UGIS Upper Gastrointestinal Series PDF

UPPER GASTRO INTESTINAL SERIE (BARIUM MEAL) (UGIS) Luisa T. Cruz, RRT  BARIUM MEAL/UGIS Radiographic Examination of the GIT Performed to evaluate the distal esophagus, stomach and small intestine (duodenum) The purposes of the upper GI are to study radiographically the form and function...

UPPER GASTRO INTESTINAL SERIE (BARIUM MEAL) (UGIS) Luisa T. Cruz, RRT  BARIUM MEAL/UGIS Radiographic Examination of the GIT Performed to evaluate the distal esophagus, stomach and small intestine (duodenum) The purposes of the upper GI are to study radiographically the form and function of the distal esophagus, stomach, and duodenum and to detect abnormal anatomic and functional conditions.  ANATOMY Stomach dilated sac like portion of the digestive tract extending from the esophagus to the small intestine. - from the greek word GASTER - dilated portion of the alimentary canal - reservoir for swallowed foods & fluids  ANATOMY Stomach Highly peristaltic organ (3-4 times wave/min) A very tolerant organ (can take in hot & cold food) 1.5 L capacity Empties about 2-3 hours First part of Ba. meal normally reaches ileocecal valve in 2-3hrs. Last portion reaches the ileocecal valve in 4-5 hrs. Barium usually reaches the rectum within 24 hrs. OPENING AND CURVATURES 1.Esophagogastric junction/ cardiac orifice opening between esophagus and stomach Terminal of esophagus / CARDIAC ANTRUM 2.Pyloric Orifice / Pylorus Stomach and SI PATHOLOGIC INDICATIONS BEZOAR Bezoar describes a mass of undigested material that becomes trapped in the stomach. This mass usually is made up of hair,certain vegetable fibers, or wood products. The material builds up over time and may form an obstruction in the stomach. PATHOLOGIC INDICATIONS Trichobezoar made up of ingested hair  PATHOLOGIC INDICATIONS Phytobezoar which is ingested vegetable fiber or seeds. Some patients are unable to break down or process certain vegetable fibers or seeds.  PATHOLOGIC INDICATIONS DIVERTICULA Diverticula or pouchlike herniations of the portion of the mucosal wall. Gastric diverticula generally are 1 to 2 cm but may range in size from a few millimeters to 8 cm in diameter. Gastric diverticula, 70% to 90% arise in the posterior aspect of the fundus. Note: 1.Lateral position taken during an upper GI study may be the only projection that demonstrates gastric diverticula. 2.A double-contrast upper GI is recommended to diagnose any tumors or diverticula. Most gastric diverticula are asymptomatic and are discovered accidentally. Although benign, diverticula can lead to perforation if untreated. Other complications include inflammation and ulceration at the site of the neoplasm formation. PATHOLOGIC INDICATIONS  PATHOLOGIC INDICATIONS EMESIS Emesis is the act of vomiting, blood in vomit is called hematemesis and may indicate that other forms of pathologic processes are present in the gastrointestinal tract.  PATHOLOGIC INDICATIONS GASTRIC CARCINOMAS Gastric carcinomas account for over 70% of all stomach neoplasm with 95% of them being adenocarcinomas. Radiographic signs 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.  PATHOLOGIC INDICATIONS GASTRITIS Gastritis is an inflammation of the lining or mucosa of the stomach. Gastritis may develop in response to various physiologic and environmental conditions. Acute gastritis manifests with severe symptoms of pain and discomfort. Chronic gastritis is an intermittent condition that may be brought on by changes in diet, stress or other factors. Gastritis is best demonstrated with double-contrast upper GI. The fine coating of barium demonstrates subtle changes to the mucosal lining. Specific radiographic appearances may include, but are not restricted to, absence of rugae, a thin gastric wall and “speckled” appearance of the mucosa. Endoscopy also may be performed to inspect the mucosa visually for signs of gastritis. PATHOLOGIC INDICATIONS Acute - severe pain/discomfort Chronic -intermittent * diet * stress  PATHOLOGIC INDICATIONS Hiatal hernia is a condition in which a portion of the stomach herniates through the diaphragmatic opening. The herniation may be slight, but in severe cases, most of the stomach is found within the thoracic cavity above the diaphragm. Hiatal hernia may be due to a congenitally short esophagus or weakening of the muscle that surrounds the diaphragmatic opening, allowing passage of the esophagus. This form of hiatal hernia may occur in both pediatric and adult patients.  PATHOLOGIC INDICATIONS Hiatal hernia is a condition in which a portion of the stomach herniates through the diaphragmatic opening. The herniation may be slight, but in severe cases, most of the stomach is found within the thoracic cavity above the diaphragm. Hiatal hernia may be due to a congenitally short esophagus or weakening of the muscle that surrounds the diaphragmatic opening, allowing passage of the esophagus. This form of hiatal hernia may occur in both pediatric and adult patients.  PATHOLOGIC INDICATIONS Sliding hiatal hernia is a second type of hiatal hernia that is caused by weakening of a small muscle (esophageal sphincter) located between the terminal esophagus and the diaphragm.  PATHOLOGIC INDICATIONS HYPERTROPHIC PYLORIC STENOSIS Hypertrophic pyloric stenosis (HPS) is the most common type of gastric obstruction in infants. It is caused by hypertrophy of the antral muscle at the orifice of the pylorus. Hypertrophy of this muscle produces an obstruction at the pylorus. Symptoms: projectile vomiting after feedings, acute pain, and possible distention of the abdomen. HPS can be diagnosed during an upper GI. PATHOLOGIC INDICATIONS Sonography has become the modality of choice in diagnosing HPS. It is reported that a muscle thickness greater than 4 mm is a positive sign of HPS. In addition, sonography does not require radiation exposure to the infant or use of contrast media.  PATHOLOGIC INDICATIONS ULCERS 1.Duodenal ulcer is peptic ulcer situated in the duodenum. These ulcers frequently are in the second or third aspect of the duodenum. Duodenal ulcers are rarely malignant.  PATHOLOGIC INDICATIONS ULCERS 2.Peptic ulcer ulceration of the mucous membrane of the esophagus, stomach, or duodenum, caused by the action of acid gastric juice. It is synonymous with gastric ulcer or duodenal ulcer. Peptic ulcer disease often is preceded by gastritis and is secondary to hyperacidity.  PATHOLOGIC INDICATIONS ULCERS 3.Gastric ulcer is an ulcer of the gastric mucosa.  PATHOLOGIC INDICATIONS ULCERS 4.Perforating ulcer is an ulcer that involves the entire thickness of the wall of the stomach or intestine, creating an opening on both surfaces. PATHOLOGIC INDICATIONS Schatzke’s ring ringlike constriction at the distal esophagus PATHOLOGIC INDICATIONS Dyspepsia uncomfortable feeling of fullness, nausea & bloating STOMACH HABITUS  STOMACH HABITUS Eutonic or Normotonic habitus the incisura angularis and the pylorus are at the same level.  STOMACH HABITUS Hypotonic habitus the pylorus is higher than the incisura angularis by greater than one (1) cm.  STOMACH HABITUS Steer Horn the incisura angularis is higher than the pylorus by greater than one (1) cm.  VARIATIONS OF THE STOMACH Infantile stomach the stomach is transversely positioned with the bulb hidden from the view  VARIATIONS OF THE STOMACH Cascade Stomach Atypical form of hourglass stomach, characterized radiologically by a drawing up of the posterior wall; an opaque medium first fills the upper sac and then cascades into lower  BODY HABITUS Hypersthenic Sthenic Hyposthenic Asthenic 5% 50% 35% 10%  BODY HABITUS Hypersthenic Massive Build Long abdomen Narrow Pelvis Short, broad, deep thorax Heart's axis nearly transverse Lungs are short, apices at or near clavicles Diaphragm is high Colon is around periphery of abdomen Gallbladder is high and outside, lies more parallel  BODY HABITUS Sthenic Moderately heavy build Moderately long abdomen Moderately short, broad, and deep thorax Relatively small pelvis Heart is moderately transverse Lungs are moderately high Stomach is high upper left Colon is spread evenly Slight dip in the transverse colon Gallbladder is centered on right side, upper abdomen  BODY HABITUS Hyposthenic Between sthenic and asthenic characteristics Asthenic Characteristics Frail Build Short Abdomen Shallow Long Thorax Wide Pelvis Heart is nearly vertical and at mid-line Lungs are long and the apices are above the clavicles, made broader above the base Diaphragm is low Stomach is low and medial in the pelvis when standing Colon is low, folds on itself Gallbladder is lower and nearer the midline  BODY HABITUS Asthenic Frail Build Short Abdomen Shallow Long Thorax Wide Pelvis Heart is nearly vertical and at mid-line Lungs are long and the apices are above the clavicles, made broader above the base Diaphragm is low Stomach is low and medial in the pelvis when standing Colon is low, folds on itself Gallbladder is lower and nearer the midline PURPOSE OF PRELIMINARY RADIOGRAPH To delineate liver, spleen, kidneys, psoas muscles and bony structure To detect any abdominal or pelvic calcifications To detect tumor masses  PRELIMINARY PREPARATION Told the patient the approximate time required for the procedure Explain the procedure NPO 8-9 hours before examination Rationale: To empty the stomach & small intestine To have colon free of gas and fecal material  PRELIMINARY PREPARATION NPO after evening meal -For small intestine study No smoking or chewing a gum Rationale: Stimulate gastric secretion and salivation Prevent excessive fluid from accumulating the stomach Prevent diluting the barium suspension  CONTRAST MEDIA USED 1. Barium Sulfate water-insoluble salt of a metallic element barium available either dry powder or liquid -mixed with plain water  CONTRAST MEDIA USED 2. Water soluble iodinated CM suitable for opacification of the alimentary canal such as: * diatrizoate sodium Hypaque 50, 75, 90 * diatrizoate meglumine - conray usually clears stomach in 1-2 hrs. reaches and outlines colon in 4 hrs. easily removed by aspiration escapes into the peritoneum through a pre-existing perforation of the stomach or intestine absorbed from peritoneal cavity and excreted by the kidney Disadvantage: strongly bitter taste  CONTRAST STUDIES 1. Single Contrast to demonstrate gross pathology only * children * very ill patient  CONTRAST STUDIES 2.Double Contrast demonstrate mucosal pattern of the stomach and to detect small lessions sparkles Gas producing tablets is given Advantages over single contrast: Small lesions are less easily obscured Mucosal lining of the stomach can be more clearly visualize Double Contrast Instructing the patient to roll side to side: Rationale: to coat the mucosal lining of the stomach Giving glucagon/anticholinergic medications before exam Rationale: To relax the GI tract To improve visualization by inducing distention of stomach and intestine  CONTRAST STUDIES 3.BIPHASIC EXAMINATION Combination of single and double contrast Advantage over single & double contrast: Increase accuracy of diagnosis without increasing the cost of the examination  CONTRAST STUDIES Ways of Producing Air in the Stomach Swallowing the patient sip the barium mixture with the use of two straws, one outside the glass and one inside the glass Breath thru his/her mouth or swallow air after ingestion of brium Gas-producing tablet “Gastroluft”, EZ Gas, Alka-Seltzer Carbonated drinks  HYPOTONIC DUODENOGRAPHY Used for evaluation of post-bulbar duodenal lesions For detection of pancreatic disease Less frequently performed Rationale: Double-contrast GI exam CT scan Needle biopsy First described by Liotta Requires intubation  PA PROJECTION Patient Position: Prone/upright Upright: used to demonstrate the size, shape and relative position of the stomach Prone: A possible hiatal hernia stomach moves superiorly 1 ½ - 4” Reference Point: Sthenic: L1-L2 (1-2 in above lower rib margin(prone) – Ballinger 3-6 in. lower (upright) L1 & 1 in. left of the vertebral column (prone) – Bontrager  PA PROJECTION Asthenic: 2 in. inferior to L1 (prone) – Bontrager Hypersthenic: 2 in. superior to L1 (prone) – Bontrager Central Ray: Perpendicular Structure Shown: Prone: barium-filled stomach and duodenal bulb Upright: shows relative size, shape and position of the 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 PA PROJECTION  PA PROJECTION TAKE NOTE: Prone Position Stomach moves superiorly 1.5-4 in. Stomach spreads horizontally and decrease in length Fundus fills in asthenic patient  PA OBLIQUE PROJECTION RAO Position Patient Position: Prone RAO 40°-70°: gives the best image of pyloric canal and duodenum Hypersthenic (70°): required greater degree of rotation Sthenic (45°-55°)/Asthenic (40°): required less degree of rotation RAO Position: Used for serial studies of pyloric canal and duodenal bulb Rationale: gastric peristalsis is more active  PA OBLIQUE PROJECTION Reference Point: Sthenic: – L1-L2 (Ballinger) – L1, midway b/n spine and upside lateral border of abdomen (Bontrager) Asthenic: 2 in. inferior to L1 (Bontrager) Hypersthenic: 2 in. superior to L1 (Bontrager) CR: Perpendicular SS: Stomach and entire duodenal loop Sthenic: Best image of pyloric canal and duodenal bulb PA OBLIQUE PROJECTION  PA OBLIQUE PROJECTION ER: For serial and mucosal studies of stomach and duodenum -Pneumatic paddle is used Positioned under pyloric sphincter & duodenal bulb -To demonstrate compression and non-compression study of the pyloric end (stomach). and duodenal bulb at different stages of filling and emptying To demonstrate compression study of the mucosa of a localized area of the GI tract  AP OBLIQUE PROJECTION LPO Position Patient Position: Supine Sthenic: LPO 45° Hypersthenic: LPO 60° Asthenic: LPO 30°  AP OBLIQUE PROJECTION Reference Point: Sthenic: L1 (midway b/n xiphoid and lower rib margin) – Ballinger & Bontrager Asthenic: 2 in. inferior to L1– Bontrager Hypersthenic: 2 in. superior to L1 – Bontrager CR: Perpendicular SS: Fundic portion of the stomach (barium-filled) Pyloric canal and duodenal bulb are not demonstrated Rationale: Not filled with barium Effect of gravity They are in opposite direction Double contrast: pyloric canal and duodenal bulb are demonstrated (air-filled)  LATERAL PROJECTION Right Lateral Position PP: Recumbent/upright Upright left lateral position: Left retrogastric space Recumbent right-lateral position: – Right retrogastric space – Duodenal loop – Duodenojejunal junction Retrogastic space: space behind the stomach  LATERAL PROJECTION Reference Point: Sthenic: – L1-L2 (recumbent); L3 (upright) – Ballinger – L1 & 1-1.5 in. anterior to MCP – Bontrager Asthenic: -2 in. inferior to L1– Bontrager Hypersthenic: -2 in. superior to L1 – Bontrager CR: Perpendicular Structure Shown: Anterior and posterior aspect of the stomach Pyloric canal and duodenal bulb Right lateral projection: -best demonstrate pyloric canal and duodenal bulb (C-loop) in HYPERSTHENIC PATIENT.  AP PROJECTION PP: Supine Full trendelenburg: diaphragmatic herniations Partial trendelenburg: for fundus filling (asthenic patient) RP: Sthenic: – L1-L2 – Ballinger – L1 & midway b/n midline & left lateral margin – Bontrager Asthenic: 2 in. inferior to L1– Bontrager Hypersthenic: 2 in. superior to L1 – Bontrager CR: Perpendicular SS: Best demonstrate retrogastric portion of the duodenum and jejunum Barium-filled fundic portion Double contrast delineation of the body, pyloric portion & duodenum In diaphragm: demonstrate organ/s involved in gross hernia protrusion  AP PROJECTION TAKENOTE: Supine Position Stomach moves superiorly and to the left Sthenic: intestinal loops move superiorly & pyloric end is elevated Effects: Barium-filled cardiac and fundic portion Asthenic: Air-filled pyloric portion intestinal loops do not move Rationale: superiorly gastric bubbles displaced into it Effects: fundic portion is not filled Allows double contrast examination of Compensation: posterior wall lesions – LPO position – Partial trendelenburg position  UGIS MODIFICATIONS GORDON’S GUGLIANTINI HAMPTON’S POPPEL’S WOLF CLUE: Go Go Harrison Plaza and Waltermart  GORDON’S MODIFICATION PA AXIAL PROJECTION PP: Prone RP: Sthenic: L2 Asthenic: 1-2 in. inferior to L2 Hypersthenic: 1-2 in. superior to L2 CR: 35°-45° cephalad SS: Greater and lesser curvature Antral portion of the stomach Pyloric canal and duodenal bulb ER: To open up the high, horizontal stomach of HYPERSTHENIC PATIENT  GUGLIANTINI MODIFICATION SS: PA AXIAL PROJECTION Greater and lesser curvature PP: Prone Antral portion of the RP: stomach Sthenic: L2 Pyloric canal and duodenal Asthenic: 1-2 in. inferior to L2 bulb Hypersthenic: 1-2 in. superior to L2 ER: For demonstration of CR: 20°-25° cephalad stomach in INFANTS HAMPTON’S MODIFICATION PP: Supine; body 45° towards the side of interest CR: Perpendicular SS: Best modification to demonstrate a leaf like pattern of the pylorus and the valve  POPPEL’S METHOD SS: Retrogastric space ER: Used to demonstrate right angle view of the stomach For evaluation of pancreatic pathology – Pancreatic mass – Pancreatic cancer – Pancreatitis  WOLF METHOD A modification of Trendelenburg Requires: semicylindric radiolucent compression device Compression device: – Provides Trendelenburg angulation – Increases intra-abdominal pressure – Permit adequate contrast filling – Permit maximum distention of the entire esophagus – stated by WOLF & GUGLIELMO Advantages: Does not require table angulation Patient can hold barium container and ingest with comparative ease  WOLF METHOD PA OBLIQUE PROJECTION RAO Position PP: Prone RAO 40°-45° Assume modified knee-chest position: during placement of compression device Compression device placement: Horizontally under the abdomen Below costal margin Barium ingestion: rapid, continuous swallow Make exposure during 3rd & 4th swallow: Rationale: to allow for complete filling of the esophagus  WOLF METHOD RP: T6-T7 CR: Perpendicular TAKENOTE: the position results in a 10-20o caudad CR angulation SS: Relationship of stomach to the diaphragm Useful in diagnosing hiatal hernia ER: For the purpose of applying greater intra- abdominal pressure For demonstration of small, sliding gastroesophageal herniation through the esophageal hiatus  UGIS FOR INFANTS In this case 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. This is done by the attending physician or the 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. ASTRO-JEJUNOSTOMY – removal of the duodenum and a portion of the distal end of the stomach PEDIATRIC PATIENT PREPARATION FOR UGIS The following guidelines are suggested, but department protocol should be followed: Infant younger than one (1) year: NPO for 4 hours Children older than one (1) year: NPO for 6 hours  BARIUM PREPARATION Dilution of the barium may be required if the child will be fed through a bottle. A larger hole in the nipple may be required to ensure a smooth flow of barium. Following are some suggested barium volume guidelines, but specific department protocol should be followed: NB to 1 year – 2 to 4 oz 1 to 3 years – 4 to 6 oz 3 to 10 years – 6 to 12 oz Older than 10 years – 12 to 16 oz  BARIUM PREPARATION milk barium mixture, 4 parts milk and 1-part water. Prepare enough amount around 50 cc. The 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. Take several projections in different positions. You must have assistance to position the patient, or you may wrap the patient in a bedsheet, like a mummy. Use fast exposure technique.