RDSC 233
Unit 3
Radiography of the Upper Gastrointestinal Tract
Bontrager chapter 14
Anatomy of the stomach & duodenum
Film Critique
Radiographic anatomy
Contrast media for the alimentary tract
and examination procedures
Positioning of:
Stomach
AP, PA, RAO, LPO,
Rt. lateral
Motility series
Exposure Factors
Radiographic
Pathology
What in the World?
Miscellaneous, but significant,
odds and ends
Atlas of Human Anatomy
Second edition (258)
Need to know
Centering of
the stomach
is the pyloric
canal/bulb.
Note the
change in
position.
Body habitus
relative to
position of
the stomach
and abdominal
viscera
Hypersthenic (5%)
Sthenic (50%)
Hyposthenic (35%)
Asthenic (10%)
Atlas of Human Anatomy
Second edition (258)
Need to know
Gastroesophageal junction
Cardiac part of Stomach
Fundus
Lesser and greater curvature
Body of stomach
Angular notch (incisure
angularis)
Pyloric antrum & canal
Greater omentum
Abdominal part of the esophagus
Atlas of Human Anatomy
Second edition (259)
Need to know
Cardiac oriface
Gastric (rugal) folds (rugae)
Pylorus (sphincter)
Superior (first) part of
duodenun (ampulla, cap, or
bulb)
Zigzag (Z) line
Atlas of Human Anatomy
Second edition (262)
Need to know
First (bulb), Second
(descendng), third (horizontal),
fourth (ascending), parts of
the duodenum
Duodenojejunal flexure
Duodenal papilla (vater)
Jejunum
Head of pancreas
Atlas of Human Anatomy
Second edition (263)
Need to know
Jejunum
Ileum
Mesentary
Visceral peritoneum (Serosa)
Circular folds
Mucosa
Radiographic Anatomy
Be prepared to identify these anatomical
structures in lab.
Radiographic Anatomy of the
upper gastrointestinal tract
Barium in
esophagus
RAO Position
Rugae (rugal
folds)
Gas and barium
in fundus of S.
Left
hemidiaphragm
Lesser
curvature of s.
body of s.
Greater
curvature of s.
Incisure angularis
Duodenal bulb
(or cap) etc.
2nd or descending
part of d.
Pyloric canal
&
Antrum
3rd or horizontal
part of d.
Pyloric orifice
(surrounded by sphincter)
Jejunum
4th or ascending part of d.
Distal esophagus
Radiographic Anatomy of the
upper gastrointestinal tract
Gastroesophageal junction (at cardiac orifice)
Cardiac zone (extends into fundus)
Area of detail
Left
hemidiaphragm
Peristalic
contraction from
distal to abdominal
part of esophagus
Anatomy
Review Know for lab
Contrast media for the alimentary tract
and examination procedures
Patient preparation (Prep)
Two kinds of Upper GIs
Fluoroscopy
Spot films Vs. Overheads
Contrast media
Barium
Water soluble iodine preparations
The Technologist’s role
Patient Prep for the Upper GI
For the stomach to be
visualized free of solids
or liquids that could
dilute the contrast, or
obscure pathology, the
patient should be NPO,
(Non Per Os), for 8 hrs
prior the exam.
This restriction includes
chewing gum and
cigarettes.
Two Kinds of Upper GIs
In the early years of radiology only
barium contrast was used. As the
film on the left demonstrates, a
concentration of barium entirely
attenuates the beam. Filling defects
appear as lucent shadows in the
midst of the barium, or as irregular
shapes on the edge of an organ.
Calcium or magnesium citrate
crystals produce C02 gas, and a
translucent, double contrast effect.
Fluoroscopy
Spot Films Vs. Overheads
Examinations of the
alimentary tract begins
under fluoroscopy to:
Since spot films allow precise
positioning, why are overheads
even taken?
* aid in diagnosis
Short answer: Geometric
factors.
(peristalic activity and filling
see next screen)
* Identify contraindications
to continuing (i.e.
fistulas, aspiration of
contrast)
* Spot filming under
fluoroscopic guidance
Using the
flouro tube
there is
variable
OID, less
SID, and
therefore
more
penumbra
Digital systems have eliminated
overhead filming some places
The effect of positions and barium
filling on the visualization of
anatomy
Identify the common anatomy on
these views
Contrast Media for the Alimentary Tract
What you need to know
Radiopaque (vs. radiolucent) contrast media is
typically barium, a soft, metallic, alkaline earth:
atomic # 56.
Processed into barium sulfate (BaSO4). Salts of barium
are chemically pure or they’re poisonous.
Insoluble in water. Collodial suspension (shake
vigorously).
In the GI tract barium is inert. Reactions are
extremely rare.
Contrast Media for the Alimentary Tract
What you need to know
Barium suspensions are tasteless, but rather
unpalatable. Flavorings are added to commercial
preparations, or may be added when used.
Added water changes viscosity and opacity.
Thin barium moves though the tract more
quickly. Thick barium adheres to the mucosa.
Mixtures are defined by department protocols.
Water is absorbed by the colon. If a patient is
dehydrated, water is absorbed and barium
becomes impacted. In addition to drinking
water, laxatives, such as castor oil may be given
after the exam.
Contrast Media for the Alimentary Tract
What you need to know
Barium is contraindicated when there is a chance
of leakage (post-surgical, or perforations), and
obstruction
Water soluble, iodine preparations are absorbed
by the body, and used in such cases.
Gastroview, Gastrografin, and Oral Hypaque are
brand names. All are bitter tasting.
Iodine sensitivity is a possibility.
Water soluble contrast is also used to dilute
barium preparations s loosing opacity.
The Technologist’s Role
Prepare materials for exam
Set up filming equipment
Greet the patient, explain exam, take Hx, answer
questions
Get and introduce radiologist, assist during
fluoroscopy.
Take and process overhead films
Clean up room, enter exam in computer
(Meditech at MWMC)
Dismiss the patient when radiologist okays
Radiographic Positioning of the
Upper Gastrointestinal Tract
Positioning of:
AP stomach
PA stomach
RAO stomach
LPO stomach
Right lateral stomach
and the
Motility series
including
Film Critique
Film Critique Reminder
In addition to criteria
specific to each
projection, all films
are evaluated for:
* Patient ID
* Rt/Lt, special marker
* Contrast & density
* Motion
* Artifacts
including
Standard UGI Positioning
Preparation
1. Evaluate the order
2. Greet the patient
3. Take History
What is pertinent Hx?
Abdominal, epigastric, or chest
pain (RO/MI), acid reflux, dyspepsia
(indigestion), ercuctation, anemia
from GI bleed, abdominal mass,
N/V, hematemesis.
4. Remove jewelry, check attire, snaps, pins, NG tubes, etc.
5. Explain the exam in layman’s terms
6. Questions?
7. Set technique before positioning
Routine UGI Positioning
Setup
1. 40” SID (relatively standard)
2. Reciprocating bucky
12:1, 16:1 grid
3. 100 + kVp for single, and 80 –
90 kVp for double contrast
(Why?)
4. 14” x 17” lengthwise for surveys, or
14” x 14” or 10” x 12” for cone down views
5. ID marker generally at bottom
6. Lt or Rt marker free of anatomy.
Routine AP Positioning
Steps
1. 14” x 17”
2. Midsagittal plane
straight, no rotation
3. CR between xiphoid
tip and lower margin
of ribs (inferior costal margin)
* 1” higher for hypersthenic,
* 2” lower for asthenic.
4. Favor left side if needed.
5. Suspend breathing on
expiration.
Routine AP Positioning
Criteria
On a 14” x 17” film, the
entire stomach, duodenum,
and the proximal jejunum
(whatever may fill) should
be included.
In the supine position the
fundus is inferior to the
pylorus. Barium fills the
fundus, and if double
contrast, air fills the body
and duodenum.
Lateral radiograph, showing
position of fundus relative to
the pylorus.
Routine PA Positioning
Steps
1. In PA position landmarks
are less accessible. In
addition to 1-2” above
lower margin of lateral
ribs (Bontrager), 6” above
the iliac crest is often
used to localize the level
of the pylorus and
duodenal bulb (center)
Higher for hypersthenic, lower for asthenic.
2. Favor left side if needed.
3. Double check Lt. marker (it’s a tricky
one)
Routine PA Positioning
Criteria
On a 14” x 17” film, the
entire stomach, duodenum,
and the proximal jejunum
(whatever may fill) should
be included.
In the prone position the
fundus is superior to the
pylorus. Barium fills the
Pylorus, duodenum, and if
double contrast, air fills
the fundus.
Lateral radiograph, showing
position of fundus relative to
the pylorus.
The “Classic” Anterior Oblique Position
* Entire spine straight (head elevated)
* Coronal plane through shoulders same as
coronal plane through hips
* Placement of arms and legs like this
The “Classic” Posterior Oblique Position
* Entire spine straight (head elevated)
* Coronal plane through shoulders same as
coronal plane through hips
* Placement of arms and legs like this
Routine RAO Positioning
The “GI Position”
Steps
1. 10” x 12” lengthwise
crosswise for transverse stomach
or 11” x 14” (dependant on
department protocol)
2. 400-700 RAO (steeper for
hypersthenic habitus)
3. CR between spine and
Lt lateral border, at level
of L2. The iliac crest is
at the level of the L4-5 interspace. The
inferior costal margin of the ribs is at L2-3.
2” higher for hypersthenic, closer to
spine, & transverse film
2” lower for asthenic (Observe fluoro)
Routine RAO Positioning
The “GI Position”
Criteria
Of the stomach
projections the
RAO is the film
of choice. In
addition to the
profile of
stomach anatomy, the duodenal
bulb and the sweep of the
duodenum must be included.
Note the marker
placement
Like the PA, air rises to the
fundus, and barium settles
in the pylorus.
Routine LPO Positioning
Steps
1. 10” x 12” lengthwise
crosswise for transverse stomach
or 11” x 14” (dependant on
department protocol)
2. 300-600 LPO (steeper for
hypersthenic habitus)
3. CR same as AP
4. Respiration: same as all
Note that the LPO is the corresponding
view to the RAO, and yet the degrees of
obliquity are 10 degrees less.
Routine LPO Positioning
Criteria
Like the RAO, the LPO demonstrates
the stomach in profile. The duodenal
bulb and the sweep of the duodenum
must be included.
Like the AP, air rises to the pylorus
and duodenum, and barium settles
in the fundus.
Routine Rt. Lateral Positioning
Steps
1. 10” x 12” lengthwise
or 11” x 14” (dependant on
department protocol)
2. True right lateral position,
mid-coronal plane to
long axis of table
3. CR to level of inferior
costal margain, between
anterior bodies of L spine, and
muscular wall of abdomen.
4. Respiration: same as all
5. 2” both, for hyper and asthenic habitus
Routine Rt. Lateral Positioning
Criteria
The Rt. lateral is unique in
demonstration of the retrogastic space.
Like the PA and RAO, air rises
to the fundus, and barium
settles in the pylorus and
duodenum.
For hypersthenic patients, the Rt. lateral
may demonstrate the profile view, pylorus,
bulb, and sweep of the duodenum much
like the RAO does for other body types.
Review of
UGI Film
Critique
On all films
Patient ID
Rt or Lt marker
Contrast & density
Motion
Artifacts
Know where the barium
and air will be on the:
1. RAO
2. PA
3. LPO
4. AP
5. Rt Lateral
If all the GI views were in
a routine, the most efficient
order would be:
1.
2.
3.
4.
5.
PA
RAO
Rt. Lateral
AP
LPO
However, for double contrast
exams the order may
purposefully roll the patient
back and forth to keep the
mucosal surface coated
with barium.
Motility Series: Chap. 15 (492-493) in Bontrager
The small intestine is studied less frequently than other
other parts of the GI tract, but when indicated, is usually
done in conjunction with the UGI.
The examination is known as a motility series
or small bowel series (SBS) or small bowel
follow through (SBFT)
Procedure: Following the UGI, 12 to 16 oz.
of thin barium is given the patient. An initial
“30 min” KUB is taken, the time is noted, and
a schedule of 15 to 30 minute intervals are
noted. AP KUBs are taken on this schedule
until the barium reached the terminal ilium.
The “30 min.” film should be
centered higher than a normal
KUB. Note the full stomach.
Jejunum
Motility Series: Chap. 15 in Bontrager
On occasion a PA KUB may be requested by the
radiologist. In this position pressure on the loops
of bowel may better demonstrate pathology
When the barium reaches the colon, KUB
filming is complete.
A small bowel series is usually completed
with fluoroscopy, and “spotting” the
terminal ileum.
A compression paddle is used to separate
loops of bowel. A metal ring
helps center it.
Ileum
Motility Series: Chap. 15 in Bontrager
A SBFT may only take an hour or two.
When a patient is very ill, unable to
keep down much barium, and laying on
a gurney between films, it may take
many hours. If the patient must remain
recumbent, a Rt lateral or RAO position
promotes motility.
If the patient is not ill, looking at pictures
of food helps speed things along
Enteroclysis: Chapter 15 in Bontrager
A method that provides greater visibility of
the small intestine is call enteroclysis
The patient is intubated with an
enteroclysis catheter (Bilbao or Sellink
tube), through the nose, directly into the
duodenum. High density barium,
followed by air or methylcellulose is
injected
Exposure Factors
From the “Rules of Thumb”
Based on: 3 phase, 100 RS film, medium speed screen, 72” SID
Compute a technique for a double contrast, and single contrast
UGI for a 26 cm abdomen in an AP position, using 400 RS system
1. (2 x 26) + 35 = 87 kVP @ 50 mAs
2. 50 mAs / 4 (RS) = 87 kVp @ 12.5 mAs (Double contrast)
3. 87 + 13 = 100 kVp @ 6 mAs (Single Contrast)
Now put the patient in an RAO (single contrast)
Up AP technique by 40 – 60 % = 108 kVp at 6 mAs
Now put the patient in a right lateral (double contrast)
Up AP kVp by 10, double mAs = 97 kVp @ 25 mAs
Significant Pathologies
of the upper gastrointestinal tract
and their
Radiographic Appearances
Thoracic stomach
Diverticula
Ulcerations
Hiatal Hernia &
Thoracic Stomach
Herniation of the stomach through the
esophageal hiatus of the diaphragm.
The degree of herniation varys.
Sliding hiatal hernia: Small portion of the stomach protrudes though the hiatus
due to a weakening of the esophageal sphincter muscle. Herniation changes
positions, and may be demonstrated by the valsalva maneuver. Reflux,
common to hiatal hernias, may be demonstrated in the trendelenburg
position. Schatzke’s ring is a radiographic sign of a sliding hernia.
Thoracic stomach:
Shown on these
images. The
majority of the
stomach
herniates into
the thoracic
cavity.
Thoracic
stomach
on CXR
Diverticula are outpouching caused by weakness
in the wall of a hollow organ. They are benign
and generally asymptomatic, though the weakened area may
perforate, and materials in blind pouches can cause
inflammation, ulceration, or infection.
Diverticula
This 4 CM diverticula of
the first part of
the duodenum
contains fibrous
materials,
creating a mass
known as a
bezoar.
Accumulations
include hair,
cellulose, and
seeds
Meckel’s diverticulum is caused by a remnant of the yolk sac (umbilical
vesicle) found 2’- 4’ from the terminal ileum
Ulcerations
Ulcers occur throughout the GI tract, but are most common in the pylorus and
duodenum due to the concentration of gastric secretions. These are known
as peptic, gastric, or duodenal. A bacteria, H pylori, is a cause of ulcers
recently discovered.
Radiographically, ulcer craters are
seen when barium fills them, and
remains after position or peristalsis
has moved the rest of the barium on.
What in the World?
Miscellaneous, but significant, odds and ends
Pathology or
What in the World?
Round, radiolucent densities in the GI tract
of a boy were very puzzling. They moved,
which was good, but what could they be?
Other than motion, why
might this spot film be
so blurry?
What in the World?
Is the barium filling
in the right
hypochondriac/epigastrium
region?
It starts
here
What in the World?
How’s it hangin’?
Things to look for
Ribs
Spot films, from the spot film device,
may be difficult to identify and hang
properly. If they are always in the
device the same way the ID marker
is used for orientation. If that is
unknown the recognition of anatomy
is the key.
Vertebral bodies
and disk spaces
Diaphragm &
lung
Esophagus
Pylorus
Cap of d.
2nd part
of d.
Vertebral bodies
and disk spaces
What in the World?
How’s it hangin’?
A
Spot films, from the spot film
device, may be difficult to
identify and hang properly.
If they are always
in the device the
same way the ID
marker is used for
orientation. If
that is unknown
the recognition of
anatomy is the
key.
B
On this and
the next two
screens, see
if you can
ID the spot
films hung
correctly
C
D
Answers follow
What in the World?
How’s it hangin’?
Screen 2
A
B
C
D
What in the World?
How’s it hangin’?
Screen 3
A
B
C
D
What in the World?
How’s it hangin’? Answers
Screen 2
Cap of d.
Sweep of
duodenum
C
B
Cap of d.
Pylorus
If you thought these
were fun, you’ll
love next weeks lab
Sweep of
duodenum
Film used
for explanation
back 4 screens
Screen 3
D
The End
42. Name this position
43. If only a tube angle is used
to accomplish it, what is
the degree and direction
of the CR?
44. Name this position
45. What pathological condition
would be demonstrated
on the up side?
46. What pathological condition
would be demonstrated on
the down side?
42. Name this position
Apical lordotic (lordotic chest)
43. If only a tube angle is used
to accomplish it, what is
the degree and direction
of the CR? 15-200 cephalad
44. Name this position (Rt) lateral
decubitus
45. What pathological condition
would be demonstrated
on the up side? Pneumothorax
46. What pathological condition
would be demonstrated on
the down side? Pleural effusion
48.
47. In which body habitus
would the stomach lie in
this extreme transverse
position?
50.
49.
48. 2nd or
descending
part of d.
47. In which body habitus
would the stomach lie in
this extreme transverse
position? hypersthenic
50. Greater
curvature of s.
49. pyloric antrum
1. What is the atomic number of barium?
2. True or false: Barium is Insoluble in water.
3. Is this film AP,
PA, or RAO?
4. Is this film AP,
PA, or RAO?
5. Is this film AP,
PA, or RAO?
6. What is the range of obliquity for an RAO stomach?
7. What body habitus requires the steepest obliquity?
1. What is the atomic number of barium? 56.
2. True or false: Barium is Insoluble in water. True
3. AP
4. PA
5. RAO
6. What is the range of obliquity for an RAO stomach? 40-700
7. What body habitus requires the steepest obliquity?
Hypersthenic