chapter 14 upper GIT.pdf

UPPER GASTROINTESTINAL SYSTEM RADIOGRAPHIC PROCEDURE Prof. Akram Asbeutah, PhD Department of Radiologic Sciences Faculty of Allied Health Sciences Kuwait University Objectives • Radiographic anatomy of upper GIS • Radiographic procedures of upper GIS • Radiographic positioning of upper GIS A- Ra...

UPPER GASTROINTESTINAL SYSTEM RADIOGRAPHIC PROCEDURE Prof. Akram Asbeutah, PhD Department of Radiologic Sciences Faculty of Allied Health Sciences Kuwait University Objectives • Radiographic anatomy of upper GIS • Radiographic procedures of upper GIS • Radiographic positioning of upper GIS A- Radiographic AnatomyUpper GIS Radiographic Anatomy- Alimentary canal • • • • • • • Oral cavity Pharynx Esophagus Stomach Small intestine Large intestine Anus Radiographic Anatomy-Accessory Organs • • • • Salivary glands Pancreas Liver Gallbladder Radiographic Anatomy- Oral cavity & Pharynx • Mouth – Upper & lower teeth – Hard & soft palates – Palatine uvula – Tongue • Pharynx (Throat) – Funnel shape of 13cm – Parts: Naso, Oro, & Laryngo – Seven openings: 4 to Naso, 1 to Oro, and 2 to larngo Radiographic Anatomy- Esophagus • Collapsed muscular tube of 25 cm and 2 cm in diameter • In front of vertebrae, posterior to trachea & heart Extend from inferior edge of larynx to join the stomach at GEJ (C5-T10) • Pierces the diaphragm at hiatus Radiographic Anatomy- Esophagus • Two indentations at posterior mediastinum: – Aortic arch – left main bronchus Radiographic Anatomy- Diaphragmatic openings • IVC- T8 • EsophagusT10, cardiac antrum (abdominal portion of the esophagus); GEJ or cardiac orifice • Aorta- T12 Radiographic Anatomy- Swallowing & peristalsis Radiographic Anatomy- Stomach Openings & Curvatures • Located between esophagus & small intestine • Most dilated part of the GIS • Reservoir of food and fluid • Varying shape and size • Openings: cardiac orifice & Pyloric orifice • Greater & lesser Curvatures Radiographic Anatomy- Stomach Subdivisions • Fundus • Body • Pylorus – pyloric antrum – pyloric canal Radiographic Anatomy- Stomach Gastric Folds (Rugae) Radiographic Anatomy- Stomach Position • Fundus: superior & posterior to body • Body: inferior and anterior to fundus • Pylorus: distal and posterior to body Air-Barium Distribution in Stomach • Supine Position: Fundus filled with barium; also pylorus will be filled with barium and the body will be filled with air • Prone position: fundus & pylorus will be filled with air and the body will be filled with barium • Erect position: Fundus filled with air and body and pylorus are filled with barium Air-Barium Distribution in Stomach Radiographic Anatomy- Duodenum • First portion of the small intestine • It is 10’’ in length • It is the shortest, widest, and most fixed portion of the small intestine • It is a retroperitoneal structure with the pancreas Radiographic Anatomy- Duodenum Four Parts • It is C-shaped • It consists of 4 parts: – Duodenal bulb/cap: superior and affected by DU – Descending part: longest and receives the CBD & PD – Horizontal part: curves back to join the last part – Ascending part: last part and join Jejunum at D-J Junction which is fixed by ligament of Treitz Anatomy Review for Upper GIS Anatomy Review for Upper GIS Functions of GIS Mechanical Digestion Chemical Digestion Body Habitus Hypersthenic (5%), sthenic (50%), hyposthenic (35%), & Asthenic (10%) B- Radiographic Procedures of Upper GIS Similarities in Radiography of the Alimentary canal • Contrast media is required to increase or decrease tissue density • The procedure is carried out with fluoroscopy/Digital • Radiographic images rare recorded during, and frequently after, the fluoroscopic examination Contrast Media- Barium Sulfate • Radiolucent-negative contrast media: air, CO2, gas crystals such as calcium and magnesium citrate carbonate crystals • Radiopaque-positive contrast media: iodinated and Barium sulfate BaSO4 • Characteristics of BaSO4: – – – – Powder chalklike Inert/insoluble in water Chemically pure not toxic It is colloidal when mixed with water Thin & Thick Barium Sulfate Contraindications to Barium Sulfate • Contraindications – Perforated viscus – Prior to surgery – Intestinal obstruction • Alternative: water soluble non-ionic iodinated lower osmolar e.g. Gastrographin, gastroview, visipaque, omnipague, ultravist Single vs Double Contrast Techniques • Positive BsSO4 contrast media is mixed with negative Co2 contrast media to coat the mucosa and give better contrast visualization of the anatomy for certain disease such as ulcer or cancer Radiography-Fluoroscopy Equipment Digital Fluoroscopy Unit • Exposure factors for radiography – kV: 100-130 (good penetration, short time, less motion, reduce patient dose, prolong tube lifespan) – mAs: AEC or high mA (>300 & shortest exposure time) • Fluoroscopic kV 80-100; mA 1-5; & every 5 minutes reset) Radiography-Fluoroscopy Equipment Digital Fluoroscopy Unit • Conventional – Film/screen casstettes – TV fluoroscopy – Photospot images – Image intensifier – Cinefluoroscopy • Digital fluoroscopy Radiography-Fluoroscopy Equipment Digital Fluoroscopy Unit • No cassettes requiredflat panel detectors • Save time • Less radiation dose to patients • Images stored in PACS for future retrieval or research work or printing Advantages of Digital Over Conventional Fluoroscopy • Post-fluoroscopy overhead images • Multiple frame formatting • Cine Loop Capability • Image enhancement & manipulation Radiation Protection During Fluoroscopy • • • • • • • Exposure pattern Lead drape shield Bucky slot shield Lead aprons Lead equivalent glasses Thyroid shields Cardinal principles of radiation protection-STD – Shield – Time – Distance Radiographic Procedures of Upper GIS Barium Swallow- Esophagram Procedure Barium Swallow- Esophagram Procedure Pathologic Indications for Barium Swallow Contraindications: sensitivity to BaSO4 or any iodinated contrast media Patient & Room Preparation for Barium Swallow Prepare the necessary drugs which might be needed during the procedure such as buscopan, glucagon, primperine Demonstration of Esophageal Reflux Demonstration of Esophageal RefluxBreathing Exercises Demonstration of Esophageal RefluxWater Test Demonstration of Esophageal RefluxCompression Paddle Demonstration of Esophageal RefluxToe-Touch Maneuver Modified Barium Swallow • Clinical history o • wheelchair bound on oral modified diet with aspiration sign. Findings ❑ The patient is being fed puree with a spoon and images are taken in lateral position. ❑ Laryngeal penetration and aspiration is seen with this consistency (at 6-7 second in the video) • Otherwise ❑ Adequate lip closure. No drooling was noted. ❑ Good initiation of swallowing and the act is present. Adequate motion of the bolus posteriorly. ❑ Good soft palate function with adequate closure of the airways. ❑ No E/O nasopharyngeal regurgitation was encountered during the study. ❑ Maintained mandibular motion. Modified Barium Swallow • Clinical history ❑ wheelchair bound on oral modified diet with aspiration sign. • Findings • ❑ The patient is being fed moist food with a spoon and images are taken in lateral position. ❑ No laryngeal penetration or aspiration is seen with this consistency. Otherwise ❑ Adequate lip closure. No drooling was noted. ❑ Good initiation of swallowing and the act is present. Adequate motion of the bolus posteriorly. ❑ Good soft palate function with adequate closure of the airways. ❑ No E/O nasopharyngeal regurgitation was encountered during the study. ❑ Maintained mandibular motion. Radiographic Procedures of Upper GIS Barium Meal Barium Meal Procedure Pathologic Indications for Barium Meal Patient & Room Preparation for Barium Meal Patient & Room Preparation for Barium Meal Summary for Upper GI Examination Alternative Modalities & procedures for Upper GI Examinations • • • • CT MRI US NM C- Radiographic Positioning of Upper GIS Basic & Post-Fluoroscopy ProjectionsBarium Swallow/Esophagram RAO Position- Esophagram Lateral Position- Esophagram AP (PA) Projection- Esophagram LAO Position- Esophagram Basic & Post-Fluoroscopy ProjectionsBarium Meal RAO Position- Barium Meal PA Projection- Barium Meal Right Lateral Position- Barium Meal LPO Position- Barium Meal AP Projection- Barium Meal