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Fluoroscopic Investigations OfFluoroscopic Investigations Of The Gastrointestinal TractThe Gastrointestinal Tract

( Introduction)( Introduction)

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With the end of this lecture the student will be With the end of this lecture the student will be able to:able to: Describe the anatomy of the digestive system, to include the Describe the anatomy of the digestive system, to include the

pharynx, esophagus ,stomach, , large intestine ,and accessory pharynx, esophagus ,stomach, , large intestine ,and accessory organsorgans

Discuss the orientation of the stomach according to body habitus, Discuss the orientation of the stomach according to body habitus, physical position and respirationphysical position and respiration

Identify the function of each of the structures of the digestive Identify the function of each of the structures of the digestive systemsystem

Describe room preparation and identify supplies needed for the Describe room preparation and identify supplies needed for the examinations of the digestive system examinations of the digestive system

Identify methods of evaluating the digestive system Identify methods of evaluating the digestive system State the criteria to evaluate the digestive system radiographs State the criteria to evaluate the digestive system radiographs in in

term of positioning ,image quality, radiographic anatomy ,and term of positioning ,image quality, radiographic anatomy ,and pathologypathology

Explain different types of contrast media used in GIT exams Explain pharmacological agents pharmacological agents used in GIT exams Differentiate between Retrograde and Antegrade GIT studies

Learning objectives

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• Radiographic procedures: By Stephen Chapman• Positioning in Radiography: By k.C.Clarke.• Text book of radiographic positioning and related anatomy; by Kenneth L.Bontrager 6th edition.

Websites

• http://www.e-radiography.net/

ReferencesReferences

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The Digestive system The Digestive system Consists of: Consists of:

Mouth Mouth Pharynx Pharynx Oesophagus Oesophagus Stomach Stomach Small Intestine Small Intestine Large Intestine Large Intestine Rectum & Anus Rectum & Anus

Accessory organs include Accessory organs include Tongue and TeethTongue and Teeth Salivary glands Salivary glands Pancreas Pancreas Liver Liver Gall bladder & Gall bladder &

biliary tractbiliary tract

Basic Basic AnatomyAnatomy

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IngestionIngestion

DigestionDigestion

AbsorptionAbsorption

EliminationElimination

Physiology of the digestive Physiology of the digestive systemsystem

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Plain film Investigation Plain film Investigation Barium Investigations Barium Investigations Radionuclide Imaging Radionuclide Imaging Computerized Tomography Computerized Tomography Magnetic Resonance Imaging Magnetic Resonance Imaging Angiography Angiography Ultrasound Ultrasound Non- Radiographic Investigations Non- Radiographic Investigations

(Endoscopy) (Endoscopy)

Investigations of the digestive Investigations of the digestive

systemsystem

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Wide range of investigations can be Wide range of investigations can be performed performed

Can incorporate plain film & fluoroscopic Can incorporate plain film & fluoroscopic

equipment equipment

Involves the use of contrast media Involves the use of contrast media

Can involve the use of pharmacological Can involve the use of pharmacological

agents agents

What is the role of the What is the role of the Radiographer?Radiographer?

Barium InvestigationsBarium Investigations

Radiographic Contrast vs. Contrast Media

• Radiographic Contrast:Radiographic Contrast: Difference between adjacent densities in a

radiograph.• The films or images have different levels of density –

different shades of gray

Long (low)Short (high)

MAJOR DIFFERENCES SLIGHT DIFFERENCES

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• Contrast Media: Contrast Media: Diagnostic agents that are instilled into body orifices or injected into the vascular system, joints, and ducts to enhance subject contrast in anatomic areas where there is low subject contrast. CONTRAST

X-RAY DYE

DYE

Radiographic Contrast vs. Contrast Media

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Purpose of Contrast Media

To enhance subject contrast or render high subject contrast in a tissue that normally has low subject contrast.

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Contrast Media Properties able to show organ better physiologically

no permanent alteration of organ non toxic and able to be eliminated / excreted

Negative contrast Radiolucent

e.g. AIR Low atomic #

material Black on film

Positive contrast Radiopaque

e.g. BARIUM High atomic

Number White on film

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Barium Sulfate: BaSO4• High atomic number• Not soluble in water = suspension• Used to coat the lining of organs• Supplied in different thicknesses• Used

– Esophogram, UGI, Small Bowel, Large Bowel

Contraindications perforations of GI tract proximal to an obstructed bowel

Precautions adequate hydration post examination

Contrast Media for GIT Exams

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Why use Barium Sulphate?Why use Barium Sulphate?

It has a high atomic number It has a high atomic number

(Z=56) (Z=56)

Non-toxic Non-toxic

Relatively cheap Relatively cheap

body cannot metabolize BaSO4

Contrast Media for GIT Exams

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Gastrografin or Hypaque

• High atomic #– Close to iodine

• Water soluble• Similar usage as Barium

Water soluble, safe in the abdominal cavity

Safe to use if perforation is suspected

Contrast Media for GIT Exams

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Buscopan Buscopan Glucagon Glucagon Maxalon Maxalon CarbexCarbex Methyl celluloseMethyl cellulose

Why are they given?Why are they given?

Pharmacological agentsPharmacological agents

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Pharmacological agentsPharmacological agents

Agents Purpose

Buscopan (20mg iv) Buscopan (20mg iv) Relax smooth muscles (Useful in Relax smooth muscles (Useful in barium enema examinations)barium enema examinations)

Glucagon (0.3mg iv) Glucagon (0.3mg iv) Relax smooth muscles ( Relax smooth muscles ( Used for Used for patients with glaucoma & patients with glaucoma & cardiovascular diseasecardiovascular disease) Useful in ) Useful in barium enema examinationsbarium enema examinations

Maxalon (20mg Maxalon (20mg iv/oral)iv/oral)

Increases gastric peristalsis (useful in Increases gastric peristalsis (useful in follow through examinations)follow through examinations)

Carbex ( Tablets) Gas producing Agent ( For double contrast Ba Meal)

Methyl cellulose Methyl cellulose ( Syrup) ( Syrup)

For small bowel double contrast exams

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Antegrade studies (with the normal flow) esophagus, stomach, small bowel Contrast (Barium / barium + air /Oral iodine

solution

BaSO4 Only BaSO4 + Air

GI Contrast Studies

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GI Contrast Studies

Retrograde studies (against the flow) Colon ( Large Bowel) Contrast barium / barium + air

Barium Only Barium + Air

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GI Contrast Studies (Supplies)

Esophagus

Contrast media Straw and spoon Cotton balls Emesis basin

Small bowel

Contrast media ( 2 large glasses) Straw Gas producing substance

( carbonated drink ) Emesis basin Timer pharmacological agentspharmacological agents

Upper GIT

Contrast media Straw and spoon Gas producing substance

( carbonated drink ) Emesis basin pharmacological agentspharmacological agents

Barium enema

Contrast filled enema bag Enema tip Lubricant Disposable gloves Towels Sheets/blankets compression paddle pharmacological agentspharmacological agents

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GI Contrast Studies (Preparation)Common patient preparation aspects for Common patient preparation aspects for barium investigations barium investigations

What would you check?

Identification, request form. Identification, request form. Pregnancy check (10 day rule) Pregnancy check (10 day rule) Review of previous examinationsReview of previous examinations Allergy checkAllergy check Abdominal preparation Abdominal preparation ?Diabetic patients (adjustment in appointment time & ?Diabetic patients (adjustment in appointment time &

preparation prior to examination) preparation prior to examination) Psychological preparation for examination Psychological preparation for examination

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Summary of abdominal preparation Summary of abdominal preparation ( Adults)( Adults)

GI Contrast Studies (Preparation)

Esophagus

No preparation needed

Small bowel

NPO after evening meal

low residue diet 1-2 days prior to

exam

Cleaning enema

Empty bladder Upper GIT

NPO after midnight ( At least 8 hours prior to exam

No gum chewing

No smoking

Barium enema

low residue diet 2-3 days prior to

exam

Increased fluid intake 2-3 days

prior to exam

Cleared liquid diet 24 hours prior

to exam

Cathartic the afternoon before the

examination

Cleaning enema

Empty bladder

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Summary of abdominal preparation Summary of abdominal preparation ( Paediatrics)( Paediatrics)

GI Contrast Studies (Preparation)

Esophagus and Upper GIT

0-2 years NPO 3-4 hours prior exam

> 2 years NPO 6 hours prior exam

Esophagus and Upper GIT

0-2 years No preparation

2-10 years Low residue diet evening meal Mild laxative with water at bed time

> 10 years As for 2-10 years patients with doubling the dose of laxative

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GI Contrast Studies (Breathing Breathing InstructionsInstructions)

To reduce the stress of the abdomen that could lead to To reduce the stress of the abdomen that could lead to involuntary motion, involuntary motion, all radiographs are obtained during suspended all radiographs are obtained during suspended respiration. respiration.

Special breathing techniques are used to increase the Special breathing techniques are used to increase the Intrathoracic and Intrathoracic and intra abdominal pressure intra abdominal pressure Valsalva maneuverWhile holding the breath on deep inspiration , the patients bears down as if trying to move the bowels

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GI Contrast Studies

Equipment considerationEquipment consideration

Tilting table (+/-90 degrees) Tilting table (+/-90 degrees) Rapid film recording Rapid film recording

facilities facilities Special feeding accessories Special feeding accessories Fluoroscopic unit (normally Fluoroscopic unit (normally

digital) digital) Additional over couch tube Additional over couch tube Lead aprons and glovesLead aprons and gloves Sponges and other supportsSponges and other supports

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GI Contrast Studies (Radiation Radiation protection) protection)

ALARA principle ALARA principle (Minimise dose to patient /staff) (Minimise dose to patient /staff)

Utilise pulsed fluoroscopy where appropriate Utilise pulsed fluoroscopy where appropriate

Record patient dose & imaging times Record patient dose & imaging times

Record any faults with equipment / regular QA Record any faults with equipment / regular QA

Practical collimation Practical collimation

Adhere to clinical protocols (minimum no of films Adhere to clinical protocols (minimum no of films

/ dose) / dose)

Always read patient history / notes Always read patient history / notes 26

GI Contrast Studies (Plain Films)Before barium Studies Plain Films are required Before barium Studies Plain Films are required To Assess:- To Assess:- Trauma Trauma Small / Large Bowel Obstruction Small / Large Bowel Obstruction Constipation Constipation Palpable Mass Palpable Mass Acute Gastro-intestinal Bleeding Acute Gastro-intestinal Bleeding Perforation (include. Chest radiograph)Perforation (include. Chest radiograph)

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GI Contrast Studies(Plain Films)

Plain films showing ObstructionPlain films showing Obstruction

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THANK YOU

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