Upper GI Contrast Studies (PDF)

CONTRAST STUDIES Henry C. Omadle Jr. RRT, RSO, MS-HSM GASTRO INTESTINAL TRACT MOUTH AND THE SALIVARY GLAND  MOUTH(ORAL CAVITY) THE MAIN CAVITY OF THE MOUTH IS BOUNDED IN FRONT AND ON THE SIDES BY THE INNER SURFACES OF THE Hard palate UPPER AND L...

CONTRAST STUDIES Henry C. Omadle Jr. RRT, RSO, MS-HSM GASTRO INTESTINAL TRACT MOUTH AND THE SALIVARY GLAND  MOUTH(ORAL CAVITY) THE MAIN CAVITY OF THE MOUTH IS BOUNDED IN FRONT AND ON THE SIDES BY THE INNER SURFACES OF THE Hard palate UPPER AND LOWER TEETH THE ROOF OF THE ORAL Posterior arch CAVITY IS THE HARD AND Uvula SOFT PALATES Anterior arch Soft Palate HANGING FRONM THE MID POSTERIOR ASPECT OF THE Tonsil SOFT PALATE IS A SMALL CONICAL PROCESS THE PALATINE UVULA THE FLOOR OF THE ORAL CAVITY IS THE TONGUE CONNECTS POSTERIOLY WITH THE PHARYNX  Tongue Sublingual space Frenulum of tongue Orifice of submandibular duct Sublingual fold  ACCESSORY ORGAN IN THE ORAL CAVITY(MOUTH) GLANDS OF SALIVA A. PAROTID B. SUBMANDIBULAR Parotid gland Parotid duct C. SUBLINGUAL SALIVA IS 99% WATER AND Sublingual ducts.5%SOLUTES OR SALT 1000-1500ML SECRETED Submandibular duct DAILY Submandibular gland Sublingual gland  Sialography The term applied to radiographic examinations of the salivary glands and ducts with the use of a contrast medium. The radiopaque contrast medium is injected into the main duct, from where it flows into the traglandular ductules Used to demonstrate conditions as inflammatory lesion an d tumors, to determine the extent of salivary fistulae and to localize diverticulae, strictures and calculi Pathologic condition Calculus Abnormal concretion of mineral salts, often called a stone Epiglottitis Inflammation of the epiglottis Fistula Abnormal connection between two internal organs or between an organ and the body surface Cont. Foreign Body Foreign material in the airway Salivary Duct Obstruction Condition preventing the passage of saliva through the duct Stenosis Narrowing or contraction of a passage Tumor New tissue growth where cell proliferation is uncontrolled Sialography steps Inject the radiopaque medium into the main duct. From there the contrast flows into the in trainglandular ductules, making it possible to demonstrate the surrounding glandular parenchyma, as well as the duct system Obtain preliminary radiographs to detect any condition demonstrable without the use of a contrast medium and to establish the optimum exposure technique Cont. About 2 or 3 minutes before the sialographic procedure, give the patient a secretory stimulant to open the duct for ready identification of its orifice and for easier passage of a cannula or catheter. For this purpose, have the patient suck a wedge of fresh lemon. On completion of the examination, have the patient suck on another lemon wedge to stimulate rapid evacuation of the contrast medium. Take a radiograph about 10 minutes after the procedure to verify clearance of the contrast medium, if needed  Parotid gland: tangential position technical factors: 8x10 length wise Position of patient ✔ Recumbent or seated AP BOBY POSITION Orbit Zygomatic arch Mandibular ramus Parotid gland area PA BODY POSITION Right cheek (arrow) distended with air in mouth. No abnormal finding in region of parotid gland.  Respiration: ✔ To study the parotid gland, better detail can be obtained, particularly for the demonstration of calculi, by having the patient fill the mouth with air and then puff the cheeks out as much as possible. When this cannot be done suspend respiration for the exposure Central ray: ✔ Perpendicular to the plane of the film, direct it along the lateral surface of the mandibular ramus Structures shown: Evaluation criteria ✔ Soft tissue density should be visible ✔ Most of the parotid gland Mastoid process should be demonstrated Opacified lateral to and clear of the parotid gland mandibular ramus Mandibular ✔ Mastoid should only ramus overlap the upper portion of the parotid gland  Parotid and submaxillary glands: lateral position Technical factor: 8x10 length wise Patient position: ✔ Semi prone or seated upright position PART POSITION ❑ Parotid gland ✔ Extend the patient neck so that the space between the cervical area of the spine and the mandibular rami is cleared ✔ Center the film to a point approximately 1 inch superior to the mandibular angle ✔ Adjust the head so that the midsagittal plane is rotated forward approximately 15 degrees from the true lateral pos.  Submandibular gland ✔ Center the film to the inferior margin of the angle of the mandible ✔ Adjust the patient head in a true lateral position ✔ Iglauer suggested depressing the floor of the mouth to displace the submandibular gland below the mandible ✔ When the patients throat is not too sensitive, this is done by placing an index finger on the back of the patient’s tongue on the affected side Respiration is suspended for the exposure  CENTRAL RAY: ✔ Perpendicular to the center of the cassette at a point (1) 1 inch superior to the mandibular angle to demonstrate the parotid gland ✔ (2) inferior margin of the mandibular angle to demonstrate the submandibular gland STRUCTURES SHOWN: ✔ Demonstrate the bony structures and any calcific deposit or swelling in the unsecured areas of the parotid and submandibular glands  Evaluation criteria: ✔ Mandibular rami should be free of overlap from the cervical vertebrae to best demonstrate the parotid gland superimposed over the ramus ✔ Mandibular rami and angles should be superimposed if no tube angulation or head rotation is used for the submandibular gland Submandibular and subligual glands Intraoral position (Occlusal 2 ½ x 3)  Film placement: ✔ Type a side marker (R or L) onto one corner of the exposure surface of the occlusal film packet ✔ Place the packet in the mouth with the long axis directed transversely ✔ Center the packet to the midsagittal plane and gently insert it far enough so that it is in contact with the anterior borders of the mandibular rami ✔ Instruct the patient to gently close the mouth (to hold the packet in position) Respiration is suspended for the exposure Central ray: ✔ Perpindicular to the plane of the film, direct it to the intersection of the sagittal plane and coronal plane passing through the second molars  STRUCTURES SHOWN: ✔ An occusal position of the floor of the mouth is demonstrated, showing the entire sublingual gland areas and the duct and anteromedial part of the submandibular gland areas EVALUATION CRITERIA: ✔ Soft tissue density of the floor of the mouth should be visible ✔ Both sides of the mandible and dental arches should be symmetric ✔ Sublingual glands should be demonstrated in their entirely along with a portion of the submandibular glands when the film includes the lower molars  T H E PA RT OF E RI O R AN T C K N E neck occupies the region between Nasal Septum the skull and the thorax Nasopharynx thyroid gland Epiglottis Soft palate consists of two lateral lobes Epiglottis Piriform connected at their lower thirds recess Vocal folds by a narrow median portion Rima called the isthmus Larynx glottidis Laryngo-pharynx parathyroid glands are small ovoid bodies, two on each side, superior and inferior. Interior posterior view of neck  PHARYNX IS ABOUT 12.5 CM LONGAND IS PART OF THE DIGESTIVE TUBE FOUND POSTERIOR TO THE NASAL CAVITY, MOUTH ANDLARYNX 3 PARTS 1. NASOPHARYNX- POSTERIOR TO THE BONY NASAL SEPTUM, NASAL CAVITIES AND SOFT PALATE 2. OROPHARYNX- DIRECTLY POSTERIOR TO THE ORAL CAVITY EXTEND FROM SOFT PALATE TO THE EPIGLOTIS 3. LARYNGOPHARYNX OR HYPOPHARYNX- EXTEND FROM THE LEVEL OF THE EPIGLOTIS TO THE LOWER BORDER OF THE LARYNX Larynx is the organ of voice. Serving as the air passage between the pharynx and the trachea, the larynx is also one of the divisions of the respiratory system.  DEGLUTITION during swallowing the soft palates closes off the nasopharynx to prevent swallowed substances from regurgitating into the nose the epiglottis is depressed to cover the laryngeal opening. the vocal folds, or cords comes together to close off the epiglotis Palatography Bloch and Quantrill investigated suspected tumors of the soft palate by a positive contrast technique Patient is seated laterally before a vertical grid device with the nasopharynx centered to the cassette the first palatogram patient is required to swallow a small amount of a thick, creamy barium sulfate suspension to coat the inferior surface of the soft palate and the uvula Second lateral position is obtained after the injection of 0.5ml of creamy barium suspension into each nasal cavity to coat the superior surface of the soft palate and the posterior wall of the nasopharynx Morgan- describe a method of evaluating abnormalities of chewing and swallowing in children Child chews barium impregnated chocolate fudge Cleft palate studies are taken with patient seated laterally upright and are centered to the nasopharynx Exposure are made during phonation to demonstrate the range of movement of the soft palate and the position of the tongue during each of the following sounds, “d-a-h”, “m-m-m”, “s-s-s” and “e-e-e” 'Randall P, O' Hara AE, Bakes FP: A simple roentgen examination for the study of soft palate function in patients with poor speech, 'O' Hara AE: Roentgen evaluation of patients with cleft palate, Pharyngography Radiographic investigation of the pharynx using either barium mixture or air Events during swallowing ✔ Nasopharynx closes at the same time breathing is inhibited ✔ Laryngeal muscles contract to close the epiglotis and elevate the larynx ✔ Peristalsis sweeps in the pharynx to propel the food with simultaneous opening of the upper esophageal sphincter  Ways of studying the pharynx ✔ By contenous quitre breathing and vasalva method ✔ By the use of paste barium mixture AP Projection Lateral projection Lateral pharynx and larynx during normal breathing.  Air filled Pharynx Hyoid bone Loryngeal structures Trachea Lateral pharynx and larynx during Lateral pharynx and larynx during Valsalva 's phonation maneuver  Gunson Method ✔ Offered a practical suggestion for synchronizing the exposure with the height of the swallowing act in deglutition studies of the pharynx and superior esophagus A, Ordinary dark shoelace has been tied snugly around patient's neck above the Adam 's apple. B, Exposure was made at peak of superior and anterior movement of larynx during swallowing. At this moment the pharynx is completely filled with barium, which is the ideal instant for making x-ray exposure. C, Double-exposure photograph emphasizing movement of Adam's apple during swallowing. Note extent of anterior and superior excursion (arrows). Templeton and Kredel , the action is so rapid that satisfactory filling is usually obtained if the exposure is made as soon as anterior movement is noted  Nasopharyngography Radiographic demonstration of the nasopharynx following instillation of contrast medium Clinical indications: ✔ Investigation of carcinoma ✔ Investigation of lymphosarcoma and angiofibroma ✔ To demonstrate the position and extent of the lession Chittinand, Patheja, and Wisenberg Described an opaque-contrast nasopharyngographic procedure in which the patient is not required to keep the neck in an uncomfortable extended position for the entire examination.  Two ways studying of the Pharynx 1. By means of CM by continous breathing technique and modified vasalva manuever 2. By means of negative CM introduced or instilled through the nostril ❖ Anatomic maneuver- patient is in supine position with head fully extended ❖ Physiologic Maneuver- tell the patient not to swallow during examination  Premidication ✔ Atropine is given 30 minutes before the examination to suppress nasophayngeal and buccal secretions Contrast medium ✔ Dionosil aqueous Preliminary film ✔ Submentovertical view  Positioning Submentovertical ✔ Patient is in supine position after a local anesthetization ✔ Elevate the shoulder to extend the neck enough to permit the orbitomeatal line to be adjusted at an angle of 40-45 degrees to a horizontal plane ✔ Keep the head in this position throughout the examination  Submentovertical cont. Both before and after instillation of contrast medium into the nasal cavities, obtain basal projections with the central ray directed midway between the mandibular angle of 15-20 degrees cephalad Obtain lateral projections with a horizontal central ray centered to the nasopharynx Upon completion of this phase, sit up and blow trhe nose. This act evacuates most of the contrast medium and the remainder will be swallowed.  Laryngography Radiographic evaluation of the larynx following the instillation of CM ❑ Clinical indications ✔ To demonstrate paresis ✔ To demonstrate edema or fibrosis, but most often in the investigation of malignancy Note: Most useful view to visualize the larynx is soft tissue lateral view because in AP view the midline structures are obscured by the much denser cercical vertebrae.  Patient preparation ✔ Patient must have nothing to eat or drink for 5hrs Premedication ✔ Atropine is given 30 minutes before the examination to suppress nasopharyngeal and bucall secretions and prevent laryngospasm ✔ Omnepon or nembutal may be given as sedation Contrast media ✔ Dionosil 10-15ml ❑ Technique ✔ Pharynx and larynx are sprayed with topical anaesthetic lidocaine 4% is instilled into larynx via a curve laryngeal syringe over the back of the tongue during insoiration ❑ Preliminary film ✔ Lateral and AP views ✔ Spot film for o With the patient performing vasalva manuever o On deep inspiration o On phonation by saying the letter “A and E”  Position AP Projection ✔ The larynx is filled with air and the trachea is overlying the cervical spine of the median plane of the body Lateral Projection ✔ The voice box is filled with air and free from bony superimposition Valleculae epiglattica Epiglottis Larynx Vallecula epiglottica Piriform recess Vestibule of Piriform larynx recess Laryngeal ventricle Trachea Trachea Normal AP laryngogram Normal lateral laryngogram  T E M S YS I VE GE ST DI  DIGESTIVE SYSTEM ALIMENTARY CANAL ACCESSORY ORGAN ORAL CAVITY PHARYNX SALIVARY GLANDS ESOPHAGUS PANCREAS STOMACH LIVER SMALL INTESTINE LARGE INTESTINE GALBLADDER ANUS  FUNCTIONS INTAKE AND DIGESTION OF FOOD, WATER ,VITAMINS AND MINERALS ABSORB DIGESTED FOOD PARTICLES, ALONG WITH WATER, VITAMINS AND ESSENTIAL ELEMENTS FROM THE ALIMENTARY CANAL INTO THE BLOOD OR LYMPHATIC CAPILLARIES ELIMINATE ANY UNUSED MATERIAL IN THE FORM OF SEMISOLIOD WASTE PRODUCT  Parotid gland Tongue Pharynx Sublingual gland Esophagus Submanibular gand Gallbladder Stomach Biliary ducts spleen Visceral surface of liver Large intestine Duodenum Large intestine Small intestine Appendix Rectum  ESOPHAGUS ABOUT 10 INCHES LONG AND ABOUT ¾ INCH IN DIAMETER EXTENDING FROM THE LARYNGOPHARYNX TO THE STOMACH BEGINS POSTERIOR TO THE LEVEL OF THE LOWER BORDER OF THE CRICOID CARTILAGE OF THE LARYNX(C5-C6) TERMINATES TO THE STOMACH AT THE LEVEL OF 11 THORACIC VERTEBRA POSTERIOR TO THE LARYNX AND TRACHEA DECENDING AORTA IS BETWEEN THE DISTAL ESOPHAGUS AND THE LOWER THORACIC SPINE  C6 Esophagus Aorta Heart Diaphragm Tl2 Fundus  SWALLOWING AND PERISTALSIS esophagus is a colapsible tube that only opens when swallowing occurs fluids tend to pass from the mouth and pharynx to stomach primarily by gravity. bulos of solid materials tend to pass both by gravity and by peristalsis peristalsis- is a wavelike series of involuntary muscular contraction propelling solid and semisolid materials through the tubular alimentary canal Characteristics of the esophagus Collapsible fibromuscular tube Posterior to the trachea and heart Begins at approximately the level of C-6 (pharynx) Connects with the stomach around T-10 Recieves bolus from the mouth and pharyngeal lumen A bolus passes to the lower esophagus in 2 to 3 seconds with assistance of gravity  layers of esophagus ✔ Fibrous layer ✔ Muscular layer ✔ Submucosal layer ✔ Mucosal layer Three segments of the esophagus ✔ Cervical segment ✔ Thoracic segment ✔ Intra-abdominal segment  Four normal points of narowness in the Esophagus ✔ Cricoid ✔ Level of the aortic knob ✔ Opposite the crossing of the left bronchus ✔ Through the diaphragm  Esophagography or Barium swallow esophagogram or barium swallow is radiographic procedure or examination of the pharynx and esophagus, utilizing a radiopaque contrast media the purpose of an esophagram is to study radiographically the form and function of the swallowing aspect of the pharynx and esophagus Indications Odynophagia Dysphagia Hematemesis Abdominal pain Unexplained weight loss  I C AT I ON S O G IC I N D PATHO L A M S O P H A G R FOR E ACHALASIA (CARDIOSPASM) IS A MOTOR DISORDER OF THE SOPHAGUS IN WHICH PERISTALSIS IS REDUCED ALONG THE DISTAL THIRDS OF THE ESOPHAGUS ANATOMIC ANOMALIES- MAY BE CONGENITAL OR CAUSED BY DISEASE, SUCH AS CANCER OF THE ESOPHAGUS BARRETT’S ESOPHAGUS (BARRETT’S SYNDROME) IS THE REPLACEMENT OF THE NORMAL SQUAMOUS EPITHELIUM WITH COLUMNAR-LINED EPITHELIUM ULCER TISSUE IN THE LOWER ESOPHAGUS Diffuse Esophageal Spasm Squamous Cell Carcinoma 1. CARCINOSARCOMA- PRODUCE A LARGED, IRREGULAR POLYPS. 2. Adenocarcinoma MOST COMMON MAGNANCY OF THE ESOPHAGUS. SYMPTOMS- ✔ DYSPHAGIA, ✔ LOCALIZED PAIN DURING MEALS AND BLEEDING.  Strictures 3. PSEUDO CARINOMA DYSPHAGIA- this difficulty may be due to a congenital or acquired condition , a trapped bulos of food, paralysis of the paralysis of the phryngeal or esophageal muscles or inflamation. ESOPHAGEAL VARICES CARACTERIZED DY DILATATION OF THE VIENS IN THE DISTAL ESOPHAGUS. WITH RESTRICTION IN THE VENOUS FLOW THROUGH THE LIVER, THE CORONARY VEINS IN THE DISTAL ESOPHAGUS BECOME DILATED, TORTUOUS AND ENGORGED WITH BLOOD NARROWING OF THE DISTAL THIRD OF THE ESOPHAGUS AND A “WORMLIKE OR COBBLESTONE APPEARANCE DUE TO ENLARGED VEINS  FOREIGN BODIES AND GERD FOREIGN BODIES- PATIENTS MAY INGEST A VARIETY, INCLUDE A BULOS OF FOOD, METALLIC OBJECTS AND OTHER MATERIALS LODGING IN THE ESOPHAGUS GASTROINTESTINAL REFLUX DISEASE (GERD) OR ESOPAGEAL REFLUX- THE ENTRY OF THE GASTRIC CONTENTS INTO THE ESOPHAGUS, IRRITATING THE LINING OF THE ESOPHAGUS -HEART BURN - LEAD TO ESOPHAGITIS DEMOSTRATED BY AN IRREGULAR APPERANCE OF THE MUCUSA OF THE ESOPHAGUS - SPECIFIC CAUSES BUT NOT CONFIRMED; CIGARETTE SMOKING AND EXCESSIVE INTAKE OF ASPIRIN, ALCOHOL, AND CAFFEINE  ZENKER,S DIVERTICULUM IS CHARACTERIZED BY A LARGED OUTPOUNCHING OF THE ESOPHAGUS JUST ABOVE THE UPPER ESOPHAGEAL SPINCTER. CAUSED BY WEAKENING OF MUSCLE WALL BECAUSE OF THE SIZE OF DIVERTICULUM THE PATIENT MAY EXPERIENCE DYSPHAGIA, ASPIRATION AND REGURGITATION OF FOOD EATEN HOURS EARLIER Crohn’s Disease  Thymoma causing compression of Scleroderma Esophagus esophagus  Two phase of studying the esophagram Filling phase ✔ Used to distend the lumen of the esophagus, thereby giving approximation of its entire length ✔ Barium preparation: 2:1 or 3:1 Mucosal phase ✔ Used to demonstrate the mucosal pattern of the esophagus ✔ Barium preparation: 4:1 Physiological Maneuver Barium paste give the patient about 2-3 table spoonful's and at the count of three swallows, take exposure Continuous swallowing of the barium mixture by letting the patient hold the glass of barium with his left hand, or by the use of a straw  DEMONSTRATION OF ESOPHAGEAL REFLUX breathing exercises- valsalva manuever the patient is asked to take a deep breath and while holding the breath in to bear down as though trying to move the bowels. forces air against the closed glottis. a modified is accomplished as patient pinches off the nose, closes the mouth and tries to blow the nose. the cheeks should expand outward as though the patient blowing up a ballon ✔ mueller maneuver-the patient exhale against a closed glottis water test- the patient in the supine position and turned up slightly on the left side. the patient ask to swallow a mouthful of water through s straw toe-touch manuever- to study possible reguritation into the esophagus frm the stomach. the patient bends over and touches the toes COMPRESSION TECHNIQUE- PLACED UNDER THE PATIENTIN THE PRONE POSITION AND INFLATED AS NEEDED TO PROVIDED PRESSURE TO THE STOMACH REGION RAO POSITION: ESOPHAGOGRAM TECHNICAL FATOR 14 X 17 SHIELDING- PELVIC REGION PATIENT POSITION- RECUMBENT OR ERECT.  CENRAL RAY CRPERPENDICULAR TO IR CR TO CENTER OF CASSETTE AT LEVEL OF T5 OR T6 (2 TO 3 INCHES, OR 5 TO 7.5 cm INFERIOR TO JUGULAR NOTCH) SUSPEND RESPIRATION AND EXPOSED ON EXPIRATION ✔ NOTE: 2 OR 3 SPOONFULS THICK BARIUM SHOULD BE INGESTED AND EXPOSED EMDIATELY AFTER LAST BULOS IS SWALLOWED ✔ NOTE 2:FOR COMPLETE FILLING OF THE ESOPHAGUS WITH BARIUM, THE PATIENT MAY NEED TO DRINK THROUGH STRAW STRUCTURES SHOWN: ESOPHAGUS SHOULD BE VISIBLE BETWEEN THE VERTEBRAL COLUMN AND HEART (RAO PROVIDES MORE VISIBILITY OF PERTINENT ANATOMY BETWEEN VERTEBRAE AND HEART THAN DOES THE LAO)  RADIOGRAPHIC CRITERIA position: adequate riotation of body projects esophagus is situated over the spine, more rotation of the body is required. netire esophagus is filled or lined with contrast media. upper limbs should not superimposed the esophagus collimation and central ray: collimation margins are seen laterally on radiograph. cr is centered at level of t5 or t6 to include the entire esophagus exposure criteria: appropriate technique is used to clearly visualize borders of contrast media-filled esophagus; sharp structural margins indicate no motion  LATERAL POSITION: ESOPHAGOGRAM shielding: over gonadal area patient position: recumbent or erect part position: position patient arms over the head, with the elbows flexed and superimposed align midcoronal plane to midline of ir and or table place shoulders and hips in a true lateral position place top of ir about 2 inches(5cm) above level of shoulders, to place cenetr of ir at cr CENRAL RAY CR PERPENDICULAR TO IR CR TO LEVEL OF T5 OR T6 (2 TO 3 INCHES, OR 5 TO 7.5 CM, INFERIOR TO JUGULAR NOTCH) RESPIRATION:SUSPEND RESPIRATION AND EXPOSE ON EXPIRATION  OPTIONAL SWIMMERS LATERAL POSITION for better demonstration of the upper esophagus without superimposition of arms and shoulders position hips and shoulders in true lateral positi0n; then separate shoulders from esophageal region by placing upside shoulder down back, with arm behind back. place downside shoulder and arm up and in front to hold cup of barium. RADIOGRAPHIC CRITERIA structures shown: entire esophagus is seen between thoracic spine and heart position: true lateral is Esophagus indicated by direct superimposition of posterior rib. the patients arms should not superimposed the esophagus. entire esophagus Thoracic vertebra is filled or lined with contrast media  AP (PA) PROJECTION ESOPHAGOGRAM pathology demonstrated: strictures foreign bodies, anatomic anomalies and neoplasm of the esophagus shielding: pelvic region patient position: recumbent or erect part position: 1. align midsagital plane to midline of ir and or table 2. ensure that shoulder and hips are not rotated 3. place right armup to hold cup of barium 4. place top of ir bout 2 inches (5cm) above top of shoulder, to place cr at center of ir  CENTRAL RAY cr perpendicular to ir cr to midsagital plane, 1 inch (2.5cm) inferior to sternal angle (t5-6) or approximately 3 inches (7.5cm) inferior to jugular notch respiration suspended and expose on expiration ✔ note: 2 or 3 spoonful's of thick barium should be ingested and exposure made after the last bulos is swallowed  RADIOGRAPHIC CRITERIA STRUCTURES SHOWN: Esophagus THE ENTIRE ESOPHAGUS IS FILLED WITH BARIUM. POSITION: NO ROTATION OF THE PATIENTS BODY IS EVIDENCED BY THE SYMMETRY OF THE STERNOCLAVICULAR Stomach JOINTS  LAO POSITION: ESOPHAGRAM pathology demonstrated: strictures, foreign bodies, and anatomic anomalies, and neosplasms of the esophagus shielding: over gonadal area patient position: recumbent or erect part position: 1. rotate 35 to 40 from a pa , with the left anterior body against ir or table 2. place left arm down by the patients side, right arm flexed at elbow and up by the patients head 3. flex right knee for support 4. place top cassette about 2 inches (5cm) above level of shoulders, to place cr at center of ir  COLLIMATION cr perpendicular to ir cr to level of t5 or t6 (2 to 3 inches, or 5 to 7.5, inferior to jugular notch) respiration suspended and expose on expiration ✔ note: 2-3 spoonful of thick barium should be ingested and the exposure made immediately after last bulos ✔ note: patient may drink through a straw. exposure made after 3-4 swallow  RADIOGRAPHIC CRITERIA structures shown: esophagus is seen between hilar region of lungs and thoracic spine. the entire esophagus is filled with contrast medium UPPER GASTROINTESTINAL SERIES(UGI)(UPPER GI) STUDY OF DISTAL ESOPHAGUS ,STOMACH AND DUODENU  STOMACH (GREEK GASTER) LOCATED BEETWEN THE ESOPHAGUS AND THE SMALL ITESTINE, IS THE MOST DILATED PORTION OF THE ALIMENTARY CANAL. SERVE AS A RESERVOIR FOR SWALLOWED FOOD AND FLUID AND REMARKABLY EXPANDABLE  Characteristics of the stomach ✔ J-shape portion of the digestive tract ✔ Located in the upper left quadrant of the abdomen ✔ Below the diaphragm ✔ Continuous with the esophagus and above the small bowel  Secretory cells of the gastric glands ✔ Parietal cell- it secretes HCI and intrinsic factor ✔ Chief cells- secrete pepsin ✔ Mucus neck cell- secretes mucus ✔ G cell- it secretes gastrin  Tissue layers of Gastrointestinal tract Mucosa – innermost lining of the digestive tract in which the actual cells vary in composition depending on the function ✔ Egestion ✔ Ingestion ✔ Digestion ✔ absorpton Submucosa – loose connective tissue adhere to the mucous membrane of the external muscular wall Muscularis externa – smooth muscles fibers that help mix food with digestive enzymes and move the bolus through the system Adventitia externa/serosa – outermost layer of the digestive tract. Externa above the diaphragm. Serosa below the diaphragm  Stomach habitus Eutonic or normotonic habitus- the incisura angularis and the pylorus are at the same level Hypotonic habitus- the pylorus is higher than the incisura ngularis by greater than one cm Speer horn – incisura angularis is higher than the pylorous by greater thabn one cm Variations of the stomach Infantile stomach- stomach is transversely positioned with the bulb hidden from the view Cascade stomach – stomach in which the upper posterior wall is pushed forward, creating an upper portion that fills until sufficient volume is present to spill into the antrum  STOMACH OPENINGS AND CURVATURES esophagogastric junction(cardiac Cardiac notch orifice)- aperture or opening between the esophagus and the stomach. cardiac notch (incisura cardica)- this distal abdominal portion of the esophagus Cardiac antrum curves sharply into expanded portion og Cardia the terminal esophagus called cardiac antrum Pyloric portion pyloric orifice(pylorous)- thickened muscular ring that leaves periodicallu Pyloric during digestion to allow stomach or sphincter gastric content to move into 1st part of the Duodenum small intestine lesser curvature- along the right extend between the cardiac and pyloric opening greather curvature- along the left or lateral boarder of the stomach  STOMACH SUDIVISION FUNDUS-BALLOON PORTION LYINGLATERAL AND SUPERIOR TO THE CARDIAC ORIFICE. FILLED WITH BUBBLE OF SWALLOWED AIR(GASTRIC BUBBLE) BODY OR CORPUS- PYLORIC PORTION 2 PARTS 1. PYLORIC ANTRUM 2. PYLORIC CANAL  GASTRIC FOLDS WITHIN STOMACH-RUGAE Cardiac sphincter RUGAE- INTERNAL LINING IS THROWN INTO NUMEROUS LONGITUDINAL FOLD WHEN THE STOMACH IS EMPTY - ASSIST WITH MECHANICAL DIGESTION OF FOOD WITHIN THE STOMACH Rugae GASTRIC CANAL- FORMED BY RUGAE ALONG THE LESSER CURVATURE  AIR BARIUM DISTRIBUTION IN STOMACH SUPINE POSITION- THE FUNDUS PART OF THE STOMACH IS THE LOWEST PART, WHERE THE HEAVY BARIUM SETTLES PRONE POSITION- THE FUNDUS IS IN THE HIGHEST PORTION, CAUSINGTHE AIR TO FILL THIS PART OF THE STOMACH ERECT POSITION- AIR RISES TO FILL THE FUNDUS, WHEREAS BARIUM DESCENDS BY GRAVITY TO FILL THE PYLORIC PORTION OF THE STOMACH  DUODENUM Cystic duct ABOUT 8 TO 10 INHES (20 Common hepatic duct TO 24) LONG Common bile duct FOUR PARTS Gallbladder 1. DUODENAL BULB(CAPOR SUPERIOR PORTION)- COMMON SITE OF ULCER DISEASE 2. DESCENDING PORTION- RECIEVES THE Hepatopancreatic COMMON BILE AND ampulla PANCREATIC DUCTS Pancreatic duct 3. HORIZONTAL Major duodenal papilla PORTION- (orifice of biliary and Pancreas 4. ASCENDING PORTION pancreatic ducts) jejunum(duodenojejunal flexure) relative ly fixed and heald in place by fibrous muscular band suspensory ligament of the doudenumligament of treits)- significant reference point in radiographic small bowel series  BODY HABITUS HYPERSTHENIC- MASSIVE BODY BUILDCHEST AND ABDOMEN BEING VERY BROAD AND DEEP FROM FRONT TO BACK. THE LUNGS ARE SHORT AND DIAPHRAGM IS HIGH. TRANVERSE COLON IS QUITE HIGH, ENTIRE LARGE INTESTINE EXTENDS TO THE PERIPHERY OF THE ABDOMINAL CAVITY GALLBLADDER IS HIGH AND ALMOST TRANSVERSE AND LIES WELL TO THE MIDLINE STOMACH IS VERY HIGH AND ASSUMES A TRANSVERSE POSITION. EXTENTENDS APPROXIMATELY T9 TO T13. 1INC DISTAL TO XIPHOID PROCESS ITS CENTER. DOUDENAL BULB IS T11 OR T12  HYPOSTHENIC/ ASTHENIC more slender and have narrow and longer lungs with low diaphragm large intestine very low in the abdomen which greatest capacity in the pelvic area stomach is j-shaped extending about t11 down below the level of the iliac crests approximately l5 or even lower. duodenal bulb near the midline at the level of l3 or l4 gallbladder- near the midline slightly to the right and just above at the level of iliac crest aproximately at l3 to l4  STHENIC stomach j-shape , located lower than in the massive body type, and generally extends from the level of t10 or t11 down about to about l2. duodenal bulb is the approximate level of l1 to l2 to right midline gallbladder less transverse and lies midway between the lateral abdominal wall and midline left colic(splenic)flexure of the large intestine is often quite high, resting under the left diaphragm RADIOGRAPH OF UPPER GASTROINTESTINAL TRACT DEMONSTRATING BODY TYPES Movement and position of the stomach in different body position Erect- stomach will move downward about 3-6 inches by gravity Supine position- stomach moves to the maximum superior movement Prone position- a greater tendency for a lower position of the stomach than in supine and fall obliquely forward and downward Right lateral recumbent- the stomach duodenum swings forward from its two areas of fixation, thereby changing its relationship to the retro-gastric structures, provides an excellent method of seperating the various anatomic parts of the stomach Obliques- design to project the different surfaces of the stomach and is used primarily for evaluation of the stomach walls as well as the duodenum.  Causes of barium retention in the stomach Hypoacidity- ✔ lack of hydrochloric acid. ✔ Permits the retention of barium coating in the mucosa, which in itself is not an indication of pathology ✔ if barium stays in the stomach beyond 6 hrs this is pathologic , and it is customary to take 3-4 hrs delayed films ✔ For infants barium will retain up to 8hrs Emotional stress ✔ Like nervousness and anxiety during the examination, tends to delay gastric emptying as a result of pyloro-bulbar spasm (closure)  DOUBLE CONTRAST DOUBLE CONTRAST TECHNEQUES HAS BEEN EMPLOYED TO ENHANCE THE DIAGNOSIS OF CERTAIN DISEASE AND CONDITION DURING UGIS RADIOLUCENT CONTRAST MEDIUM IS EITHER ROOM AIR OR CARBON DIOXIDE GAS. IXTURE, AIR IS DRAWN INTO THE BODY 2 COMMON FORMS OF CO2 GAS 1. MAGNESIUM CITRATE 2. CALCIUM POSTEXAM ELIMANATION (DEFECATION PATIENT MAY REQUIRE LAXATIVE TO HELP REMOVE THE BARIUM SULFATE  UPPER GI SERIES PROCEDURE radiographic examination of the distal esophagus, stomach and duodenum purpose- to study radiographically the form and function of the distal esophagus, stomach and duodenum as well as to detect abnormal anatomic and functional conditions contraindication- if the patient has history of bowel perforation, laceration, or viscus rupture, the use of barium sulfate may be containdicated. oral, water soluble contrast meadia may be used.  PATHOLOGIC INDICATION FOR UPPER GI SERIES bezoar- a mass of undigested materials that becomes trapped in the stomach. this mass is made up of hair, certain vegetable fibers or wood products build up over of time and may formed obstruction in the stomach. trichobezoar, made up of ingested hair. phytobezoar- is ingested vegetable fiber or seeds  DIVERTICULA weakining and blind outpouching of a portion of the mucosal wall rage between 1 and 2 cm but may be as small as a few millimeters to 8 cm in diameter asymptomatic and are discovered accidentally benign can lead to perforation if unreated other complication include inflamation, and ulceration at the site of neoplasm formation emesis- is the act of vomiting gastric carcinoma- comprises 70% of all stoamch neoplasm. radiographic sign include a large irregular filling defect within the stomach, marked or nodular edges of the stomach lining, rigidity of the stomach and associated ulceration of the mucosa gastritis- an inflamation of the lining or mucosa of the stomach acute gastrityis- severe pain and discomfort chronic gastritis- intermitentcondition that may brought on by changes in diet, stress HIATAL HERNIA- CONDITION IN WHICH PORTION OF THE STOMACH HERNIATES THROUGH THE DIAPHRAGMATIC OPENING - MAY DUE TO A CONGENETAL SHORT ESOPHAGUS OR AWAKENING OF THE MUSCLE THAT SURROUNDS THE DIAPHRAGMATIC OPENING ALLOWING PASSAGE OF ESOPHAGUS SLIDING HIATAL HERNIA- DUE TO WEAKENING OF SMALL MUSCLE (ESOPHAGEAL SPHINCTER) LOCATED BETWEEN THE TERMINAL ESOPHAGUS AND THE DIAPHRAGM. -PRODUCE RADIOGRAPHIC SIGN SCHATZKI RING.RINGLIKE CONSTRICTION AT THE DISTAL ESOPHAGUS  HYPERTROPHIC PYLORIC STENOSIS MOST COMMON GASTRIC OBSTRUCTION IN INFANT CAUSED BY HYPERTROPHY OF THE ANTRAL MUSCLE AT THE ORIFICE OF THE PYLORUS SYMPTOMS: PROJECTILE VOMITING FOLLOWING FEEDINGS, ACUTE PAIN, AND POSSIBLE DISTENTION OF THE ABDOMEN PRESENT AS DISTENSION OF THE STOMACH WITH SMALL CHANNEL OF BARIUM PASSING THROUGH THE PYLORUS INTO THE DUODENUM  ULCERS ARE EROSIONS OF THE STOMACH OR DUODENAL MUCOSA DUE TO VARIOUS PHYSIOLOGIC OR ENVIRONMENTAL CONDITIONS SUCH AS EXCESSIVE GASTRIC SECRETION, DIET AND SMOKING APPEARS AS PUNCTATE BARUIM COLLECTION THJAT MAY BE SURROUNDED BY A LUCENT HALO APPEARANCE  TYPES OF ULCER DUODENAL ULCER- IS A PEPTIC ULCER SITUATED IN THE DUODENUM - RARELY MALIGNANT PEPTIC ULCERULCERATION OF THE MUCOUS MEMBRANE OF THE ESOPHAGUS, STOMACH, OR DUODENUMCAUSED BY THE ACTION OF GASTRIC JUICE GASTRIC ULCER- ULCER OF THE GASTRIC MUCOSA PERFORATING ULCER- AN ULCER INVOLVES THE ENTIRE THICKNESS OF THE WALL OF THE STOMACH OR INTESTINE, CREATING AN OPENING ON BOTH SURFACES - PRECENSE OF FREE AIR UNDER THE DIAPHRAGM, AS SEEN IN THE ERECT RADIOGRAPH  PATIENT PREPARATRIONS Light supper in the evening prior to the examination Laxative such as castor oil if not contraindicated, to rid the intestines of fecaloid materials NPO this should be done for not less than 8-10 hours prior to the schedule of the examination, in order to ensure complete gastric emptying No smoking on or before the examination, because nicotine when taking in, will initiate gastric juice formation No breakfast so that the stomach is emptied. This will allow the barium mixture to easily coat into the mucosal lining wall. ANY ANTISPASMODIC MEDICATION SHOULD BE PREFERABLY DISCONTINUED ATLEAST 24 HOURS BEFORE THE EXAM  PEDIATRIC APPLICATIONS PEDIATRIC BARIUM PREPARATION PREPARATION FOR UPPER GI - NB TO 1 YEAR: 2 TO 4 OZ. -INFANT UNDER 1 YEAR: NPO FOR 4 - 1 TO 3 YEAR: 4 TO 6 OZ HOURS - 3 TO 10 YEAR: 6 TO 12 -CHILDREN OLDER OZ THAN 1 YEAR: NPO - OLDER THAN 10 FOR 6 HOURS YEARS: 12 TO 16 OZ  RADIOGRAPHIC POSITIONING UPPER GI ROUTINE ESOPHAGRAM - AP SCOUT(SUPINE) ROUTINE - RAO (RECUMBENT) - RAO - PA (RECUMBENT) - LEFT LATERAL - RIGHT LATERAL - AP (RECUMBENT) - LPO (RECUMBENT) - PA - AP (RECUMBENT) - LAO - DOUBLE CONTRAST TECHNIQUES  Barium preparation ✔ 2:1 (60-66%) or 70-80%) barium mixture Methods of administering the contrast medium ❖ Double meal method ✔ The patient is required to bring home a glassful of barium mixture to be ingested 5hrs prior to the examination ✔ Second meal is administered during the examination ✔ Disadvantage: there will be superimposition between the filled up small intestine and the stomach ❖ Single meal method ✔ Barium mixture is administered during the actual examination  Scout film purpose To check the technical factors To demonstrate calcific densities within the abdominal cavity; in short for incidental findings To know if the patient is well prepared for the examination To locate the reference structure which is the pylorus, in order to be able to determine the exact location of the R.P which is four inches to the left of the pylorus Patient lies flat on his back, or on his Supine or Prone abdomen Center the MSP to the midline of the table Reference plane- along the level of the lower lateral coastal arches or 2-3 inches above the ASIC Adjust the cassette so that its upper border is approximately two inches above the xiphoid process Reference point- midpoint of the cassette Central ray is directed vertically to the midpoint of the film Ask the patient to suspend respiration for the exposure  RAO POSITION: UGIS PATHOLOGY DEMONSTRATED: POLYPS AND ULCER OF THE PYLOROUS, DUODENAL BULB, AND C LOOP OF THE DOUDENUM TECHNICAL FACTORS: 10X12 OR 11X14 LENGTHWISE; MOVING OR STATIONARY GRID SHIELDINGS: PELVIC REGION PATIENT POSITION: RECUMBENT WITH THE BODY PARTIALLY ROTATED INTO RAO POSITION; PROVIDE PILLOW FOR HEAD FROM A PRONE POSITION ROTATE 40-70 WITH RIGHT PART POSITION ANTERIOR BODY AGAINST IR OR TABLE(MORE ROTATION SOMETIMES REQUIRED FOR HEAVY HYPERSTHENIC TYPE PATIENTS AND LESS FOR THIN ASTHENIC TYPES) PLACE RIGHT ARM DOWN AND LEFT ARM FLEXED AT ELBOW AND UP BY THE PATIENTS HEAD FLEX LEFT KNEE FOR SUPPORT  CENTRAL RAY DIRECT CR PERPINDICULAR TO IR STHENIC TYPE: CENTER CR AND IR TO DOUDENAL BULB AT LEVEL OF L1 (1-2 INCHES, OR 2.5-5CM, ABOVE LOWER LATERAL RIB MARGIN), MIDWAY BETWEEN SIPNE AND UPSIDE LATERAL BORDER OF ABDOMEN, 45-55 OBLIQUE ASTHENIC: CENETER ABOUT 2 INCHES (5CM) BELOW LEVEL OF L1, 40 OBLIQUE HYPERSTHENIC: CENETER ABOUT 2 INCHES (5CM) ABOVE LEVEL OF L1 AND NEARER MIDLINE, 70 INCHES OBLIQUE CENTER CASSETTTE TO CR MINIMUM SID IS 40 INCHES (100CM) COLLIMATION COLLIMATE ON 4 SIDES TO OUTER MARGINS OF IR TO AREA OF INTEREST ON LARGER IR RESPIRATION SUSPENDED AND EXPOSED ON EXPIRATION  Fundus Greater curvature Duodenal bulb Pylorus Single-contrast PA oblique stomach and duodenum. Double-contrast PA oblique stomach and RAO position. duodenum. Note esophagus entering stomach (arrow).  RADIOGRAPHIC CRITERIA POSITION: DUODENAL BULB IS IN PROFILE EXPOSURE CRITERIA: APPROPRIATE TECHNIQUE IS USED TO CLEAR LY VISUALIZED THE GASTRIC FOLDS WITHOUT OVEREXPOSING OTHER PERTINENT ANATOMY. SHARP STRUCTURAL MARGINS INDICATE NO MOTION  PATHOLOGY DEMONSTRATED: PA PROJECTION: UGIS POLYPS, DIVERTICULA, BEZOARS, AND SIGN OF GASTRITIS IN THE BODY AND PYLOROUS OF THE STOMACH ARE SHOWN TECHNICAL FACTORS: 10X12 OR 11X14 LENGTHWISE OR 14X17 IF SMALL BOWEL INCLUDED; SHIELDING: PELVIC REGION PATIENT POSITION: PRONE, WITH ARMS UP BESIDES HEAD; PROVIDE PILLO PART POSITION: 1. ALIGN MIDSAGITTAL PLANE TO CR AND TO TABLE 2. ENSURE THAT THE BODY IS NOT ROTATED  CENTRAL RAY DIRECT CR PERPINDICULAR TO IR STHENIC TYPE: CENTER CR AND IR TO LEVEL OF PYLOROUS AND DOUDENAL BULB LEVEL OF L1 (1-2 INCHESS OR 2.5-5cm, ABOVE LOWER LATERAL RIB) AND ABOUT 1INCH LEFT OF THE VERTEBRAL COLUMN ASTHENIC: CENETER ABOUT 5 CM OR 2 INCHES BELOW LEVEL OF L1 HYPERSTHENIC: CENTER ABOUT 5CM OR 2 INCHES ABOVE LEVEL OF L1 AND NEARER MIDLINE CENTER CASSETTE TO CR RESPIRATION SUSPENDED AND EXPOSE ON EXPIRATION  COLLIMATION ALTERNATE PA AXIAL: POSITION OF THE HIGH TRANSVERSE STOMACH ON A HYPERSTHENIC PATIENT 35-45 CEPHALIC ANGLE OF THE CR INFANTS: 20-25 CEPHALIC CR ANGLE TO OPEN THE BOBY AND PYLOROUS OF STOMACH STRUCTURES SHOWN: RADIOGRAPHIC CRITERIA ENTIRE STOMACH AND DOUDENUM ARE VISIBLE POSITION: BODY AND PYLOROUS OF THE STOMACH ARE BARIUM FILLED EXPOSURE CRITERIA: APPROPRIATE TECHNIQUE IS USED TO VISUALIZE THE GASTRIC FOLDS WITHOUT OVEREXPOSING OTHER PERTINENT ANATOMY; SHARP STRUCTURAL MARGINS INDICATE NO MOTION  RIGHT LATERAL: UGIS pathology demonstrated: pathologic process of the retrogastric space(space behind the stomach). diverticula, tumors, gastric ulcers, trauma to the stomach may be demonstrated along the posterior margin of the stomach technical factors: 10x12 or 11x14 lengthwise shielding: pelvic region  patient position: recumbent in a right lateral position. part position: 1. ensure that shoulders and hips are in a true lateral position 2. center ir at cr (bottom cassette about at level of iliac crest) Center the IR at the level of Ll -L2 for the rec umbent position (about 1 -2 inches above the lower rib margin) and at L3 for the upright position. Respiration: Suspend at the end of expiration unless otherwise requested.  RADIOGRAPHIC CRITERIA STRUCTURES SHOWN:ENTIRE STOMACH AND DOUDENUM ARE VISIBLE. RETROGASTRIC SPACE IS DEMONSTRATED. PLYLOROUS OF STOMACH Fundus AND C-LOOP OF DOUDENUM SHOULD BE VISUALIZED WELL on HYPERSTENIC PATIENTS Body EXPOSURE CRITERIA: Duodenum APPROPRIATE TECHNIQUE IS USED TO VISUALIZED THE Duodenal bulb GASTRIC FOLDS WITHOUT OVEREXPOSING OTHER PERTINENT ANATOMY; SHARP Pyloric portion STRUCTURAL MARGINS INDICATE NO MOTION  LPO POSITION: UGIS PATHOLOGY DEMONSTRATED: WHEN A DOUBLE CONTRAST TECHNIQUE IS USED, THE AIR FILLED PYLOROUS AND DOUDENAL BULB MAY BETTER DEMONSTRATE SIGNS OF GASTRITIS AND ULCER TECHNICAL FACTORS: IR 10X12 OR 11X14 LENGTHWISE SHIELDING: PELVIC REGION PATIENT POSITION: RECUMBENT, WITH THE BODY PARTIALLY ROTATED INTO AN LPO POSITION; ROTATE 30-60 DEGREE FROM PART POSITION SUPINE POSITION, WITH LEFT POSTERIOR AGAINST IR OR TABLE (MORE ROTATION POSSIBLY REQUIRED FOR HEAVY HYPERSTHENIC PATIENT AND LESS FOR THIN ASTHENIC TYPE FLEX RIGHT KNEE FOR SUPPORT EXTEND LEFT ARM FROM BODY AND RAISE RIGHT ARM HIGH ACROSS CHEST TO GRASP END OF TABLE FOR SUPPORT. (DO NOT PINCH FINGERS WHEN MOVING BUCKY.) CENTER IR AT CR (BOTTOM OF CASSETTE AT LEVEL OF ILIAC CREST)  CENRAL RAY DIRECT CR PERPENDICULAR TO IR STHENIC: CENTER CR AND IR TO LEVEL OF L1 (ABOUT MIDWAY BETWEEN XIPPOID TIP AND LOWER LATERAL MARGIN OF RIBS) AND MIDWAY BETWEEN MIDLINE OF BODY AND LEFT LATERAL MARGIN OF ABDOMEN, 45 DEGREE OBLIQUE HYPERSTHENIC: CENTER ABOUT 2 INCHES ABOVE L1, 60 DEGREE OBLIQUE ASTHENIC: CENTER ABOUT 2 INCHES BELOW L1 AND NEARER TO MIDLINE, 30 DEGREE OBLIQUE RESPIRATION SESPENDED AND EXPOSED ON EXPIRATION Esophagus Fundus Body us Pylous Duodenum  RADIOGRAPHIC CRITERIA EXPOSURE CRITERIA: APPROPRIATE TECHNIQUE IS USED TO VISUALIZE GASTRIC FOLDS WITHOUT OVEREXPOSING OTHER PERTINENT ANATOMY; SHARP STRUCTURAL MARGINS INDICATE NO MOTION  AP PROJECTION: UGIS pathology demonstrated: possible hiatal hernia may be demonstrated in trendelenburg position technical factor: ir 11x14 or 14x17 lengthwise shielding: pelvic region patient posti0n: supine, arms at sides; provide pillow for head  part position: 1. align midsagittal plane to ir 2. ensure that body is not rotated 3. center cassette to cr (bottom of 11x14 casette should be about at level of iliac crest  CENTRAL RAY CENTER CR PERPENDICULAR TO IR STHENIC: CENTER CR AND IR TO LEVEL OF L1 (MIDWAY BETWEEN XIPHOID TIP AND LOWER MARGIN OF RIBS), MIDWAY BETWEEN MIDLINE AND LEFT LATERAL MARGIN OF ABDOMEN HYPERSTHENIC: CENTER ABOUT 1 INCH ABOVE L1 ASTHENIC: POSITION CR ABOUT 2 INCHES BELOW AND NEARER TO MIDLINE RESPIRATION SUPENDED AND EXPOSE ON EXPIRATION  structures shown Fundus Body Pyloric portion Duodenal loop  Esophagus Fundus Lung Duodenum AP stomach and duodenum. showing hiatal hernia above the level of the diaphragm (arrow). Upright left lateral stomach showing hiatal hernia  RADIOGRAPHIC CRITERIA exposure criteria: appropriate technique is used to visualiozed the gastric folds withut overexposing other pertinent anatomy. sharp structural margins indicate no motion  PA oblique projection (wolf method) for hiatal hernia ✔ Modification of the trendelenburg position ✔ Semicylindrical radiolocent compression device measuring 22 inches long. 10 inches wide and 8 inches high Patient position ✔ Place the patient in the prone position on the radiographic table  Part position ✔ Instruct the patient to assume a modified knee chest position during placement of the compression device ✔ Place the compression device horizontally under the abdomen and just below the costal margin ✔ Adjust the patient in a 40-45 degree RAO position, with the thorax centered to the midline of the grid  Central ray ✔ Perpendicular to the long axis of the patients back and centered at the level of either T6 or T7. this position usually result in 10-20 degrees caudad angulation Respiration is suspended at the end of expiration Structures shown ✔ Demonstrate the relationship of the stomach to the diaphragm and is useful in diagnosis a hiatal Comparison PA axial oblique images in one patient. A, Without abdominal hernia compression: no evidence of hernia. B, With abdominal compression: obvious large sliding hernia  One hour delayed film Purpose ✔ To determine gastric emptying ✔ To know how much barium was left ✔ To demonstrate the presence of ascaris worms  Positioning Supine or prone ✔ Place the patient in the recumbent position either prone or supine ✔ Adjust the body and center the MSP to the midline of the table ✔ Reference plane: along the level of the lower lateral coastal arches or 2-3 inches above the ASIC ✔ Central ray is projected perpendicularly passing thru the R.P. and to a point of the film ✔ Respiration is suspended for the exposure  Ways of producing air in the stomach By allowing the patient to sip the barium mixture with the use of two straw, one outside the glass and the other inside By instructing the patient to breath thru his mouth or swallow air after the ingestion of the barium mixture By giving the patient gas producing tablets like “gastroluft” By giving the patient carbonated drink  Modification in UGIS Gordon’s Modification the best projection to demonstrate the pylorus and the bulb for hypersthenic patients ✔ Patient is place in the Parts position prone position ✔ Adjust the body and center a plane that passes 4 inches to the left of the pylorus to the midline of the table ✔ Reference point: 4 inches to the left of the pylorus ✔ Central ray is projected 35-45 degree cranially passing thru the R.P.  Use 10X12 film placed lengthwise and adjust it so that its midpoint coincides with the Fundus direction of the C.R Exposure is at the end of suspended respiration Structures shown Body ✔ Gordon developed the PA axial Lesser curvature projection to “open up” the Greater curvature high horizontal (hypersthenic Type) stomach for demonstration of the greater Pyloric region and lesser curvatures, the antral portion of the stomach, the pyloric canal and the duodenal DOUDENUM bulb  Gugliantini Modification This modification is for infants ✔ The position of the patient is the same in gordon’s modification ✔ The C.R. is directed at an angle of 35 degree cranially  Hampton’s Modification (LPO) This is the best modification to demonstrate a leaf-like pattern of the Pylorus and the bulb ✔ Patient first assumes a supine position ✔ Elevate the right side of the body approximately 45 degrees in such a way that the bulb is separated from the vertebrae ✔ Place support under the elevated side ✔ Center a plane that passes midway between the MSP and the mid axillary plane to the midline of the table or cassette ✔ Reference point: along the level of the pylorus ✔ Adjust a 10x12 film placed lengthwise and center it to the reference plane ✔ Reference point: midpoint of the film ✔ Central ray is directed perpendicularly to the midpoint of the film ✔ Respiration is suspended for the exposure Poppel’s Method: (right angle view of the stomach Used to demonstrate the retrogastric space and to evaluate pancreatic mass Note: in this case the patient should be positioned right after the ingestion of the CM  Positioning 1st exposure ✔ With the C.R. directed horizontally, place the patient in the supine position ✔ Adjust the cassette placed vertically at the right side and center it to a plane that passes midway between the mid axillary plane and the anterior aspect of the body, at the level of the umbilicus ✔ Adjust the C.R. and direct it to the midpoint of the film ✔ Use 10x12 film placee lenghtwise ✔ Exposure is taken at the end of exhalation  2nd exposure ✔ Shift the tube and direct the C.R. vertically passing thru the R.P. which is 4 inches to the left of the pylorus, centered to the midline of the table ✔ Adjust a 10x12 film placed lengthwise and center it to the direction of the C.R. ✔ Ask the patient to suspend respiration for the exposure Structure shown ✔ Used to demonstrate the right angle view of the stomach and the retrogastric space, and for the elevation of pancreatic mass, pancreatic cancer and pancreatitis  UGIS for infants ✔ The most frequent indication is obstruction ✔ No feeding prior to the examination to starve the patient ✔ A catheter is inserted down to the stomach thru the nose Pediatric patient preparation for the upper GI ✔ Infant younger than one year NPO for 4hrs ✔ Children older that one year NPO for 6 hrs  Barium preparation Milk barium mixture, 4 parts milk and I part water Prepare enough amount around 50 cc barium mixture may be introduced by the pressure (syringe) method, or the gravity method, via the catheter If no catheter is available, a feeding bottle may be used  PEDIATRIC APPLICATIONS PEDIATRIC BARIUM PREPARATION PREPARATION FOR - NB TO 1 YEAR: 2 TO 4 UPPER GI OZ. -INFANT UNDER 1 - 1 TO 3 YEAR: 4 TO 6 OZ YEAR: NPO FOR 4 HOURS - 3 TO 10 YEAR: 6 TO 12 OZ -CHILDREN OLDER THAN 1 YEAR: NPO FOR - OLDER THAN 10 6 HOURS YEARS: 12 TO 16 OZ  RADIOGRAPHIC POSITIONING UPPER GI ROUTINE - AP SCOUT(SUPINE) ESOPHAGRAM ROUTINE - RAO (RECUMBENT) - RAO - PA (RECUMBENT) - LEFT LATERAL - RIGHT LATERAL (RECUMBENT) - AP - LPO (RECUMBENT) - PA - AP (RECUMBENT) - LAO - DOUBLE CONTRAST TECHNIQUES  Barium preparation ✔ 2:1 (60-66%) or 70-80%) barium mixture Methods of administering the contrast medium ❖ Double meal method ✔ The patient is required to bring home a glassful of barium mixture to be ingested 5hrs prior to the examination ✔ Second meal is administered during the examination ✔ Disadvantage: there will be superimposition between the filled up small intestine and the stomach ❖ Single meal method ✔ Barium mixture is administered during the actual examination LOWER GASTROINTESTINAL SYSTEM  COMMON RADIOGRAPHIC PROCEDURES SMALL BOWEL SERIES (SBS) – STUDY OF SMALL INTESTINE - THIS EXAMINATION IS OFTEN COMBINED WITH AN UGIS AND UNDER THESE CONDITIONS MAY BE TERMED A SMALL BOWEL FOLLOW THROUGH BARIUM ENEMA (BE, LOWER GI SERIES, COLON) – STUDY OF LARGE INTESTINE - THE RADIOGRAPHIC PROCEDURE DESIGNED TO STUDY THE LARGED INTESTINE  3 PARTS OF SMALL INTESTINE DUODENUM (RUQ AND LUQ)- IT IS THE SHORTEST, WIDEST AND MOST FIXED PORTION OF THE SMALL BOWEL JEJUNUM (LUQ AND LLQ) – (2/5)BEGINS AT THE SITE OF THE DUODENOJEJUNAL JUNCTION SLIGHTLY TO THE LEFT OF THE MIDLINE IN THE LUQ ILEUM (RLQ AND LLQ)- (3/5) THE LONGEST PORTION OF THE SMALL BOWEL. THE TERMENAL ILEUM JOINTS THE LARGE INTESTINE AT THE ILEOCECAL VALVE FOUR MAJOR PARTS OF THE LARGE INTESTINE Left colic flexure Right colic-flexure Descending colon Ascending colon Taenia coli Ileocecal valve Haustra Cecum Sigmoid colon Anus  LARGE VERSUS SMALL INTESTINE INTERNAL DIAMETER OF THE LARGE INTESTINE IS USUALLY GREATER THAN THE DIAMETER OF THE SMALL INTESTINE MUSCULAR PORTION OF THE INTESTINAL WALL CONTAINS 3 EXTERNAL BANDS OF LONGITUDINAL MUSCLE FIBERS OF THE LARGE BOWEL TO FORM 3 BANDS OF MUSCKLE CALLED TAENIAE COLI W/C TEND TO FULL THE LARGED INTESTINE INTO POUCHES CALLED HAUSTRUM RELATIVE POSITION; LARGE INTESTINE EXTENDS AROUND THE PERIPHERY OF THE ABDOMINAL CAVITY. SMALL IS MORE CENTERALLY LOCATED  LOWER DIGESTIVE FUNCTION FUNCTION RESPONSIBLE COMPONENT OF INTESTINE DIGESTION: CHEMICAL AND SMALL INTESTINE: MECHANICAL ABSORPTION : NUTRIENTS, H2O, DUODENUM SALTS, PROTIENS REABSOPTION: H2O AND SALTS AND ORGANIC SALTS JEJUNUM VITAMIN B AND K AND AMINO ACIDS- PRODUCED BY BACTERIAL ACTION; RELEASE OF GASES (FLATUS) LARGE INTESTINE ELIMANATION (DEFECATION  DIGESTIVE MOVEMENTS AND ELIMANATION RESPONSIBLE COMPONENT OF FUNCTION INTESTINE SMALL INTESTINE PERISTALSIS RHYTHMIC SEGMENTATION PERISTALSIS LARGE INTESTINE HAUSTRAL CHURNING MASS PERISTALSIS DEFECATION  SMALL BOWEL SERIES PURPOSE: TO STUDY THE FORM AND FUNCTION OF THE THREE COMPONENTS OF THE SMALL BOWEL, AS WELL AS DETECT ANY ABNORMAL CONDITIONS- WATER SOLUBLE, IODENATED MEDIA SHOULD BE USED CONTRAINDICATIONS: 1. PRESURGICAL PATIENTS AND PERFORATED HALLOW VISCUS 2. BARIUM SULFATE BY ORAL IS CONTRAINDICATED WITH POSIBLE LARGED BOWEL OBSTRUCTION- SHOULD BE R/O WITH AN ACUTE ABDOMINAL SERIES AND A BARIUM ENEMA  PATHOLOGIC INTRAINDICATION ENTERITIS- INFLAMATION OF THE INTESTINE, CAUSED BY BACTERIAL OR PROTOZOAN ORGANISM OF OTHER ENVIRONMENTAL FACTOR GASTROENTERITIS- CHRONIC IRRATATION CAUSE THE LUMEN OF THE INTESTINE TO BECOME THICKENED, IRREGULARAND NARROWED REGIONAL ENTERITIS (SEGMENTAL ENTERITIS OR CROHNS DISEASE)- CHRONIC INFLAMMATORY DISEASE OF UNKNOWN ITIOLOGY, INVOLVING ANY PART OF THE GI TRACT BUT COMMONLY INVOLVING TERMINAL ILEUM, WITH SCARRING AND THICKENING OF THE BOWEL WALL PRODUCE COBBLESTONE APPEARANCE  GIARDIASIS- COMMON INFECTION OF THE LUMENOF THE SMALL INTESTINE DUE TO FLAGELLATE PROTOZOAN. SYMPTOMS: NONSPECIFIC GI DISCOMFORT, MILD TO PROFUSE DIARRHEA, NAUSEA, ANOREXIA AND WIEGHT LOSS ILEUS- AN OBSTRUCTION OF THE SMALL INTESTINE. 2 TYPES: 1. ADYNAMIC OR PARALYTIC- ILEUS IS DUE TO CESSATION OF PERISTALSIS. CAUSES: INFECTION SUCH PERITONITIS OR APENDICITIS, PRESENCE OF CERTAIN DRUGS, OR POSTSURGICAL COMPLICATION 2. MECHANICAL OBSTRUCTION- PHYSICAL BLOCKAGE OF THE BOWELDUE TO TUMORS, ADHESION OR HERNIAS. LOOPS OF INTESTINE PROXIMAL TO THE SITE OF OBSTRUCTION ARE MARKEDLY DILATED WITH GAS CALLED CIRCULAR STAIRCASE OR HERRINGBONE PATTERN MECKELS DIVERTICULUM- FAIRLY COMMON BIRTH DEFECT FOUND IN THE ILEUM OF THE SMALL INTESTINE. MEASURE AS LARGE AS 10-12CM IN DIAMETER, USUALLY 2-4 FEET PROXIMAL TO THE ILEOCECAL VALVE NEOPLASM- MEANING “NEW GROWTH” MAY BE BENIGN OR MALIGNANT(CANCEROUS). COMMON BENIGN TUMORS OF THE SMALL INTESTINE INCLUDE ADENOMAS AND LEIOMYOMAS CARCINOID TUMORS- MOST COMMON TUMORS OF THE SMALL BOWEL. SMALL SIZE LESIONS THAT TEND TO GROW SUBMUCOSALLY AND ARE FREQUENTLY MISSED RADIOGRAPHICALLY LYMPHOMA AND ADENOCARCINOMA- MALIGNANT TUMORS OF THE SMALL INTESTINE. LYMPHOMAS ARE DEMONSTRATED DURIND SMS AS PRODUCING “STACKED COIN” SIGN CAUSED BY THICKENING, COARSENING, AND POSSIBLE HEMORRHAGE OF THE MUCOSAL WALL. ADENOCARCINOMASPRODUCE SHORT AND SHARP “NAPKIN-RING” DEFECTS WITHIN THE LUMEN AND MAY LEAD COMPLETE OBSTRUCTION SPRUE AND MALABSORPTION SYNDROMES- CONDITIONS IN WHICH THE PATIENTS GI TRACT IS UNABLE TO PROCESS AND ABSORB CERTAIN NUTRIENTS. DUE TO INTRALUMIBNAL DEFECTS , MUCOSAL ABNORMALITY, OR LYMPHATIC OBSTRUCTION. CELIAC DISEASE- FORM OF SPRUE OR MALABSORPTION DISEASE AFECTING THE PROXIMAL SMALL BOWEL, ESPECIALLY THE PROXIMAL DUODENUM WHIPPLES DISEASE- DISORDER OF THE PROXIMAL SMALL BOWEL. SYMPTOMS INCLUDE DILATATION OF THE INTESTINE EDEMA, MALABSORPTION, DEPOSITE OF FAT IN THE BOWEL WALL AND MESENTERIC NODULES CONDITION OR DISEASE MOST COMMON RADIOGRAPHIC POSSIBLE RADIOGRAPHIC APPEARANCE EXAM ENTERITIS SBS, ENTEROCLYSIS THICKENING OF MUCOSAL FOLDS AND POOR DIFINATION OF CIRCULAR FOLDS RTEGIONAL ENTERITIS SBS, ENTEROCLYSIS SEGMENTS OF LUMEN NARROWED AND IRREGULAR; (CROHNS DISEASE) “COBBLESTONE” APPEARANCE AND “STRING SIGN” BEING COMMON GIARDIASIS SBS, ENTEROCLYSIS DILATATION OF THE INTESTINE, WITH THECKENING OF THE CIRCULAR FOLDS ILEUS (OBSTRUCTION) ACUTE ABDOMEN SERIES, SBS, ABNORMAL GAS PATTERNS, DILATED LOOPS OF BOWEL ADYNAMIC MECHANICAL ENTEROCLYSIS “CIRCULAR STAIRCASE” OR “HERRINGBONE” PATTERN MALABSORPTION SBS, ENTEROCLYSIS OR CT OF THICKENING OF MUCUSAL FOLDS AND POOR SYNDROMES (SPRUE) THE ABDOMEN DEFINATION OF NORMAL “FEATHERY” APPEARANCE MECKELS DIVERTICULUM NUCLEAR MEDICINE SCAN, SBS, LARGE DIVERTICULUM OF THE ILEUM, PROXIMAL TO ENTROCLYSIS ILEOCECAL VALVE; RARELY SEEN ON BARIUM STUDIES NEOPLASM SBS, ENTEROCLYSIS, OR CT OF NARROWED SEGMENTS OF INTESTINE, “APPLE-CORE” THE ABDOMEN OR “NAPKIN RIGN SIGN”; PARTIAL OR COMPLETE OBSTRUCTION WHIPPLES DISEASE SBS DILATATION AND DISTORTED LOOPS OF SMALL BOWEL Preliminary preparation of the patient for SIS Light supper in the evening prior to the examination Cathartics or purgatives like castor oil to be administered before bedtime, to evacuate all the facaloid materials in the intestine NPO No breakfast Patients is told to report on time  Objectives in doing SIS To know the anatomy of the small intestine To know the physiology. Transit or emptying time- 5 to 6 hrs To demonstrate such pathology in the small intestines as 1. Obstructive phenomenon, whether muscular or vascular 2. Absorption phenomenon. Ex. Malabsorption 3. Congenital anomaly. Ex. Double wall intestine 4. Intestinal bleeding  SMALL BOWEL PROCEDURES UGI SMALL BOWEL COMBINATION- PROCEDURE A ROUTINE UGIS IS DONE FIRST. AFTER THE ROUTINE STOMACH STUDY PROGRESS OF THE BARIUM IS FOLLOWED THROUGH THE ENTIRE SMALL BOWEL. - PATIENT INGESTED 1 FULL CUP OR 8 OUNCES OF BARIUM SULFATE MIXTURE. SMALL BOWEL ONLY SERIES-2 CUPS (16 OUNCES) OF BARIUM ARE INGESTED , THE TIME IS NOTED. ENTEROCLYSIS-DOUBLE CONTRAST SMALL BOWEL- THE INJECTION OF A NUTRIENT OR MEDICINAL LIQUID INTO THE BOWELSMALL BOWEL PROCEDURES, STUDY WHERE THE PATIENT IS INTUBATED UNDER FLOUROSCOPIC CONTROL WITH A SPECIAL ENETEROCLYSIS CATHETER THAT PASSES TROUGH THE STOMACH INTO THE DUODENUM TO THE REGION OF THE DUODENOJEJUNAL JUNCTION (SUSPENSORY LIGAMENT). BILBAO O SELLINK TUBE IS PLACE INTO TERMINAL DUODENUM. BARIUM SULFATE IS INJECTEDAT AT A RATE OFF 100mL/MINUTE. AIR OR METHELCELLULOSE IS INJECTED INTO THE BOWEL TO DESTEND AND PROVIDE A DOUBLE CONTYRAST EFFECT DISADVANTAGE: ENTEROCLYSIS ARE INCREASED PATIENT DISCOMFORT AND THE POSIBILITY OF BOWEL PERFORATION DURING CATHETER PLACEMENT INDICATED WITH PATIENT WITH CLINICAL HISTORIES OF SMALL BOWEL ILEUS, REGIONAL ENTERITIS, OR MALABSORPTION SYNDROME. INTUBATION METHOD- SINGLE CONTRAST MEDIA STUDY (SMALL BOWEL ENEMA)- TECHNIQUE WHERE BY A NASOGASTRIC TUBE IS PASSED THROUGH THE PATIENT NOSE, ESOPHAGUS, STOMACH, DUODENUM AND INTO JEJUNUM -DIAGNOSTIC INTUBATION – A SINGLE LUMEN TUBE IS PASSED INTO THE PROXIMAL JEJUNUM - THERAPUTIC- PROCEDURE IS OFTEN PERFORMED TO RELIEVE POST OERATIVE OR DECOMPRESS A SMALL BOWEL OBSTRACTION. A DOUBLE LUMEN CATHETER, TERMED MILLER ABBOTT(MA)TUBE IS ADVANCED INTO THE STOMACH Reasons why supine position is recommended in SIS To avoid abdominal pressure thus preventing overlapping of the loops of the small intestine To avail of the of the superior movement of the stomach, thus demonstrating the C-loop and the retrogastric better  UGI- SMALL BOWEL COMBINATION basic: routine gi first notation of time patient ingested first cup (80z) of barium ingestionof second cup of barium 30 min pa radiograph (centering high for proximal sb) half our interval radiographs, centered to iliac crest, until barium reaches large bowel (usually 2 hrs) 1 hour interval radiographs if more time is needed after 2 hrs optional: flouroscopy and sp[ot filming of iliocecal valve and terminal ileum(compression cone may be used) SMALL BOWEL ONLY SERIES BASIC: PLAIN ABDOMEN RADIOGRAPH (SCOUT) 2 CUPS (16 OZ) OF BARIUM INGESTED (NOTING TIME) 15 TO 30 MINUTE RADIOGRAPH (CENTERED HIGH FOR PROXIMAL SB) HALF HOUR INTERVAL RADIOGRAPH (CENETERED TO CREST)UNTIL BARIUM REACHES LARGE BOWEL (USUALLY 2 HOURS) 1 HOUR INTERVAL RADIOGRAPH, IF MORE TIME IS NEED (SOME ROUTINES INCLUDING CONTINOUS HALF HOUR INTERVALS) OPTIONAL: FLOUROSCOPY WITH COMPRESSION SOMETIMES REQUIRED) ENTROCLYSIS (DOUBLE-CONTRAST SBS Procedure: special catheter advanced to duodenojejunal junction thin mixture of barium sulfate instilled ir or methylcellulose instilled flouroscopic spot films and conventional radiograph taken on successful completion of exam, intubation tube is remove INTUBATION METHOD (SINGLE CONTRAST SBS) SINGLE LUMEN CATHETER ADVANCED TO PROXIMAL JEJUNUM (DOUBLE LUMEN CATHETER FOR THERAPEUTICINTUBATION) WATER SOLUBLE IODINATED AGENT OR THIN MIXTURE OF BARIUM SUFATE INSTILLED TIME NOTED AT WHICH THAT CONTRAST MEDIA INSTILLED CONVENTIONAL RADIOGRAPH OPR OPTIONAL FLOUROSCOPIC SPOT FILMS TAKEN AT SPECIFIC TIME INTERVALS  PATIENT PREPARATION foods and fluid must be witheld for atleast 8 hrs before the exam patient should be on a low residue diet 48 hrs before the small bowel series the patient should not smoke cigarettes or chew gum during NPO period. before the procedure the patient should be asks to void. so as not to caused displacement of the ileum due to distended bladder  Precaution For patients who are actively bleeding, barium should be mixed with CM. prepare thin mixture only, also no cleansing enema in this case so as not to aggravate condition of the patient For definite obstruction- give low pressure enema only, so as not to cause rupture of the obstructed area In case of patient having diarrhea-no cleansing enema In case of acute appendicitis-no barium enema  How to clean the enema system Place soap suds in the enema can before using it to remove the barium and then put water to wash out the soap and the barium left in the tubing. Then boil the entire system for about five minutes  How to operate the enema system Place the enema can about 18 – 24 inches above the patients anus for low pressure enema and then introduce the mixture slowly BARIUM ENEMA (BE OR LOWER GI SERIES) IT REQUIRES THE USE OF A CONTRAST MEDIA TO DEMONSTRATE THE LARGE INTESTINE AND ITS COMPONENTS PURPOSE:IS TO RADIOGRAPHICALLY STUDY THE FORM AND FUNCTION OF THE LARGE INTESTINE TO DETECT ANY ABNORMAL CONDITIONS CONTRAINDICATIONS: 1. POSSIBLE PERFORATED HOLLOW VISCUS 2. POSIBLE LARGED BOWEL OBSTRUCTION APPENDECITIS- NOT PERFORM BECAUSE OF THE DANGER OF PERFORATION NOTE:IF A BIOPSY OF THE COLON WAS PERFORMED DURING THE PROCEDURE , TH EINVOLVE SECTION OF THE COLON WALL AMAY BE WEAKNED, WHICH MAY LEAD TO PERFORATION DURING THE EXAM  PATHOLOGIC INTRAINDICATION colitis- inflamatory condition of the large intestine that may be caused by many factors including bacterial infection, diet, stress and other environmental conditions. the intestinal wall has a “saw tooth” or jagged appearance ulcerative colitis- severe colitis that most common in young adults. often leads to coinlike ulcers developing within the mucosal wall. multiple ring shaped filling defects , creating “cobblestone” appearance along the mucosa.patients with long term bouts of ulcerative colitis may develop “stovepipe” colon, in which the haustral markings and flexures are mostly absent DIVERTICULUM- OUTPOUCHING OF THE MUCOSAL WALL RESULTING FROM HERNIATION OF THE INNER WALL OF THE COLON. MOST COMMON IN ADULT PAST 40YRS OLD. DIVERTICULOSIS; CONDITION OF HAVING NUMEROUS DIVERTICULA. DIVERTICULITIS; INFECTED DIVERTICULA DIVERTICULA- APPEAR AS SMALL BARIUM FILLED CIRCULAR DEFECTS PROJECTING OUTWARD FROM THE COLON WALL DURING BARIUM INTUSSUSCEPTION- TELESCOPING OR INVAGINATION OF ONE PART OF THE INTESTINE INTO ANOTHER. COMMON IN INFANTS UNDER 2 YRS OLD. BARIUM ENEMA OR AIR/GAS ENEMA MAY PLAY A THERAPEUTIC ROLE IN EXPANDING THE INVOLVE BOWEL. BARIUM COLUMN TERMINATES INTO :MUSHROOM SHAPED” DILATATION WITH LITTLE BARIUM/GAS PASSING BEYOND IT NEOPLASM- BENIGN TUMORS DO OCCUR, CARCINOMA OF THE LARGE INTESTINE IS A LEADING CAUSE OF DEATH IN BOTH MALE AND FEMALE. OCCUR MAJORITY IN THE RECTUM AND SIGMOID COLON. APPLE CORE” OR NAPKIN-RING LESSION ANNULAR CARCINOMA (ADENOCARCINOMA)- ONE OF THE MOST TYPICAL FORMS OF COLON CANCER THAT MAY FORM AN “APPLE CORE” OR NAPKIN RING APPEARANCES AS THE TUMORS GROWS AND INFILTRATES THE BOWEL WALLS. POLYPS- SACLIKE PROJECTIONS SIMILAR TO DIVERTICULA EXCEPT THAT THEY PROJECT INWARD INTO THE LUMEN RATHER THAN OUTWARD AS DO DIVERTICULA. VOLVULUS- TWISTING OF A PORTION OF THE INTESTINE ON ITS OWN MESENTERY, LEADING TO A MECHANICAL TYPE OBSTRUCTION FOUND IN JEJUNUM OR ILEUM OR CECUM AND SIGMOID. OCCOR IN MALES THAN FEMALE AND MOST COMMON BETWEEN 20 TO 50 YRS. THE CLASSIC SIGN IS CALLED “BEAK” SIGN CECAL VOLVULUS- DESCRIEBE THE ASCENDING COLON AND THE CECUM HAVING A LONG MESENTERY, MAKING THEM MORE SUSCEPTABLE TO A VOLVULUS CONDITION OR DEASE MOST COMMON RADIOGRAPHIC POSSIBLE RADIOGRAPHIC APPEARANCE EXAM COLITIS SINGLE –AND DOUBLE CONTRAST THICKENING OF MUCOSAL WALL WITH LOSS OF (PREFERRED) BA HAUSTRAL MARKINGS SINGLE AND DOUBLE CONTRAST COBBLESTONE AND POSSIBLE STOVEPIPE ULCERATIVE COLITIS (PREFERRED) BA APPEARANCE WITH SEVEN FORMS DIVERTICULUM DOUBLE CONTRAST BE BARIUM FILLED CIRCULAR DEFECTS PROJECTING (DIVERTICULOSIS/ RECOMMENDED OUTWARD FROM COLON WALL; JAGGED OR DIVERTICULITIS) SAWTOOTH APPEARANCE OF THE MUCOSA INTUSSUCEPTION SINGLE OR AIR CONTRAST ENEMA MUSHROOM SHAPED DILATATION AT THE DISTAL RECOMMENDED ASPECT OF THE INTUSSUSCEPTION, WITH VERY LITTLE BARIUM OR GAS PASSING BEYOND IT NEOPLASM DOUDLE CONTRAST BE FILLING DEFECTS; NARROWNESS OR TAPERING RECOMMENDED TO DETECT SMALL OF LUMEN; APPLE CORE OR NAPKIN RING POLYS LESIONS POLYPS DOUBLE CONTRAST BE BARIUM FILLED, SACKLIKE PROJECTIONS RECOMMENDED PROJECTING INWARD INTO THE LUMEN OF BOWEL VOLVULUS SINLE CONTRAST BE TAPERED OR CORKSREW APPEARANCE WITH AIR FILLED DISTENDED BOWEL  BARIUM ENEMA PROCEDURE PATIENT PREPARATION: SECTION OF ALIMENTARY CANAL TO BE EXAMINED MUST BE EMPTY CONTRAINDICATION TO LAXATIVES(CATHARTICS) 1. GROSS BLEEDING 2. SEVERE DIARRHEA 3. OBSTRUCTION 4. INFLMATORY CONDITION SUCH AS APPENDICITIS 2 CLASSES OF LAXATIVES 1. IRRITANT LAXATIVES (CASTOR OIL 2. SALINE LAXATIVES (MAGNESIUM CITRATE OR MAGENSIUM SULFATE)  CONTRAST MEDIA single contrast-sandard mixture of contrast medium range 15%- 25% wieght volume (w/v) double contrast barium enema the thicker weight volume concentration between 75%- 95% or higher evacuative proctogram requires a contrast mwdia with minimum wieght to volume of 100% negative contrast agent- room air, nitrogen and carbon dioxide are most common carbon dioxide is gaining wide use bcoz it is well tolerated by the larged intestine and its absorb rapidly after the procedure carbon dioxide and oxegen strored in a small tank and can be introduced into the rectum through an air contrast retention enema tip lower kv(70-80) should be used with water soluble and negative contrast agent  CONTRAST MEDIA PREPARATION -COLD WATER (40-50 DEGREE f). HAVE AN ANESTHETIC EFFECT ON THE COLON AND INCRESE RETENTION OF THE CONTRAST MEDIA. MAY LEAD TO COLONIC SPZASM - ROOMTEMPERATURE (85-90 DEGREE f) PRODUCE SUCCESFUL EXAMINATION WITH MIXIMAL PATIENT COMFORT. TECHNOLOGIST NEVER PREPARED USE HOT WATER MAY SCALD THE MUCOSAL LINING OF THE COLON - SPASM IS A COMMON SIDE EFFECT PROCEDURE PREPARATION - COTTON GOWN WITH THE OPENING AND TIES IN THE BACK -PATIENT HISTORY TAKEN AND CAREFULLY EXPLAINED OF THE PROCEDURE - SIMS POSITION THE PATIENT IS ASK TO ROLL ONTO THE LEFT SIDE AND LEAN FORWARD. RIGHT LEG IS FLEXED AT THE KNEE AND HIP AND IS PLACED INFRONT OF THE LEGS. IT RELAX HA ABDOMINAL MUSCLES AND DECREASE PRESSURE WITHIN THE ABDOMEN  PREPARATION FOR RECTAL TIP INSERTION WEAR A RECTAL GLOVE AND ENFOLD THE ENEMA TIP IN SEVERAL SHEETS OF PAPER TOWELING RECTAL TIP IS PROPERLY LUBRICATED WITH WATER SOLUBLE LUBRICANT PATIENT SHOULD BE INSTRUCTED: 1. KEEP THE ANAL SPHINCTER TIGHTLY CONTRACTED AGAINST THE RECTAL TUBE TO HOLD IT IN POSITION AND PREVENT LEACKAGE 2. RELAX THE ABDOMINAL MUSCLE TO PREVENT INCREASE INTRAABDOMINAL PRESURE 3. CONCENTRATE ON BREATHING BY MOUTH TO REDUCE SPASM AND CRAMPING  ENEMA TIP ENSERTION DESCRIBE THE TIP INSERTION PROCEDURE TO THE PATIENT. ANSWER ANY QUESTION PLACE THE PATIENT IN SIMS POSITION. PATIENT SHOULD LIE ON THE LEFT SIDE, WITH THE RIGHT LEG FLEXED AT THE KNEE AND HIP SHAKE ENEMA BAG ONCE MORE TO ENSURE PROPER MIXING OF BARIUM SULFATE SUSPENSION. ALLOW BARIUM TO FLOW THROUGH THE TUBING AND FROM TIP TO REMOVE ANY AIR IN THE SYSTEM WEARING GLOVES, COATE ENEMA TIP WELL WITH WATER SOLUBLE LUBRICANT. WRAP PROXIMAL ASPECT OF ENEMA TIP IN PAPER TOWEL ON EXPIRATION, DIRECT ENEMA TIP TOWARD THE UMBILICUS APROXIMATELY 1 TO 11/2 INCHES (2.5-4 cm) AFTER INITIAL INSERTION, ADVANCE UP SUPERIORLY AND SLIGHTLY ANTERIORLY. THE TOTAL INSERTTION SHOULD NOT EXCEED 3-4 cm. DO NOT FORCE ENEMA TIP. TAPE TUBING TO PREVENT SLIPPAGE. DONOT INFLATE RETENTION TIP UNLESS DIRECTED BY RADIOLOGIST ENSURE IV POLE/ENEMA BAG IS NO MORE THAN 24 INCHES (60cm) ABOVE THE TABLE. ENSURE TUBING STOPCOCK IN THE CLOSED POSITION AND NO BARIUM FLOWS INTO THE PATIENT. TYPES OF LOWER GI EXAMINATION SINGLE CONTRAST BARIUM ENEMA- IS A USING ONLY A POSITIVE CONTRAST MEDIUM. MOST CASES THE CONTRAST MATERIASL IS BARIUM SULFATE IN THIN IXTURE DOUBLE CONTRAST BARIUM ENEMA- ARE MORE EFFECTIVE IN DEMONSTRATING POLYPS AND DIVERTICULA THAN THE SINGLE CONTRAST BARIUM ENEMA PROCEDURE. CLEAN LARGE BOWEL IS ESSENTIAL TO THE DOUBLE CONTRAST STUDY AND A MUCK THICKER BARIUM MIXTURE IS REQUIRED EVACUATIVE PROCTOGRAPHY (DEFECOGRAM)- IS MORE SPECIALIZED PROCEDURE PERFORMED IN SOME DEPARTMENTS, ESPECIALLY CHILDREN OR YOUNGER ADULT PATIENTS TWO STAGE PROCEDURE- THE THICK BARIUM IS ALLOWED TO FILL THE LEFT SIDE OF THE INTESTINE INCLUDING THE LEFT COLIC FLEXURE(THE PORPUSE IS TO FACILITATE ADHERENCE TO THE MUCOSAL LINING) AIR IS THEN INSTILLED TO THE BOWEL PUSHING THE COLUMN THROUGH THE RIGHT SIDE. THE SECOND STAGE CONSIST OF INFLATION OF THE BOWEL WITH LARGE AMOUT OF AIR/GAS THAT MOVES THE MAIN COLUMN OF BARIUM FORWARD, LEAVING THE MUCOSAL WALL. THIS PROCEDURE DEMONSTRATE NEOPLASM OR POLYPS THAT MY BE FORMING ON THE INNER WALL OF THE BOWEL PROJECTING INTO THE OPENING OF THE BOWEL SINGLE STAGE PROCEDURE- ESUD WHEREIN THE BARIUM AND AIR ARE INSTILLED IN A SINGLE PROCEDURE THAT REDUCES TIME AND RADIATION EXPOSURE TO THE PATIENT. THIS METHOD SOME HIGH DENSITY BARIUM IS 1ST INSTILLED INTO THE RECTUM WITH THE PATIENT IN A SLIGHT TRENDELENBURG POSITIONTHE BARIUM IS THE CLAMPED AND WITH THE TABLE IN AHORIZONTAL POSITION THE PATIENT IS PLACED INTO VARIUS OBLIQUE POSITION AND LATERAL POSITION AFTER THE ADDITION OF VARIUS AMOUNTS OF AIR WITH THE DOUBLE CONTRAST PROCEDURE SPOT FILMS (DURING FLOUROSCOPY)- ARE OBTAINED TO DOCUMENT ANY SUSPICIOUS AREA DIGITAL FLOUROSCOPY- THESE SPOT IMAGES ARE OBTAINED DIGITALLY RATHER THAN WITH SEPARATE SPOT FILM CASSETTES AND IMAGE INTENSIFICATION. IMAGES ARE STORED IN THE MEMORY OF COMPUTER. ONCE THE IMAGE IS UNDERGONE QUALITY ASSURANCE THEY ARE TRANFERRED TO THE PACS SYSTEM FOR INTERPRETATION POSTEVACUATIVE RADIOGRAPH- USUALLY TAKEN IN PRONE POSITION, SUPINE IF NEEDED. - POSTPROCEDURE INSTRUCTION- PATIENT SHOULD INCREASED LIQUID INTAKE AND A HIGH FIVER DIET BECOUSE OF THE POSIBILITY OF CONSTIPATION FROM THE BARIUM EVACUATIVE PROCTOGRAPHY- DEFECOGRAPHY IS AFUNCTIONAL STUDY OF THE ANUS AND RECTUM DURING THE EVACUATION AND REST PHASES OF DEFECATION PATHOLOGIC INDICATIONS – RECTOCELES, RECTAL INTUSSUSCEPTION AND PROLAPSE OF THE RECTUM RECTOCELE- IS A BLIND POUCH OF THE RECTUM CAUSED BY WEAKENING OF THE ANTERIOR OR POSTERIOR WALL. MAY REATAIN FECAL MATERIAL EVEN AFTER EVACUATION