Chapter 12
Biliary Tract and Upper
Gastrointestinal System
Liver and Gallbladder
Copyright © 2018, Elsevier Inc. All Rights Reserved.
2
Liver and Gallbladder
Anterior View
Posterior/Inferior View
Copyright © 2018, Elsevier Inc. All Rights Reserved.
3
Bile Route
Biliary Anatomy
YouTube
Right and left
hepatic ducts
▼
Common hepatic duct
▼
Common bile duct
▼
Pancreatic duct
▼
Duodenum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
4
Gallbladder
Copyright © 2018, Elsevier Inc. All Rights Reserved.
5
Functions of Gallbladder


Storage of bile
Concentration of bile



Hydrolysis
Choleliths
(gallstones)
Contraction when
stimulated

Cholecystokinin
(CCK)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
6
Distal Common Bile Duct
ERCP
YouTube
Copyright © 2018, Elsevier Inc. All Rights Reserved.
7
Anatomic Relationships


PA to reduce OID
Supine for gallbladder drainage
Copyright © 2018, Elsevier Inc. All Rights Reserved.
8
Anatomy Review
Gallbladder
What position is
this?
35-40°LAO
Copyright © 2018, Elsevier Inc. All Rights Reserved.
9
Copyright © 2018, Elsevier Inc. All Rights Reserved.
10
Operative Cholangiogram
Anatomy Review of Biliary Ducts
Copyright © 2018, Elsevier Inc. All Rights Reserved.
11
ERCP Video
Copyright © 2018, Elsevier Inc. All Rights Reserved.
12
Biliary System and Procedure
Terminology
Copyright © 2018, Elsevier Inc. All Rights Reserved.
13
Terminology Quiz
“Chole” refers to:
?
“Cysto” describes:
?
“Angio” defines:
?
“Graphy” refers to:
?
Copyright © 2018, Elsevier Inc. All Rights Reserved.
14
Radiographic Procedures
A study of
Chole + Cysto + Graphy
=
Chole + Angio + Graphy
=
Cholecystocholangiogram
=
Copyright © 2018, Elsevier Inc. All Rights Reserved.
15
GI Tract
Upper and Lower GI Anatomy
Copyright © 2018, Elsevier Inc. All Rights Reserved.
16
Alimentary Canal
(Mouth–Anus)



Upper GI tract
Lower GI tract
(Chapter 13)
Accessory organs
GI Anatomy and Physiology
YouTube
Copyright © 2018, Elsevier Inc. All Rights Reserved.
17
Common Radiographic Procedures
1. Esophagogram
(or barium swallow)
2. Upper GI series
(UGI)
 Purpose of
esophagography

Study the form and
function of the
pharynx and the
esophagus
Copyright © 2018, Elsevier Inc. All Rights Reserved.
18
Common Radiographic Procedures
1. Esophagogram
(barium swallow)
2. Upper GI series
(UGI)
 Purpose of upper GI

Study the form and
function of the distal
esophagus,
stomach, and
duodenum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
19
Accessory Organs in Mouth
(Oral Cavity)

Terms



Mastication
Deglutition
Peristalsis
Copyright © 2018, Elsevier Inc. All Rights Reserved.
20
Pharynx
(Three Parts)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
21
Esophagus
Copyright © 2018, Elsevier Inc. All Rights Reserved.
22
Esophagus in Mediastinum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
23
Diaphragmatic Openings
Copyright © 2018, Elsevier Inc. All Rights Reserved.
24
PA Esophagogram
(Slight RAO Oblique)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
25
RAO Esophagram
Upper and Mid Esophagus
Copyright © 2018, Elsevier Inc. All Rights Reserved.
26
Stomach
Frontal View
Copyright © 2018, Elsevier Inc. All Rights Reserved.
27
Stomach Synonyms



Gaster
(Greek for
“stomach”)
Ventriculus
(Latin for “little
belly”)
Gastro(modern prefix for
“stomach”)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
28
Anatomy of Distal Esophagus and
Stomach
Copyright © 2018, Elsevier Inc. All Rights Reserved.
29
Coronal Sectional View of Stomach
Copyright © 2018, Elsevier Inc. All Rights Reserved.
30
Barium-Filled Stomach and
Duodenum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
31
Stomach Orientation



Fundus:
most posterior
Body:
anterior/inferior to
fundus
Pylorus:
posterior/distal to
body
Copyright © 2018, Elsevier Inc. All Rights Reserved.
32
Air-Barium Distribution
Black = Air White = Barium
Copyright © 2018, Elsevier Inc. All Rights Reserved.
33
Which was taken PA (prone) and
which AP (supine)?
A
B
Copyright © 2018, Elsevier Inc. All Rights Reserved.
34
AP supine
(barium in fundus)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
RAO prone
(air in fundus)
35
Duodenum




Shortest and widest
C-loop
“Romance of the
abdomen”
Retroperitoneal
Copyright © 2018, Elsevier Inc. All Rights Reserved.
36
4 Parts of Duodenum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
37
Anatomy Review
What is the position—supine or prone?
Copyright © 2018, Elsevier Inc. All Rights Reserved.
38
Summary of Mechanical Digestion

Mastication (chewing)
Deglutition (swallowing)
Pharynx

Deglutition
Esophagus

1-8 seconds

Deglutition
Peristalsis (waves of muscular contractions)
Stomach

2-6 hours

Small intestine

3-5 hours

Oral cavity

Mixing
Peristalsis
} Chyme
Rhythmic segmentation (churning)
Peristalsis
Copyright © 2018, Elsevier Inc. All Rights Reserved.
39
Summary of Chemical Digestion
Substances ingested, digested, and absorbed:
1. Carbohydrates
→ Simple sugars
(mouth and stomach)
2. Proteins
→ Amino acids
(stomach and small bowel)
3. Lipids (fats)
→ Fatty acids and glycerol
(small bowel only)
Substances absorbed but NOT digested:
4. Vitamins
5. Minerals
6. Water
Enzymes (digestive juices)
• Biologic catalysts
Bile (from gallbladder)
• Emulsifies fats
Copyright © 2018, Elsevier Inc. All Rights Reserved.
40
Three Primary Functions
of Digestive System
1. Ingestion and/or
digestion
2. Absorption
3. Elimination
•
•
•
•
•
•
Oral cavity
Pharynx
Esophagus
Stomach
Small intestine
Small intestine (and
stomach)
• Large intestine
Copyright © 2018, Elsevier Inc. All Rights Reserved.
41
Body Habitus
Copyright © 2018, Elsevier Inc. All Rights Reserved.
42
Body Habitus
(Stomach and Large Intestine Locations)
Hypersthenic
Sthenic
Hyposthenic/
Asthenic
High and
transverse
J-shaped
J-shaped and
low
Duodenal T11-T12
bulb/GB:
L1-L2
L3-L4
Large
intestine:
L colic flexure
high
Low near pelvis
Stomach:
Widely distributed
Copyright © 2018, Elsevier Inc. All Rights Reserved.
43
Body Habitus
(Stomach and Large Intestine Locations)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
44
Hypersthenic
• Duodenal bulb:
– To right of midline
– Level of T11-T12
Sthenic
• Duodenal bulb:
– Slightly to right of midline
– Level of L1-L2
Copyright © 2018, Elsevier Inc. All Rights Reserved.
Hyposthenic/
Asthenic
• Duodenal bulb:
– At midline
– Level of L3-L4
45
Quiz Me
The distal end of the gallbladder is termed:
A.
B.
C.
D.
Apex
Base
Fundus
Neck
Copyright © 2018, Elsevier Inc. All Rights Reserved.
46
Quiz Me
The mucosal folds found within the cystic duct
are termed:
A.
B.
C.
D.
Rugae
Circular folds
Billiard villi
Spiral valves
Copyright © 2018, Elsevier Inc. All Rights Reserved.
47
Quiz Me
The hepatopancreatic sphincter is located at the
_____.
A. terminal end of the common bile duct
B. junction of the common bile and pancreatic
ducts
C. neck of the gallbladder
D. junction of the left and right hepatic ducts
Copyright © 2018, Elsevier Inc. All Rights Reserved.
48
Quiz Me
Cholelithiasis is defined as _____.
A. an inflamed gallbladder
B. the surgical removal of the gallbladder
C. the radiographic examination of the
gallbladder
D. the condition of having gallstones
Copyright © 2018, Elsevier Inc. All Rights Reserved.
49
Quiz Me
Which of the following is not one of the salivary
glands?
A.
B.
C.
D.
Submandibular
Sublingual
Parotid
Supramandibular
Copyright © 2018, Elsevier Inc. All Rights Reserved.
50
Quiz Me
A wavelike series of involuntary muscular
contractions that propel solid and semisolid
materials through the alimentary tract is termed:
A.
B.
C.
D.
Peristalsis
Rhythmic segmentation
Deglutition
Mastication
Copyright © 2018, Elsevier Inc. All Rights Reserved.
51
Quiz Me
The angular notch is located _____.
A. on the fundus next to the esophagogastric
junction
B. on the greater curvature
C. on the lesser curvature
D. within the gastric canal
Copyright © 2018, Elsevier Inc. All Rights Reserved.
52
Quiz Me
If a patient lies supine during an upper GI
series, where would most of the barium settle
within the stomach?
A.
B.
C.
D.
In the fundus
In the body
In the body and pylorus
In the body and C-loop of the duodenum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
53
Quiz Me
What structure helps to create the C-loop of the
duodenum?
A.
B.
C.
D.
Tail of pancreas
Liver
Stomach
Head of pancreas
Copyright © 2018, Elsevier Inc. All Rights Reserved.
54
Radiographic Procedures
Contrast Media and
Technical Considerations
Copyright © 2018, Elsevier Inc. All Rights Reserved.
55
Upper GI Procedures


Contrast medium required
Increases or decreases tissue density
AP abdomen
PA upper GI
Copyright © 2018, Elsevier Inc. All Rights Reserved.
56
Fluoroscopy

Ability to view and record anatomy in motion
(evaluate function and form)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
57
Barium Sulfate




Positive or radiopaque
Chalk-like substance
Absorbs more x-rays
BaSO4
Copyright © 2018, Elsevier Inc. All Rights Reserved.
58
Colloidal Suspension



Never dissolves in water
Rate of separation varies by brand
Contraindications: perforated viscus or
presurgical procedure
Copyright © 2018, Elsevier Inc. All Rights Reserved.
59
Barium
Thick Barium

3:1 or 4:1 ratio of
BaSO4 to water
Thin Barium

Copyright © 2018, Elsevier Inc. All Rights Reserved.
1:1 ratio of BaSO4
to water
60
Water-Soluble Iodinated Contrast
Media

Indications



Perforated viscus
Presurgical
procedure
Contraindications

Hypersensitivity to
iodine
Copyright © 2018, Elsevier Inc. All Rights Reserved.
61
UGI
Single-Contrast UGI

Barium sulfate
Double-Contrast UGI


Barium sulfate
Carbon dioxide gas or
room air
Copyright © 2018, Elsevier Inc. All Rights Reserved.
62
Double-Contrast Upper GI
Mucosal Folds Demonstrated
Copyright © 2018, Elsevier Inc. All Rights Reserved.
63
Esophagography:
Radiographer’s Responsibilities
1. Prepare
fluoroscopy room.
2. Prepare contrast
media.
3. Obtain clinical
history.
4. Explain procedure.
Copyright © 2018, Elsevier Inc. All Rights Reserved.
64
5. Introduce and assist
the fluoroscopist.
6. Assist the patient.
Copyright © 2018, Elsevier Inc. All Rights Reserved.
65
RAO: Projection Commonly Taken
During Esophagography
Copyright © 2018, Elsevier Inc. All Rights Reserved.
66
Diagnosis of Esophageal Reflux
1.
2.
3.
4.
Breathing exercises (two types)
The water test
Compression paddle technique
The toe-touch test
Copyright © 2018, Elsevier Inc. All Rights Reserved.
67
1. Breathing Exercises

Valsalva maneuver


Patient takes in deep breath and holds in breath
while bearing down as if trying to move the
bowels.
Mueller maneuver

Patient exhales, then tries to inhale against closed
glottis.
Copyright © 2018, Elsevier Inc. All Rights Reserved.
68
2. Water Test

Positive if barium
regurgitates into
esophagus (LPO
position, swallow
water through straw)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
69
3. Compression Paddle


Paddle inflated
under stomach with
patient in prone
position
Pressure applied to
stomach region
to create reflux
Copyright © 2018, Elsevier Inc. All Rights Reserved.
70
4. Toe-Touch Maneuver

Effective for reflux
and hiatal hernia
Copyright © 2018, Elsevier Inc. All Rights Reserved.
71
Upper GI Clinical Indications
1. Peptic ulcer
Diverticulum in duodenum
2. Hiatal hernia
3. Diverticula
4. Gastritis
5. Tumor
6. Bezoar-Solid
mass of indigestible
material
Copyright © 2018, Elsevier Inc. All Rights Reserved.
72
Upper GI Clinical Indications
1. Peptic ulcer
2. Hiatal hernia
Copyright © 2018, Elsevier Inc. All Rights Reserved.
73
Trichobezoar
(Specific Type of Bezoar)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
74
Duodenal Diverticulum
Copyright © 2018, Elsevier Inc. All Rights Reserved.
75
Sliding Hiatal Hernia

What is Schatzki’s
ring?
A narrowing of the
distal esophagus
causing dysphagia
Copyright © 2018, Elsevier Inc. All Rights Reserved.
76
Gastritis
Thickening of rugal folds
Absence of rugal folds
Copyright © 2018, Elsevier Inc. All Rights Reserved.
77
Positioning for Esophagogram and
Upper GI
Copyright © 2018, Elsevier Inc. All Rights Reserved.
78
Upper GI Patient Preparation




NPO 8 hours prior to study
No gum chewing
No smoking
Determine
pregnancy
Copyright © 2018, Elsevier Inc. All Rights Reserved.
79
Upper GI Fluoroscopy


Room preparation
Variable table positions, assist patient
Copyright © 2018, Elsevier Inc. All Rights Reserved.
80
4-Part Summary of Positioning and
Procedure Tips for Upper GI
1. Clinical history:
Review clinical history with
patient and documentation
2. Body habitus:
Affects positioning
3. Fluoroscopy:
Identify positioning
landmarks
4. High kV: Analog and
digital systems
Short exposure time:
100-125 (90-100 for doublecontrast procedure)
Control voluntary motion
Copyright © 2018, Elsevier Inc. All Rights Reserved.
81
Postfluoroscopy Projections

Esophagogram

Routine
• RAO (35° to 40°)
• Lateral
• AP (PA)

Special
• LAO
• Soft tissue lateral
Copyright © 2018, Elsevier Inc. All Rights Reserved.
82
RAO Esophagogram


35° to 40° oblique
CR to T5-T6 (1 inch [2.5 cm] inferior to sternal
angle)
Routine
• RAO
Copyright © 2018, Elsevier Inc. All Rights Reserved.
83
Evaluation Criteria
RAO Esophagogram



Entire esophagus
demonstrated
Esophagus midway
between spine and
heart
Optimal exposure
factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
84
Lateral Esophagogram


True lateral
CR to T5-T6
Routine
• RAO
• Lateral
Copyright © 2018, Elsevier Inc. All Rights Reserved.
85
Upper Esophagus

Swimmer’s lateral (for better visualization of
proximal esophagus)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
86
Evaluation Criteria
Lateral Esophagogram





Entire esophagus
demonstrated
Esophagus midway
between spine and heart
Arms not superimposing
esophagus
True lateral position
Optimal exposure factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
87
AP (PA) Esophagogram


AP (PA) projection
CR to T5-T6
Routine
• RAO
• Lateral
• AP (PA)
Copyright © 2018, Elsevier Inc. All Rights Reserved.
88
Evaluation Criteria
(AP Esophagogram)


No rotation
Optimal exposure
factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
89
LAO Esophagogram


35° to 40°
oblique
CR to T5-T6
Special
• LAO
Copyright © 2018, Elsevier Inc. All Rights Reserved.
90
Evaluation Criteria
LAO Esophagogram



Entire esophagus
demonstrated
Esophagus midway
between spine and
hilar region
Optimal exposure
factors
Arrows indicate region of
possible pathology
Copyright © 2018, Elsevier Inc. All Rights Reserved.
91
Double-Contrast Esophagram
Copyright © 2018, Elsevier Inc. All Rights Reserved.
92
Upper GI Series
Routine
 RAO
 PA
 Right lateral
 LPO
 AP
Copyright © 2018, Elsevier Inc. All Rights Reserved.
93
RAO Upper GI


40° to 70° oblique
CR to L1
Routine
• RAO
Copyright © 2018, Elsevier Inc. All Rights Reserved.
94
Evaluation Criteria
RAO Upper GI




Entire stomach and
duodenum
demonstrated
Body and pylorus
barium filled
Duodenal bulb and
C-loop in profile
Optimal exposure
factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
95
PA Upper GI


No rotation
CR to L1
Routine
• RAO
• PA
Copyright © 2018, Elsevier Inc. All Rights Reserved.
96
Evaluation Criteria
PA Upper GI



Entire stomach and
duodenum
demonstrated
Body and pylorus
barium filled, air in
fundus
Optimal exposure
factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
97
Right Lateral Upper GI


True lateral
CR to L1
Routine
• RAO
• PA
• R Lat
Copyright © 2018, Elsevier Inc. All Rights Reserved.
98
Evaluation Criteria
Right Lateral Upper GI




Entire stomach and
duodenum
demonstrated
Retrogastric space
demonstrated
Vertebrae in true
lateral perspective
Optimal exposure
factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
99
LPO Upper GI


30° to 60° oblique
CR to L1
Routine
• RAO
• PA
• R Lat
• LPO
Copyright © 2018, Elsevier Inc. All Rights Reserved.
100
Evaluation Criteria
LPO Upper GI



Entire stomach and
duodenum
demonstrated
Fundus filled with
barium
Optimal exposure
factors
Copyright © 2018, Elsevier Inc. All Rights Reserved.
101
AP Upper GI


No rotation
CR to L1
Routine
• RAO
• PA
• R Lat
• LPO
• AP
Copyright © 2018, Elsevier Inc. All Rights Reserved.
102
Evaluation Criteria
AP Upper GI



Entire stomach and duodenum demonstrated
Fundus is barium filled
Optimal exposure factors
AP supine
AP Trendelenburg
Copyright © 2018, Elsevier Inc. All Rights Reserved.
103
UGI Explained
Copyright © 2018, Elsevier Inc. All Rights Reserved.
104
Review of Patient Doses
Upper GI (postfluoro overhead exam exposures*)
cm
kV
mAs
Sk
mL
PA
18
125
4
113
38
Male 0.1
Female 9
AP
18
125
4
114
39
Male 0.1
Female 10
RAO
17
125
5
147
51
Male 0.1
Female 12
LPO
17
125
5
157
49
Male 0.1
Female 12
R Lat
22
125
7
275
48
Male 0.1
Female 21
*Actual dose dependent on system used, size of patient, and other factors.
Copyright © 2018, Elsevier Inc. All Rights Reserved.
105
Quiz Me
This pathologic condition is also known as
cardiospasm.
A. Barrett’s esophagus
B. Dysphagia
C. Esophageal varices
D. Achalasia
Copyright © 2018, Elsevier Inc. All Rights Reserved.
106
Quiz Me
This pathologic condition is often secondary to
acute liver disease such as cirrhosis.
A. GERD
B. Zenker’s diverticulum
C. Esophageal varices
D. Barrett’s esophagus
Copyright © 2018, Elsevier Inc. All Rights Reserved.
107
Quiz Me
A trichobezoar is a _____.
A. carcinoid tumor
B. mass of hair trapped in the stomach
C. mass of vegetable material trapped in the
stomach
D. benign polyp
Copyright © 2018, Elsevier Inc. All Rights Reserved.
108
Quiz Me
Which one of the following projections will best
demonstrate the proximal esophagus?
A. Right lateral
B. Swimmer’s lateral
C. RAO
D. LAO
Copyright © 2018, Elsevier Inc. All Rights Reserved.
109
Quiz Me
Which of the following upper GI projections will
demonstrate the duodenal bulb in profile?
A.
B.
C.
D.
AP
PA
RAO
Right lateral
Copyright © 2018, Elsevier Inc. All Rights Reserved.
110
Quiz Me
Which of the following upper GI projections will
best demonstrate the retrogastric space?
A.
B.
C.
D.
Right lateral
RAO
LPO
PA
Copyright © 2018, Elsevier Inc. All Rights Reserved.
111
Quiz Me
How much rotation of the body is required for
the LPO position during an upper GI?
A. 10° to 20°
B. 20° to 25°
C. 25° to 30°
D. 30° to 60°
Copyright © 2018, Elsevier Inc. All Rights Reserved.
112