus and duodenal bulb. Gastric peristalsis is more active in this position.

• Rotate 40-70 degrees - Hypersthenic patients requires more rotation

• 11×14 IR

• CR - At the level 1-2 inches above lower rib margin (L1-L2) Midway between the vertebrae nd the lateral border of the elevated side

• Mark Left Side

• Suspend respiration at the end of expiration

• Shield Gonads

AP Oblique Stomach and Duodenum (CR and Positioning)

• Recumbent LPO - visualized the fundic stomach portion. It does not fill the pyloric canal and duodenal bulb as well as RAO

• Rotate 30-60 degrees - Average 45 Hypersthenic requires more rotation

• 11×14 IR

• CR - Midways between the xiphoid process and the lower margin of the ribs

• Mark left side

• Suspend respiration at the end of expiration

• Shield Gonads

Lateral Stomach and Duodenum (CR and positioning)

• Recumbent Right Lateral - Visualized the right retro-gastric space, duodenal loop and the duodenaljejunal junction

• Upright left lateral - Visualized the left retro-gastric space

• 11×14 IR

• CR - At the level 1-2 inches above the lower rib margin (L1-L2) Center between the midcoronal plane and the anterior surface of the abdomen

• Mark right side down - anterior

• Suspend respiration at the end of expiration

• Shield gonads

PA Stomach with proper positioning

PA Stomach with blotchy appearance within the barium. residual food particles

PA Stomach with fundus overexposed either due to mAs too high or AEC positioned beneath the barium filled body and pylorus

PA Stomach taken on inspiration, compressing and foreshortening the stomach

PA Stomach with proper expiration

Oblique stomach with proper positioning

Oblique stomach with bony cortices are sharp and the gastric and intestines are blurry. Peristaltic activity of the stomach and small intestines

Lateral stomach with proper positioning

Lateral stomach descending duodenum is partially superimposed over the duodenal bulb and vertebrae, and the posterior surfaces of the thoracic and lumbar vertebrae are not superimposed. Patient was not in a true lateral position