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Questions and Answers
What is the primary positioning technique for the AP projection of the stomach in a sthenic patient?
What is the primary positioning technique for the AP projection of the stomach in a sthenic patient?
What is the significance of using a 35°-45° cephalad angle in the Gordon's modification?
What is the significance of using a 35°-45° cephalad angle in the Gordon's modification?
In which projection is the air-filled pyloric portion typically observed in asthenic patients?
In which projection is the air-filled pyloric portion typically observed in asthenic patients?
Which modification aims to highlight the greater and lesser curvature of the stomach?
Which modification aims to highlight the greater and lesser curvature of the stomach?
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What key feature differentiates the positioning of hypersthenic patients in the Gordon’s modification?
What key feature differentiates the positioning of hypersthenic patients in the Gordon’s modification?
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What characterizes the cascade stomach in radiological terms?
What characterizes the cascade stomach in radiological terms?
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Which body habitus is described as having a massive build and a high diaphragm?
Which body habitus is described as having a massive build and a high diaphragm?
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Which statement about the asthenic body type is accurate?
Which statement about the asthenic body type is accurate?
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What is one of the purposes of a preliminary radiograph?
What is one of the purposes of a preliminary radiograph?
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Prior to a small intestine study, patients are advised to follow which instruction?
Prior to a small intestine study, patients are advised to follow which instruction?
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What should patients avoid before a radiographic study to prevent excessive fluid accumulation?
What should patients avoid before a radiographic study to prevent excessive fluid accumulation?
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How does the colonic position differ in the sthenic body type compared to the hypersthenic type?
How does the colonic position differ in the sthenic body type compared to the hypersthenic type?
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What position is the stomach in for a hyposthenic body habitus?
What position is the stomach in for a hyposthenic body habitus?
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What is the position used to achieve the best image of the pyloric canal and duodenum when performing a PA oblique projection?
What is the position used to achieve the best image of the pyloric canal and duodenum when performing a PA oblique projection?
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For a patient with an asthenic body type, where is the central ray positioned when performing a PA projection?
For a patient with an asthenic body type, where is the central ray positioned when performing a PA projection?
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What is the effect of the stomach's position in an asthenic patient during a prone PA projection?
What is the effect of the stomach's position in an asthenic patient during a prone PA projection?
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Which projection allows for a clear view of both the stomach and the entire duodenal loop?
Which projection allows for a clear view of both the stomach and the entire duodenal loop?
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What is the required degree of rotation for a sthenic patient in the RAO position during a PA oblique projection?
What is the required degree of rotation for a sthenic patient in the RAO position during a PA oblique projection?
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During a PA projection, what area is not adequately demonstrated according to the provided guidelines?
During a PA projection, what area is not adequately demonstrated according to the provided guidelines?
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In which kind of study is a pneumatic paddle used under the pyloric sphincter and duodenal bulb?
In which kind of study is a pneumatic paddle used under the pyloric sphincter and duodenal bulb?
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What anatomical reference point is used for a hypersthenic patient in the LPO position during an AP oblique projection?
What anatomical reference point is used for a hypersthenic patient in the LPO position during an AP oblique projection?
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What is a primary advantage of using double contrast over single contrast in gastrointestinal studies?
What is a primary advantage of using double contrast over single contrast in gastrointestinal studies?
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What is the role of glucagon or anticholinergic medications before a double contrast exam?
What is the role of glucagon or anticholinergic medications before a double contrast exam?
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Which of the following describes the biphasic examination in contrast studies?
Which of the following describes the biphasic examination in contrast studies?
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What is the main purpose of hypotonic duodenography?
What is the main purpose of hypotonic duodenography?
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Which method is effective for producing air in the stomach during a contrast study?
Which method is effective for producing air in the stomach during a contrast study?
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In contrast studies, which description applies to a single contrast examination?
In contrast studies, which description applies to a single contrast examination?
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What happens to water-soluble iodinated contrast media once it enters the peritoneum?
What happens to water-soluble iodinated contrast media once it enters the peritoneum?
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Which patient position is best used to demonstrate a possible hiatal hernia during a PA projection?
Which patient position is best used to demonstrate a possible hiatal hernia during a PA projection?
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What is the primary purpose of Hampton's modification in radiographic examinations?
What is the primary purpose of Hampton's modification in radiographic examinations?
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What is a key advantage of the Wolf method compared to other methods?
What is a key advantage of the Wolf method compared to other methods?
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Which of the following statements is true about Poppel's method?
Which of the following statements is true about Poppel's method?
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What does the CR angulation of 10-20° caudad during the Wolf method indicate?
What does the CR angulation of 10-20° caudad during the Wolf method indicate?
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During the Wolf method's PA oblique projection, at which position is the patient placed?
During the Wolf method's PA oblique projection, at which position is the patient placed?
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What is the recommended preparation for infants undergoing UGIS?
What is the recommended preparation for infants undergoing UGIS?
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Which term refers to the procedure where only a portion of the stomach is surgically removed?
Which term refers to the procedure where only a portion of the stomach is surgically removed?
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What is typically the most frequent indication for conducting a UGIS on infants?
What is typically the most frequent indication for conducting a UGIS on infants?
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Study Notes
Variations of The Stomach
- The Infantile stomach is positioned transversely with the bulb hidden from view
- The Cascade Stomach is a variation of the hourglass stomach and has a posterior wall which is drawn up
- The Cascade stomach is characterized by a radiographic image where barium fills the upper sac before cascading to the lower sac
Body Habitus
- Hypersthenic: Massive build, long abdomen, narrow pelvis, short and broad thorax, high diaphragm, colon around periphery of abdomen.
- Sthenic: Moderately heavy build, moderately long abdomen, moderately short thorax, relatively small pelvis, colon spread evenly, gallbladder centered on the right upper abdomen.
- Hyposthenic: Characteristics between sthenic and asthenic. Shallow and long thorax, wide pelvis, low diaphragm, stomach low and medial in pelvis when standing, colon low and folds on itself.
- Asthenic: Frail build, short abdomen, shallow thorax, wide pelvis, heart nearly vertical, lungs are long, low diaphragm, stomach low and medial when standing, colon low and folds on itself.
Purpose of Preliminary Radiograph
- Delineate liver, spleen, kidneys, psoas muscles and bony structures
- Detect any abdominal or pelvic calcifications
- Detect tumor masses
Preliminary Preparation
- Patient should be informed of approximate time required
- Explain the procedure clearly
- Patient should have nothing to eat or drink 8-9 hours prior
- Rationale: Empty stomach and small intestines, free colon of fecal matter and gas
- No smoking or chewing gum after evening meal (for small intestine study)
- Rationale: To prevent stimulation of gastric secretion and salivation & prevent excessive fluid build up in the stomach
- Rationale: To prevent dilution of barium suspension
Contrast Media Used
- Barium Sulfate: Water-insoluble salt of barium, available in powder or liquid form, mix with plain water.
- Water-soluble iodinated contrast media: Suitable for opacification of alimentary canal. Examples include diatrizoate sodium Hypaque 50, 75, 90 and diatrizoate meglumine - conray. Clears stomach in 1-2 hours, reaches and outlines colon in 4 hours, easily removed by aspiration, escapes into the peritoneum through perforation of stomach or intestine, absorbed and excreted by kidney.
- Disadvantage of water soluble iodinated contrast media = strongly bitter taste
Contrast Studies
- Single Contrast: Demonstrates gross pathology only. Use in children or very ill patients.
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Double Contrast: Demonstrates mucosal patterns of the stomach. Useful for detecting small lesions.
- Use gas-producing tablets.
- Advantages over single contrast: small lesions less easily obscured, mucosal lining visualized more clearly.
- Instruct patients to roll side to side to coat mucosal lining.
- Give glucagon or anticholinergic medication before exam to relax GI tract and improve visualization.
- Biphasic Examination: Combination of single and double contrast. Improves accuracy of diagnosis without increasing cost.
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Ways of Producing Air for Double Contrast:
- Swallow barium with two straws, one in and one out of a glass
- Swallow air after drinking barium.
- Gas producing tablets such as “Gastroluft”, EZ Gas, Alka-Seltzer
- Carbonated drinks
Hypotonic Duodenography
- Used for evaluation of post-bulbar duodenal lesions.
- Used for detection of pancreatic disease.
- Less frequently performed, due to double-contrast gastrointestinal exams and CT scanning, as well as needle biopsy are now more widely used.
- First described by Liotta, requires intubation
PA Projection
- Patient Position: Prone/Upright
- Upright: Demonstrate size, shape and position of stomach.
- Prone: Demonstrate a possible hiatal hernia (stomach moves superiorly 1.5-4 inches).
- Reference Point:
- Sthenic: L1-L2 (1-2 inches above lower rib margin, prone) or 3-6 inches lower in upright. (Ballinger)
- Sthenic: L1 and 1 inch left of vertebral column (prone) (Bontrager)
- Asthenic: 2 inches inferior to L1 (prone) (Bontrager)
- Hypersthenic: 2 inches superior to L1 (prone) (Bontrager)
- Central Ray: Perpendicular.
- Structures Shown:
- Prone: Barium-filled stomach and duodenal bulb.
- Upright: Shows relative size, shape and position of filled stomach. Fundus not adequately demonstrated.
- Asthenic/Hyposthenic: Pyloric canal and duodenal bulb (well demonstrated).
- Sthenic: Pyloric canal and duodenal bulb (partially obscured). Compensation: PA Axial Projection.
- Hypersthenic: Pyloric canal and duodenal bulb (completely obscured). Compensation: PA Axial Projection.
- Take Note: In Prone Position the stomach moves superiorly 1.5-4 inches. Stomach spreads horizontally & decreases in length. Fundus fills in Asthenic patients.
PA Oblique Projection
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RAO Position: Patient Position: Prone.
- RAO 40 - 70 degrees: Gives the best view of pyloric canal and duodenum.
- Hypersthenic (70 degrees): requires greater degree of rotation.
- Sthenic (45-55 degrees)/Asthenic (40 degrees): Requires less degree of rotation.
- Used for serial studies of pyloric canal and duodenal bulb because gastric peristalsis is more active.
- RAO 40 - 70 degrees: Gives the best view of pyloric canal and duodenum.
- Reference Point:
- Sthenic: L1-L2 (Ballinger), L1 midway between spine and upside lateral border of abdomen (Bontrager).
- Asthenic: 2 inches inferior to L1 (Bontrager).
- Hypersthenic: 2 inches superior to L1 (Bontrager).
- Central Ray: Perpendicular.
- Structures Shown:
- Sthenic: Best view of pyloric canal and duodenal bulb.
- ER: Serial and mucosal studies of stomach and duodenum.
- Pneumatic paddle used, positioned under pyloric sphincter and duodenal bulb.
- Demonstrate compression and non-compression study of pyloric end and duodenal bulb.
- Demonstrate compression study of mucosa of the GI tract.
AP Oblique Projection
-
LPO Position: Patient Position: Supine.
- Sthenic: LPO 45 degrees
- Hypersthenic: LPO 60 degrees
- Asthenic: LPO 30 degrees
- Reference Point:
- Sthenic: L1 (midway between xiphoid process and lower rib margin) (Ballinger & Bontrager)
- Asthenic: 2 inches inferior to L1 (Bontrager)
- Hypersthenic: 2 inches superior to L1 (Bontrager)
- Central Ray: Perpendicular.
- Structures Shown:
- Best demonstrate retrogastric portion of duodenum and jejunum, barium filled fundic portion.
- Double-contrast delineation of the body, pyloric portion and duodenum.
- In Diaphragm: demonstrate organ/s involved in gross hernia protrusion.
AP Projection
-
Take Note: In Supine Position, stomach moves superiorly and to the left.
- Sthenic: Intestinal loops move superiorly and pyloric end is elevated. Effect = Barium-filled cardiac and fundic portion, air-filled pyloric portion. Rationale: Gastric bubbles are displaced into it allowing double contrast examination of the posterior wall lesions.
- Asthenic: Intestinal loops do not move superiorly. Effect = Fundic portion is not filled. Compensation: LPO position, Partial Trendelenburg position.
UGIS Modifications
- Gordon's
- Gugliantini
- Hampton's
- Poppel's
- Wolf
Gordon's Modification
- PA Axial Projection.
- Patient Position: Prone.
- Reference Point:
- Sthenic: L2
- Asthenic 1-2 inches inferior to L2.
- Hypersthenic: 1-2 inches superior to L2.
- Central Ray: 35-45 degrees cephalad.
- Structures Shown:
- Greater and lesser curvature
- Antral portion of the stomach.
- Pyloric canal and duodenal bulb.
- ER: To open up the high, horizontal stomach of a hypersthenic patient.
Gugliantini Modification
- PA Axial Projection.
- Patient Position: Prone.
- Reference Point:
- Sthenic: L2
- Asthenic: 1-2 inches inferior to L2.
- Hypersthenic: 1-2 inches superior to L2.
- Central Ray: 20-25 degrees cephalad.
- Structures Shown:
- Greater and lesser curvature
- Antral portion of the stomach.
- Pyloric canal and duodenal bulb.
- ER: For demonstration of stomach in infants.
Hampton's Modification
- Patient Position: Supine, body 45 degrees toward the side of interest.
- Central Ray: Perpendicular.
- Structures Shown:
- Best modification to demonstrate a leaf-like pattern of the pylorus and the valve.
Poppel's Method
- Structures Shown: Retrogastric space.
- ER:
- To demonstrate a right angle view of the stomach.
- For evaluation of pancreatic pathology: pancreatic mass, pancreatic cancer, pancreatitis.
Wolf Method
- Modification of Trendelenburg.
- Requires a semicylindrical radiolucent compression device.
- Compression device: Provides Trendelenburg angulation, increases intra-abdominal pressure, permits adequate contrast filling, allows maximum distention of the entire esophagus.
- Advantages: Does not require table angulation, patient can hold the barium container and ingest with relative ease.
- PA Oblique Projection (RAO Position).
- Patient Position: Prone RAO 40-45 degrees, assume a modified knee-chest position while device is being placed.
- Compression Device Placement: Horizontally under the abdomen, below costal margin.
- Barium Ingestion: Rapid, continuous swallow, expose during 3rd and 4th swallow. Rationale: Allows for complete filling of the esophagus.
- Reference Point: T6-T7.
- Central Ray: Perpendicular.
- Take Note: Position results in a 10-20 degree caudal CR angulation.
- Structures Shown: Relationship of stomach to the diaphragm, useful in diagnosing hiatal hernia.
- ER: For the purpose of applying greater intra-abdominal pressure, demonstration of small, sliding gastroesophageal herniation through the esophageal hiatus.
UGIS for Infants
- Most frequent indication for this exam is obstruction.
- No feeding prior to the examination to starve the patient.
- Catheter is inserted through the nose and into the stomach by the attending physician or radiologist.
- UGIS FOR INFANTS: indicated for OBSTRUCTION (Terms)
- Partial GASTRECTOMY - wherein only the portion of the stomach pathologic is being removed.
- SUB-TOTAL GASTRECTOMY - wherein only one half of the stomach is being removed.
- TOTAL GASTRECTOMY - wherein the whole stomach is being removed.
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