Upper GI Procedures

Esophagus

• A long, straight, tube communicating in a direct path with the stomach.

• It extends from the pharynx to the stomach for a distance of 10 inches.

• It is posterior to the trachea and anterior to the vertebrae column, it passes through the diaphragm in front of the aorta to enter the stomach.

Cervical, Thoracic, & Intra-abdominal

3 Segments of Esophagus

Cricoid, Level of aortic knob, Opposite crossing of left bronchus, & Through diaphragm

4 points of narrowness

Filing Phase

This is used to distend the lumen of the esophagus, thereby giving approximation of the entire length.

2:1 or 3:1

Barium Preparation for Filing Phase

Mucosal Phase

This is used to demonstrate the mucosal pattern of the esophagus

4:1

Barium Preparation for Mucosal Phase

Pathologic Indications

• Achalasia

• Barret’s esophagus

• Dysphagia

• Adenocarcinoma (Most common malignancy)

• Esophageal varices

• Foreign bodies

• Gastroesophageal Reflux Disease/Esophageal Reflux

Contraindication

• No major contraindication

• Sensitivity to CM

Preliminary Preparation (Upper GI Procedures)

• Tell the patient not to eat too much prior to the examination

• Remove all metallic materials

AP/PA Projection

• PP: Supine/Prone

• CR: perpendicular

• RP: T5-T6

• SS: Esophagus superimposing thoracic vertebra

Recumbent (AP/PA Projection)

• Obtain more complete contrast filling

• Filling of proximal part of esophagus

• Used for demonstration of variceal distentions of the esophagus

PA Oblique Projection (RAO Position)

• PP: 35-40 degrees body obliquity

• CR: perpendicular

• RP: T5-T6

• SS:

  • Best demonstrate the esophagus

  • Esophagus between vertebral column and heart

PA Oblique Projection (LAO position)

• PP: 35-40 degrees body obliquity

• CR: perpendicular

• RP: T5-T6

• SS: esophagus b/n hilar region of lungs and thoracic spine

Lateral Projection

• PP: Patient’s arm forward; pillow near head

• CR: perpendicular

• RP: T5-T6

• SS: esophagus between thoracic spine and heart

Swimmer’s Lateral Position

• For better visualization of upper esophagus

• Prevent superimposition of upper esophagus to arms and shoulder.

• Breathing exercises

• Water test

• Compression paddle technique

• Toe-touch maneuver

Demonstration of Esophageal Reflux

Breathing Exercises

To increase both intrathoracic and intraabdominal pressures

Valsalva Maneuver

• Patient is asked to take a deep breath

• While holding the breath in, to bear down as through trying to move the bowels

• It forces air against the closed glottis

Modified Valsalva Maneuver

• Patient pinches of the nose

• Closes the mouth

• Tries to blow the nose

• Cheeks should expand outward

Mueller Maneuver

• Tries to inhale against closed glottis

Water Test

• Supine

• LPO – fills fundus with barium

• Patient is asked to swallow a mouthful of water through straw

Positive Water Test

Occurs when significant amount of barium regurgitate into esophagus from the stomach

Compression Technique

• Prone

• Compression paddle placed under the patient and inflated

  • To provide pressure to the stomach region

Toe-Touch Maneuver

• Under fluoroscopy, cardiac orifice is observed

• Patient bends over and touches the toes

• Demonstrates hiatal hernias and esophageal reflux

Upper GI Series

A special examination which includes the distal part of esophagus, stomach, duodenum and proximal part of the jejunum with the use of barium

Stomach

• Enlargement of GI tract

• J-shaped organ

• Connecting organ between esophagus & duodenum

• Cardia

• Fundus

• Body

• Pylorus

4 parts of the stomach

Cardia

Located near the opening

Fundus

Rounded portion

Body

Large central portion

Greater & Lesser Curvature

Present below the fundus

Greater curvature

Concave border

Lesser curvature

Convex border

Pylorus

Present below the body

Pylorus antrum

Connects to the body of stomach

Pylorus canal

Connects to the duodenum

Peristaltic Movement

Which moves the mass from cardiac to the pyloric end and onward into intestine

Peristalsis

Contraction waves by which the digestive tube propels its contents toward the anus

3-4 waves/min

Stomach

2-3 hrs

Stomach emptying time

Upper part (Intestine)

Greatest peristaltic action

Lower part (Intestine)

Decreased peristatic action

Duodenum & jejunum

Localized contraction

2-3 hrs (when barium reaches)

Ileocecal valve

4-5 hrs

Sigmoid colon

24 hrs

Rectum

Body Habitus

• General appearance physical body

• Classification of the four general shapes of the trunk

Mills

Studied the primary classifications of body habitus

Sthenic

• 50%

• Heart: moderately transverse

• Lungs: moderate length

• Diaphragm: moderately high

• Stomach: high, upper left

• Colon: spread evenly; slight dip in transverse colon

• Gallbladder: centered on right side upper abdomen

Characteristics of Sthenic

• Build: moderately heavy

• Abdomen: moderately long

• Thorax: moderately short, broad and deep

• Pelvis: relatively small

Asthenic

• 10%

• Heart: nearly vertical and at midline

• Lungs: long; apices above clavicles; may be broader above base

• Diaphragm: low

• Stomach: low and medial in the pelvis when standing

• Colon: low; folds on itself

• Gallbladder: low and nearer the midline

Characteristics of Asthenic

• Build: frail

• Abdomen: short

• Thorax: shallow

• Pelvis: wide

Hyposthenic

• 35%

• Lies between sthenic and asthenic

Hypersthenic

• 5%

• Heart: axis nearly transverse

• Lungs: short; apices at or near clavicles

• Diaphragm: high

• Stomach: high, transverse and in the middle

• Colon: around periphery of abdomen

• Gallbladder: high; outside; lies more parallel

Characteristics of Hypersthenic

• Build: massive

• Abdomen: long

• Thorax: short, broad and deep

• Pelvis: narrow

Eutonic/Normotonic, Speer Horn & Hypotonic

3 Stomach Habitus

Eutonic or Normotonic

The incisura angularis and pylorus are at about the same level

Speer Horn

The pylorus is higher than the incisura angularis by 1 cm

Hypotonic

The incisura angularis is higher than the pylorus by 1 cm

Infantile Stomach & Cascade Stomach

2 Variation of the Stomach

Infantile Stomach

The stomach is transversely positioned with the bulb hidden from the view

Cascade Stomach

The fundus is lower than the gastroesophageal junction

Supine

• This offers the most superior displacement of the stomach. In this position the gastric contents tends to flow into the fundus with some air within the stomach while fluid gravitates to the most dependent of the stomach

• This is the best position to demonstrate double contrast study of the body of the stomach and the pylorus.

Erect

• The stomach moves inferiorly in the erect position especially the distal and pyloric portion with the pylorus moving from as high as (T12) to as low as the sacrum.

• Ba. mixture tends to gravitate and fills up the distal and of the stomach, the pylorus, the bulb, and the duodenum and a portion of the body of the stomach depending upon the amount of Barium ingested by the patient. Air contrast is achieved in the fundus.

• The left lateral erect position offers the best depiction of the relationship of the stomach to the spine which mensuration indicates the depth of the retrogastric, space.

Prone

• In this position there is a greater tendency for a lower position of the stomach then in supine and to fall obliquely forward and downward.

• In this case the Ba. mixture tends to gravitate and fills up the distal end of the body of the stomach, the pylorus, bulb, and the C-loop, while there is usually a mixture of air and Ba. coated in the mucosa of fundus.

Right Lateral Decubitus

• The stomach duodenum swings forward from its two areas of fixation thereby changing its relationship to the retrogastric structures

• This projection provides an excellent method of separating the various anatomic parts of the stomach, but not provide for an accurate detection of the relationship of the retro-gastric structures of the stomach.

Obliques

• This projection are designed to project the different surfaces of the stomach and is used primarily for evaluation of the stomach walls as well as the duodenum

• The (LAO) is designed demonstrate double contrast study of the body of the stomach, the pylorus, bulb and the duodenum, while filling of the fundus is achieved.

Barium Sulfate & Iodinated Contrast Media

What are the 2 contrast media being used in examination?

Barium transit

• Suspending medium

• Temperature of the medium

• Consistency of the preparation

Iodinated Contrast Media

• Move quicker than barium

• Clears stomach: 1-2 hours

• Reaches colon: 4 hours

Advantages of Iodinated Contrast Media

1. It outlines the esophagus

2. It permits rapid survey of entire small intestine

3. Rapid investigation of large intestine can be performed (oral route)

   1. a. (For uncooperative patient during BE)

4. Easily removed by aspiration

5. No ill effects when escape in the peritoneum

Double Meal Method & Single Meal Method

2 Methods of Administering CM

Double Meal Method

• Wherein the patient is required to bring home with a glassful of barium mixture and to be ingested hours prior to the examination

• The second meal is being administered during the examination

• Its disadvantage lies in the fact that there will be superimposition between the filled up small intestines and the stomach.

Single Meal Method

• Wherein the barium mixture is administered during the actual examination.

• This is the method that is most frequently employed.

Single Contrast, Double Contrast, Biphasic examination, & Hypotonic duodenography

Contrast Studies

Double Contrast

• Small lesions are less easily obscured; mucosal lining of the stomach can be more clearly visualize

• Instruct patient to roll side to side – coat mucosal lining of the stomach

• Give glucagon/anticholinergic medications before exam – relaxes GI tract, improves visualization by inducing distention of stomach and intestine

Biphasic examination

• Single + double contrast

• Increased accuracy of diagnosis without increasing the cost of the examination

Hypotonic duodenography

• For evaluation of postbulbar duodenal lesions

• For detection of pancreatic disease

• Requires intubation

• Described by Liotta

Hypoacidity

• If barium stays in the stomach for beyond 6 hours

• Take 3 to 4 hours delayed films

Emotional Stress

• Nervousness and anxiety during exam tends to delay gastric emptying as a result of pyloro-bulbar spasm.

• In this case it is advisable to keep the patient calm and relieve him/her from anxiety. In some cases we give the patient candy to help relieve spasm.

Preliminary Preparation (Positioning Routines)

• Light supper evening prior the examination

• Laxative if not contraindicated

• No breakfast

• NPO 8-9 hours before examination

• NPO after evening meal – small intestine study

• No smoking and chewing gum

Scout Film (Purpose of Preliminary Radiograph)

• To delineate liver, spleen, kidneys, psoas muscle and bony structure

• To detect any abdominal or pelvic calcifications

• To detect tumor masses

Supine/Prone

Projection for Scout Film

Esophagus

• Continuous swallowing or give the patient mouthful of barium mixture, instructing him not to swallow until told.

• Position patient before swallowing.

RPO/LAO

Position for Esophagus

PA Projection (Stomach)

• PP: Prone/Upright (demonstrates the relative position of the stomach)

• CR: Perpendicular

• RP:

  • Asthenic – 2 in. inferior to L1 (prone)

  • Hypersthenic – 2 in. superior to L1 (prone)

  • Sthenic – L1 & 1 in. left of the vertebral column (prone)

PA Oblique Projection – RAO (Stomach)

• PP: Prone

  • RAO (40-70 degrees) - best image of pyloric canal and duodenum

  • Hypersthenic (70 degrees)

  • Sthenic (45-55 degrees); Asthenic (40 degrees)

• CR: Perpendicular

• RP:

  • Sthenic – L1-L2

  • Asthenic – 2 in. inferior to L1

  • Hypersthenic – 2 in. superior to L2

• SS: Stomach and entire duodenal loop

Sthenic

Best image of pyloric canal and duodenal bulb

PA Projection (Stomach)

• SS: Prone: barium-filled stomach and duodenal bulb

  • Upright: shows relative size, shape, and position of the filled stomach

  • Asthenic/hyposthenic: pyloric canal and duodenal bulb

  • Sthenic: pyloric canal and duodenal bulb (partially obscured) - PA Axial

  • Hypersthenic: pyloric canal and duodenal bulb (completely obscured) - PA Axial

AP Oblique Projection – LPO (Stomach)

• PP: Supine

  • Sthenic – 45 degrees

  • Hypersthenic – 60 degrees

  • Asthenic – 30 degrees

• CR: Perpendicular

• RP:

  • Sthenic – L1-L2

  • Asthenic – 2 in. inferior to L1

  • Hypersthenic – 2 in. superior to L1

• SS: Fundic portion of the stomach (barium-filled)

• Double Contrast: pyloric canal and duodenal bulb are demonstrated (air filled)

Lateral Projection (Stomach)

• PP: Recumbent/Upright

  • Upright Left Lat – left retrogastric space

  • Recumbent Right Lat – right retrogastric space, duodenal bulb, duodenal junction

• CR: Perpendicular

• RP:

  • Sthenic – L1-L2

  • Asthenic – 2 in. inferior to L1

  • Hypersthenic – 2 in. superior to L1

• SS: anterior and posterior aspect of stomach, pyloric canal, and duodenal bulb

AP Projection (Stomach)

• Sthenic: intestinal loops move superiorly & pyloric end is elevated

• Effects:

  • Barium-filled cardiac and fundic portion

  • Air-filled pyloric portion

• Asthenic: intestinal loops do not move superiorly Effects: fundic portion is not filled

  • Compensation:

    • LPO Position

    • Partial trendelenburg position

• PP: Supine

  • Full trendelenburg – diaphragmatic herniations

  • Partial trendelenburg – for fundus filling (asthenic)

• CR: Perpendicular

• RP:

  • Sthenic – L1-L2

  • Asthenic – 2 in. inferior to L1

  • Hypersthenic – 2 in. superior to L1

• SS:

  • Best demonstrate retrogastric portion of the duodenum and jejunum

  • Barium-filled fundic portion

  • Double contrast delineation of the body, pyloric portion and duodenum

Full trendelenburg

Diaphragmatic herniations

Partial trendelenburg

For fundus filling (asthenic)

Purpose for 1 Hour Delay

• In order to be able to determine the gastric emptying and to know how much barium is left

• To demonstrate presence of ASCARIS WORMS.

Positioning for 1 Hour Delay

• AP/PA

• Same as scout film

• Respiration: exposure

Ways of Producing Air in the Stomach

1. By allowing the patient to sip the barium mixture with the use of two straws, one outside the glass and other inside.

2. By instructing the patient to breath thru his mouth or swallow air after the ingestion of the barium mixture

3. By giving the patient gas producing tablets like “gastroluft”

4. By giving the patient carbonated drinks.

PA Axial Projection – GUGLIENTINI'S METHOD

• PP: Prone

• CR: 20-25 degrees cephalad

• RP: L2

• SS: greater and lesser curvature, antral portion of the stomach, pyloric canal and duodenal bulb

• Demonstration of stomach in INFANTS

PA Axial Projection – GORDON’S METHOD

• PP: Prone

• CR: 35-35 degrees cephalad

• RP: L2

• SS: greater and lesser curvature, antral portion of the stomach, pyloric canal and duodenal bulb

• To open up the high, horizontal stomach of HYPERSTHENIC PATIENT