ABDOMINAL RADIOLOGY, FLUOROSCOPY

PROCEDURE MANUAL &

EDUCATIONAL GOALS
 TABLE OF CONTENTS

Goals and Objectives for the GI/GU Rotations .................................................4

GI Resident Responsibilities .............................................................................8
Resident Curriculum ..........................................................................................15
Educational List .................................................................................................16
Procedures and Techniques ..............................................................................13
Preliminary Supine Abdominal Film Prior to GI Contrast Examination . .13
Plain Abdominal Films ............................................................................13
Contrast studies ......................................................................................15
Drugs and Contrast Media ......................................................................16
SITMARKS Colonic Transit Study...........................................................18
Esophagram ...........................................................................................20
Post-operative Esophagus...............................................................21
Esophagram for Suspected Tracheal or Esophageal Injury
(e.g. Boerhaave Syndrome)............................................................23
Upper GI Series.......................................................................................23
Modified Barium Swallow .......................................................................27
Post-operative Stomach..........................................................................29
Bariatric Surgery......................................................................................30
Small Bowel Series (Follow Through).....................................................33
Gastrografin Small Bowel Challenge.......................................................36
Retrograde Small Bowel Series (through ileostomy)..............................36
Contrast Enema.......................................................................................37
Post-operative Colon...............................................................................38
Therapeutic (Cleansing) Enema..............................................................40
Defecography..........................................................................................41
Fistulography ..........................................................................................44
Endoscopic Retrograde Choledochopancreatography (ERCP) .............46
Post-Operative Cholangiography ...........................................................46
Hysterosalpingography ...........................................................................47
Cystography & VCUG.............................................................................48
Retrograde Urethrography......................................................................49

GI Curriculum & Reading Assignments.........................................................51

Additional Reference Textbooks.........................................................................52

Society of Abdominal Radiology Curriculum......................................................53

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Welcome to Abdominal Radiology.

The fluoroscopy service is an integral component of the Abdominal Imaging

service. On this service, residents will learn to interpret plain radiographs of the
abdomen and pelvis and to perform and interpret fluoroscopic studies of the
gastrointestinal and genitourinary systems. Fluoroscopy is a learned skill and can
only be mastered by performing as many procedures as possible on the several
Stanford Hospital (and VA) rotations.

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 GOALS AND OBJECTIVES FOR THE GI/GU ROTATIONS

Many of the goals and objectives apply to all GI/GU rotations and are listed
immediately below. Those goals that are more specific to a particular rotation are
listed separately.

Goals and Objectives for ALL GI/GU Rotations

1. Demonstrate learning of the knowledge-based objectives.
2. Review the request, all applicable clinical history, pertinent laboratory tests
and previous imaging studies to be certain that the proper test has been
ordered, that the patients condition is such that the examination is safe
and that any necessary preparation for the test has been completed
before starting the examination. If the indication for the examination is
unclear, contact the referring physician or another of the patients
appropriate and knowledgeable health care providers.
3. Perform all examinations in the appropriate way. If you have a question,
ask before performing the examination.
4. Accurately dictate all studies in a timely fashion.
5. Communicate effectively and courteously with referring clinicians:
a. Including obtaining relevant history for study interpretation.
b. Regarding important findings on studies performed.
6. Demonstrate learning of the clinical indications for ordering and using
radiological examinations including advanced GI/GU imaging.
7. Demonstrate responsible work ethic and professionalism.
a. This includes being present at the GI/GU station by 8:30 am.
b. Throughout the workday, this means completion of dictation
of all reviewed studies in a timely manner, attendance at all
departmental teaching conferences, and grand rounds
presentations.
8. Facilitate the learning of medical students, peers, and other professionals
participating in the GI/GI service including speech pathologists, nurses,
nurse practitioners, and speech therapy students.
9. Build confidence in reading routine and STAT GI/GU studies.
10. Review ACR Appropriateness Criteria and Standards regarding GI and
GU tracts (including the Communications Standard).
11. Follow up results of surgery or examinations performed by other clinical
services to determine final diagnosis.

Core Competencies by Goal

! Medical Knowledge - Goals 1 through 13
! Interpersonal and Communication Skills - Goals 2, 4, 5, 8, and 12
! Practice Based Learning and Improvement - Goals 2, 3, 4 and 13
! Professionalism Goals 5, 7, 8 and 9
! Patient Care - Goals 2, 3, 4, 9

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Assessment Tools Utilized
! Global ratings by faculty including rotation evaluation sheet
! Conference attendance logs
! In-service examination and through RADPrimer
! Plan
o Develop 360 degree evaluations
o Individuals to be included - technologists on day shift in radiology
core, technology supervisor for radiology

Goals and Objectives for 1st and 2nd Fluoro Rotations

Knowledge-Based Objectives
At the end of these rotations, the resident should be able to

1. Discuss the proper clinical and radiologic indications for the following studies:
a. Esophagram (Barium swallow)
b. Upper gastrointestinal series (UGI)
c. Barium enema (BE)
d. Small bowel follow-through (SBFT)
e. Endoscopic retrograde cholangiopancreatogram (ERCP)
f. Fistulograms
g. Cystogram
h. Voiding cystourethrogram
i. Hysterosalpingogram (HSG)
j. Defecography

2. State the physiologic properties, proper concentrations and proper indications for
the use of the following contrast materials:
a. Barium
b. Water soluble contrast media (Gastrografin/Gastroview,
Cystografin/CystoConray, Omnipaque)

3. Discuss the following information about Glucagon:

a. Proper indications and dosages used in GI radiology
b. Physiologic and side effects; contraindications

4. List the high risk factors, pretreatment and treatments for adverse reactions to
intravenous contrast media.

5. Demonstrate ability to interpret plain films of the abdomen, including common

conditions such as bowel obstruction, volvulus, pneumatosis,
pneumoperitoneum, common support apparatus, devices and foreign bodies.

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 6. Achieve > 90% score on the Stanford Radiography and Fluoroscopy
Inservice Exam.

Technical Skills
By end of the 2nd rotation, the resident should be able to

1. Demonstrate basic knowledge of the equipment used during fluoroscopy,

radiation safety features of the machines, and proper radiation safety
techniques.

2. Demonstrate knowledge of patient positioning, and type of films that

should be taken for the procedures listed in #2 above.

3. Competently and with limited supervision perform and interpret the

following:

a. Barium swallow (esophagrams; including post-operative)

b. Upper GI series
c. Contrast enema (including post-operative state)
d. Small bowel follow through
e. Fistulogram
f. Cystogram
g. Voiding cystourethrogram
h. Hysterosalpingogram
i. ERCP (interpretation only)
j. Defecography

Decision Making and Judgment Skills

At the end of the rotation, the resident should be able to

1. Review history of the patient for whom a procedure has been ordered and
determine the appropriateness of the study requested.

2. Communicate with the referring physician about any recommendations for

change in the type of procedure to be performed.

3. Communicate with the technologist about any special or additional views

that should be obtained to demonstrate the pathology identified.

4. Read and dictate the studies performed, with the assistance of the faculty
radiologist.

5. Communicate to the referring physician on the day of the exam any

significant abnormalities identified on the examination.

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Goals and Objectives for 3rd Rotation
Knowledge Based Objectives
At the end of the rotation, the resident should be able to

1. Demonstrate continued increase in knowledge in the areas listed in the previous

rotations.

2. Achieve a score > 80% on the RADPrimer Basic and Intermediate level In-
service Exam (GI & GU).

Technical Skills
At the end of the rotation, the resident should be able to independently perform and
interpret most fluoroscopic and plain abdominal radiographic studies.

Decision-Making and Judgment Skills

At the end of the rotation, the resident should be able to demonstrate more advanced
and independent decision-making and patient management skills.

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 GI RESIDENT RESPONSIBILITIES

General Responsibilities
The adult Fluoroscopy service handles adults and some children referred by the
adult clinicians, surgeons or gastroenterologists for evaluation of abdominal
disorders by plain radiography or fluoroscopy.

The morning is dedicated to GI fluoro studies that the resident is expected to

perform with supervision. The resident will review the abdominal plain films in
the GI worklists on the PACS, as well as the fluoroscopy studies, and present
her/his preliminary impression of the study to the faculty prior to dismissal of the
patient. The afternoon is used for additional overflow studies,
hysterosalpingograms, and GU studies such as cystograms or nephrostograms,
as well as the afternoon plain films.

Good, interested, well-trained technologists are critical to the performance of

technically adequate GI studies. It is imperative that they be accorded the full
respect and cooperation commensurate with their professional status.

Scheduling
Our general philosophy is to provide the best, most expeditious care of the
patients as possible, with prompt reporting to the referring physician. There will
be flux in the daily schedule, as we try to accommodate as many patients as
possible.

The technologist staffing of the fluoroscopic area consists of two technologists

and, during most of the year, one or two students. One technologist arrives at
7:30 am and the other at 8:00 am. The technologists coordinate patient flow, film
quality control and scheduling.

Three fluoroscopic/radiographic rooms are available. No limit exists regarding

the number of patients scheduled per day; all inpatients will be done the day of or
after the physician requests the study. If possible, outpatients are scheduled
according to the patients' wishes; however we limit the daily number in an effort
to distribute the daily work volume. Diabetic and cardiac patients should be
scheduled in the early morning, if possible, to allow medications to be regulated.

Emergency cases will be added to the schedule automatically; a request for an

emergency study usually means that, if the fluoro study demonstrates what the
clinicians believe to be present, the patient will receive the appropriate
interventional or surgical therapeutic procedure immediately following the
radiologic examination. If the schedule is light, and a physician requests that an
elective study be done on either an inpatient or outpatient that day for patient
convenience, the study may be added on.

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The technologists should stagger their one half hour lunch breaks if the cases will not all
be completed by noon. One technologist should have lunch from 11:30 am -12:00 pm
and the other from 12:00 - 12:30 pm. This allows one technologist to always be
available in the area to finish any examinations not completed by noon and to obtain
follow-up films on patients needing them (such as small bowel series, etc.).
Technologists and students should also each have a fifteen-minute break in the morning
and afternoon.

If any delays are incurred in examining a patient at the time he/she is scheduled, the
resident or staff is expected to greet the patient and assure her/him that we are aware
they are available. Explain the delay and apologize. This demonstrates our respect
and decreases their annoyance. A greeting and a smile go a long way; it also reduces
the complaints the technologists and front desk personnel receive while the patient is
waiting.

The resident is expected to perform all studies. However, if the caseload is heavy and
the resident falls behind, the faculty will help until the schedule is back on time. Every
attempt should be made to get the resident to the noon conference, usually
meaning an 11:45 AM departure.

Patient Care and Priorities

No patient should be coerced into a fluoroscopic exam. Patients may refuse to start or
continue any examination. Be sure the patient understands both the nature and
importance of the study. Many times patient lack of compliance is due to fear.
Communicate with the patient's physician if a study cannot be completed.

Patient triage is an important part of the residents job. The resident and technologist
must continuously check to assess which patients are most medically unstable and
make sure they are handled expeditiously. This includes getting them in and out of the
fluoroscopy suite and expediting their exit from the department.

Exam Preparation and Performance

Each examination must be tailored to answer the question being asked. The protocols
described in this manual refer to routine examinations. Although this is a reasonable
basis from which to start, in many instances exams must be modified due to a patients
history, clinical condition or information desired.

Preparation for each study includes careful reading of the requisition to obtain history,
special instructions or precautions. All patient records are now available online in EPIC.
Check their records for history, indication for study and prior surgery, etc. In addition,
note whether endoscopy or biopsy has recently been performed. BEs may be
performed the day following the superficial biopsy that is obtained via a colonoscope,
although large amounts of air often preclude an ideal study.

NOTE: No study should be performed without a completed requisition.

Prior studies, particularly plain films, GI, CT, US etc., must be reviewed.

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Before beginning any study, the resident should introduce her/himself to the
patient. An attempt should be made to ascertain the possibility of pregnancy in
any female patient of childbearing age. Radiation to the abdomen is particularly
likely to be harmful between the second and sixth week post conception but
unnecessary radiation should be avoided at any stage of pregnancy. You should
inquire of the patient, "Is there any possibility that you are pregnant?" If the
answer is "yes" or if her menstrual period is overdue, the general rule is to
postpone any abdominal radiographic procedures which are elective in nature.
Patients should also be questioned about relevant symptoms, prior abdominal
surgery, having been NPO after 9:00 pm, and whether they received the
"Instruction Sheet" explaining the examination and whether they followed the
routine preparation. If a patient has active ulcerative colitis or Crohn's disease,
the only preparation is NPO after 9:00 pm of the night preceding the examination.
If the patient has not received the "Instruction Sheet" detailing the examination,
the procedure and length of time necessary to complete it should be explained to
them. Explain breath holding during spot filming to all patients, i.e., "don't take a
breath in, just stop breathing."

Important concepts to keep in mind prior to proceeding with the study include:

! The use of rectal balloons should be limited if at all possible; rectal

balloons must not be used with known or suspected proctitis or rectal
carcinoma.

! A barium enema is contraindicated with fulminant colitis, toxic megacolon

or suspected colonic perforation.

! If perforation of any portion of the GI tract is suspected, the study should

be performed with iodinated water-soluble contrast material. (e.g.,
Gastrografin, Cystografin)

! In suspected aspiration, high osmolality iodinated water-soluble contrast

material (e.g., Gastrografin) is contraindicated; when these contrast
agents come into contact with the lung they cause a severe pneumonitis.
Consult the attending radiologist regarding use of Omnipaque (a nonionic,
isotonic iodinated agent) in complex situations.

When the study has been completed, the resident will instruct the technologist if
views other than routine are required. Any unusual anatomy should be
mentioned or shown fluoroscopically to the technologist at this time.

Immediately after completing each study, a short fluoroscopic impression written

on the requisition is suggested. This should include comments pertaining to
esophageal motility abnormalities, reflux, findings on palpation, etc., to refresh
your memory when you view and report the study. After the initial set of
radiographs has been obtained, it may be necessary to re-fluoroscope or obtain
further views to clarify initial ambiguities. Patients may be more tolerant of this

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"second look" or "extra films" if you explain this as a continuation of the examination
rather than a re-examination or re-spot. Try to keep re-fluoroscopies to a minimum.

Record Keeping and Educational Responsibilities

All examinations are reviewed with the attending and dictated on the day of the
examination except for SBFT examinations that may not yet be complete at the end of
the workday. The resident is responsible for proofreading and initialing all dictated
reports.

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FLUOROSCOPIC TECHNIQUES

Fluoroscopic techniques will vary somewhat among even experienced

radiologists, and must be tailored to individual patients and conditions. For
instance, a study performed 24 hours following bariatric surgery will be much
more limited and focused than one performed electively on an ambulatory patient
to evaluate vague abdominal pain.

Before beginning a study, know what the specific goals are and make sure you
answer the clinical question.

Good fluoroscopy is 95% based on anatomy and gravity. (How must you
position the patient in order to get the contrast material &/or air where you need
it?) Example: when evaluating for a gastric outlet or duodenal disorder, the
patient must be placed right side down with the head of the fluoro table elevated
to have the contrast medium leave the stomach and pool within the duodenum.

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PROCEDURES AND TECHNIQUES
Preliminary Supine Abdominal Film Prior to GI Contrast Examination
A preliminary (scout) film of the abdomen prior to a fluoroscopic exam is not routinely
performed because of proven low-yield, radiation exposure and cost. However, it
should be obtained in any patient who has had previous surgery or intervention (e.g.
biopsy or balloon dilation) because surgical staple lines and other artifacts may
simulate pathology, such as a leak of contrast medium. Note: If a scout film is obtained
it must be interpreted as a separate, initial paragraph in the final report.

Plain Abdominal Films

(See McCort, Mindelzun, Filpi, Rennell-Abdominal Radiology and
Baker S. The abdominal plain film)

The information sought dictates the extent of examination performed.

Techniques
For adults, the lower edge of the film is centered on the superior margin of the
symphysis pubis. For a large patient, two (14 x 17) films cross-wise. Lower edge of one
on symphysis, lower edge of the other on iliac crest. With optimum exposure both
lateral properitoneal fat lines should be visible on all films.

Single Abdominal Film or KUB (kidneys, ureter and bladder)

Indications
! Preliminary for many studies.
! Search for masses; calcifications, particularly gallbladder, appendix or kidney;
position of tubes and catheters

Three-Way Abdominal Study

! Necessary for evaluation for bowel perforation and obstruction.
! Left lateral decubitus, patient remains in this position 10 minutes prior to
filming (ideally)
! Upright.
! Supine.

For the upright and decubitus films, the X-ray beam must be horizontal. An upright PA
chest is often obtained unless one has been done within a few hours. This enables the
examiner to exclude lung or diaphragmatic disease as the cause of the abdominal
symptoms. Lower lobe abnormalities are often better seen on an abdominal film than on
chest x-rays. It will also confirm the presence of free intraperitoneal gas.

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Evaluation of Plain Films of the Abdomen
Analyze all films using a well-conceived search pattern. The following can serve
as a model. Do not focus immediately on a perceived abnormality but evaluate all
information available from the film.

1. Supporting Structures

Start with tubes, devices and altered anatomy. Important clues are often
available by noting evidence of prior surgery (e.g. skin staples, anastomotic
bowel staple lines, ostomies.)

Residents must be able to identify the most common types of catheters,

drains, surgical devices and foreign bodies, including retained surgical
sponges and needles. (See: Abdominal Incision and Injection Sites,
STATdx)

2. Abdominal Calcifications

Residents must be able to identify renal calculi, gallstones, pancreatic

calcifications, vascular calcifications, injection granulomas, and calcified
lymph nodes, among others. (See: Expert DDx: Abdominal Calcifications in
STATdx)

3. Organomegaly and Masses

Hepatomegaly will displace the hepatic flexure down and splenomegaly will
displace the splenic flexure down and the stomach medially. The kidneys can
be seen, at least partially, in most patients because of adjacent perirenal fat.
Similarly, the bladder can usually be visualized because of surrounding
perivesical fat. Masses may be evident by localized soft tissue density that
displaces bowel and other structures. (Read: RUQ masses, LUQ mass,
Splenogegaly in STATdx)

4. Bowel Gas and Fluid

Normal stomach = gas + fluid. Normal small bowel (ambulatory patient) =

minimal gas. Normal colon = no fluid; formed stool in left side of colon.

Abnormal patterns:

Ileus: Increased gas and fluid in small bowel (diameter > 3 cm) and colon (>
6 cm) without a transition point.

Obstruction: Dilation upstream from a transition point; collapsed bowel

downstream

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 Aerophagia: Increased gas within SB and colon, but no significantly dilated
segments.

Note: In patients with both ileus and ascites, the mesenteric bowel segments (SB
and transverse and sigmoid colon) will be dilated while the ascending and
descending colon and rectum will be collapsed, often resulting in a mistaken
diagnosis of colonic obstruction.

5. Abnormal Gas Collections

Read in STATdx:
1. Pneumoperitoneum
2. Portal Venous Gas
3. Gas in Bile Ducts or Gallbladder
4. Pneumatosis of SB or Colon

6. Abnormal Fluid Collection

Residents must learn to recognize signs of ascites on plain films, such as the flank
stripe sign and obscuration of the margin between the Liver and Kidney. (Read:
Ascites in STATdx and in any standard abdominal radiology textbook.)

CRITICAL RESULTS

In the abdomen, critical test results that MUST to communicated with clinical
teams and recorded are as follows:

1. Non iatrogenic pneumoperitoneum

2. Retained foreign body
3. Bowel obstruction with strangulation
4. Misplaced enteric tubes or instruments
5. Complications of procedures or contrast reactions
6. Leaks

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 CONTRAST MEDIA
VARIBAR 40%
Thin Liquid Barium (used by Speech Pathologists)
98% w/v
E-Z-M HD barium (thick for double contrast UGI,
esophaghram)
60%w/v
41%w/w
Liquid EZpaque barium
(general purpose, esophagus, UGI, diluted
~ for SBFT)
VARIBAR 40% w/v
Target Viscosity 29% w/w
Honey (Speech Pathologist studies)
60% w/w
E-Z-PASTE
(to coat marshmallow or cookie for
Barium Sulfate Esophogeal
esophagram)
GASTROGRAFIN 37% Organically
Diatrizoate Meglumine & Bound Iodine
Diatrizote Sodium Solution USP (hypertonic, hyperosmolar for oral
(identical to Gastroview) administration)

CYSTOGRAFIN 300mL
Injection USP 30%
Diatrizoate Meglumine
(contrast enema in Large patients)
(similar to Cystoconray)

Injection USP 18%

CYSTOGRAFIN 300mL
(nearly isosmolar; for rectal or bladder
Diatrizoate Meglumine
administration)

240mg/mL
OMNIPAQUE 10mL (isosmolar; for HSG, I.V. or oral
(iohexol)) administration)
[very expensive; use sparingly]

OMNIPAQUE 10mL 300mgl/Ml

(iohexol)) (myelography, rarely for GI/GU)

OMNIPAQUE 100mL 350mgl/Ml

(iohexol)) (oral admin; risk of aspiration and leak)

CONRAY 43 430 mg I/mL

(iothalamate meglumine) (hypertonic; used for nephrostograms and
fistulograms)
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Potential Contra-Indications
Where GI or GU perforation is suspected use water-soluble contrast first.

Oral barium not given in the presence of colonic obstruction.

Don't give barium prior to ultrasound or CT examination.

Drugs
Glucagon
Used to relax spasm of stomach, bowel or colon. Produces hypotonia throughout the
GI tract almost immediately, but does not abolish peristalsis in the esophagus. To
prevent nausea, give slowly over 1 minute I.V.
Dosages
Upper GI 0.1 - 0.5 mg I.V.
Colon 1 mg I.M
Post Op. Stomach 1 mg. I.M
IV lasts 10 - 20 minutes.
IM lasts 20 - 30 minutes.
Contraindications
Pheochromocytoma, insulinoma, diabetic on insulin.

Metoclopramide (Reglan)

To enhance peristalsis for small bowel enema or small bowel follow through.
Stimulates gastric emptying. Facilitates duodenal intubation by feeding tube.

Dose
20 mg PO 15 minutes before procedure.

Contradictions
GI hemorrhage, perforation or obstruction.

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SITZMARKS Colonic Transit Study

On day one the patient ingests a SITZMARKS capsule containing 24 barium-

impregnated radioopaque markers. On day 5, an abdominal supine radiograph is
taken.

How to interpret a SITZMARKS test

Reading the Results:

If over 80% of the markers are passed by day 5, colonic transit is not grossly abnormal.
If the remaining markers are scattered about the colon, the condition is most likely
hypomotility or colonic inertia. If the remaining markers are accumulated in the rectum
or rectosigmoid, the condition is most likely functional outlet delay, e.g., internal rectal
prolapse, anismus.

1. If 5 or less markers remain, patient has grossly normal colonic transit

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2. If most rings are scattered about the colon, patient most likely has hypomotility or
colonic inertia.

3. If most rings are gathered in the rectosigmoid, patient has functional outlet obstruction.

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 FLUOROSCOPIC PROCEDURES

1. Esophagram
Before any barium swallow is performed, a full history must be obtained.
The examination can then be appropriately tailored. Ask specifically about
prior surgical procedures and food sticking in throat (big pills, dry toast,
meat).

Preparation
Although an urgent esophagram may be done without the patient fasting,
the optimal preparation is NPO after midnight.

Filming
Spot (3/sec for 2 sec) films. On any esophagus where a morphologic
abnormality is detected and further study not contraindicated, overhead
esophagus films should be performed. The technologists should do this at
the completion of your study, ideally with the patient positioned to show the
lesion optimally, and while the patient is drinking barium.

1.A. Esophagram with a History of Dysphagia, Food Sticking, or

Suspected Obstruction

The patient is initially placed in the upright left posterior oblique position.
The examination is begun with dilute (60%) barium. Teach the patient a
slow consistent cadence "one, two three." The patient is asked to take one
mouthful, hold it in his mouth and swallow when told. Follow the bolus
from mouth to the gastroesophageal junction with fluoroscopy, observing
the tail of the peristaltic wave. If no obstruction, aspiration or emesis is
encountered, proceed as in the next section. If obstruction is encountered,
spot views should be taken in at least two projections at the site, (e.g. LPO
& RPO).

Motility Study

Following the upright swallow, place the patient in a prone 25 RAO

projection with the table horizontal (swimmers position). Collimate to
show from the thoracic inlet to the upper abdomen (16 field of view). Have
the patient take one mouthful of barium and swallow only once.
Fluoroscopically monitor the tail of barium column. Repeat at least twice.
Record tertiary contractions and other abnormalities on spot films. Then
have the patient drink barium continuously while obtaining distended films
of the entire esophagus, including several of the EG junction. Have the
patient bear down when the esophagus is distended at the EG junction to
bring out a hiatal hernia or Schatzki ring.

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 An alternative to the prone position, especially for elderly or ill patients is filming in
the supine LPO position, with the patients right side supported by an angle
sponge.

Hypopharynx

If a morphologic lesion or motility disorder of the hypopharynx or upper

esophagus (e.g. crico pharyngeal spasm, tumor, Zenker's) is suspected, spot
films are necessary. Position the patient upright in a straight lateral or steep
oblique position. Collimate to show from the hard palate to the C7-T1 interspace.
Have the patient take one large mouthful of dilute barium (60%).
Depress rapid filming button and then have the patient swallow. Watch
fluoroscopy screen closely until the barium bolus passes. Turn the patient to AP
position. Be sure the patient's head is elevated so that the mid point of the jaw is
aligned with the posterior arches of the cervical spine (chin up). Repeat the
sequence. At least two swallows in each position should be performed.
Generally, only AP + Lat filming is helpful in diagnosis. Obliques may be helpful
when C7 and thoracic inlet region is not well seen as in patients with large
shoulders. The upper thoracic esophagus must be included for complete
evaluation of a large Zenker diverticulum.

Barium tablet or Food Bolus Administration

A 13mm Barium tablet may be given to evaluate esophageal narrowing as in

Schatzki ring, or any other cause of known or suspected mechanical narrowing of
the esophagus.
Occasionally the following is helpful. Bread or a marshmallow coated with a
spread of heavy barium. The patient is placed in an upright LPO position, then
instructed to chew as much as he does at home in the first bite and swallow it with
a mouthful of light barium. The food bolus is observed as it passes through the
esophagus, at least twice.

1.B Post-Operative Esophagus Studies

These patients may be studied in the immediate post-operative period to rule out
anastomotic leaks or later for suspected anastomatic stricture, severe reflux, etc.
Gastrografin is the medium of choice.

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The Ivor Lewis esophagectomy

This and its many alternative procedures are the most common surgical
procedures for resection of esophageal cancer. The distal esophagus and
proximal stomach are resected and the EG anastomosis may be created at
any level from the thoracic inlet to the subcarinal region.

Mandatory reading: RG 2001; 21: 1119 and RG 2007; 27: 409

Post-Fundoplication

Various forms of fundoplication are performed as anti-reflux surgical

procedures, with the most common being the Nissen (360wrap)
procedures. Esophagography is often requested in the early postoperative
period to evaluate leak or high-grade (too tight) luminal narrowing through
the wrap. Studies performed weeks or months later are usually to evaluate
suspected complications such as dehiscence or slip of the fundoplication

Early Post-operative Period.

Following a scout film of the epigastric region, the patient is placed upright
in the LPO position and given Gastrografin to drink while obtaining rapid
sequence (2/sec) spot films of the E-G junction. Following several
swallows and filming in both the LPO & RPO positions, the patient is
placed supine in order to fill the gastric fundus. This allows evaluation for
leak and the Gastrografin pool will outline the fundoplication as a filling
defect.

Later Post-operative Period.

Barium is the contrast agent and a complete esophagram is performed

(see above; Esophagram)
22
 Mandatory reading: RadioGraphics 2005; 25:1485-1499

1.C. Suspected Aspiration, Tracheoesophageal Fistula or Tracheal

Laceration
A single swallow of Omnipaque should be performed, filming at 4 frames /sec. If
no significant leak is detected, a single-contrast barium study should be
completed with the patient examined in at least two positions that are at 90 to
each other. (e.g., LPO and RPO)

1.D. Suspected Esophageal Laceration or Perforation

(e.g., Boerhaave syndrome or trauma)

Begin with a small swallow of water to see how the patient tolerates this. Follow
with Gastrografin. Again, one swallow should be performed and monitored
fluoroscopically with images. If a leak is demonstrated, the examination is
completed. (Note: Lacerations of the esophagus in Boehaave syndrome are
almost always in the distal esophagus and best demonstrated in the LPO position.

If a leak is not demonstrated the patient MUST be given a swallow of 60% barium
because barium will in 15-20 % of patients demonstrate a tear not visualized with
water-soluble agents.

1.E. Esophagram in patients evaluated for lung transplantation

End-stage lung disease patients, particularly those with idiopathic pulmonary

fibrosis or cystic fibrosis often have clinically significant GERD. Reflux has been
associated with bronchiolitis obliterans syndrome, which represents a leading
cause of death after lung transplantation. Many surgical teams have suggested
antireflux surgery to preserve the allografts. Patients at Stanford routinely
undergo an esophagram in anticipation of surgery.

We perform a complete esophagram emphasizing both anatomic and functional

detail with special attention to the EG junction and reflux. All of these patients are
deconditioned and many are on oxygen therapy. The examination can be quite
trying for some of them. It is important to proceed slowly so as not to fatigue the
patient and yet gather as much information as possible.
Technique is the same as outlined above.

J Amer Coll Surgeons 2013; 217: 586-597

1. F. Double contrast Upper Gastrointestinal Studies: Esophagram or

Upper GI Series

Double contrast examinations of the upper gastrointestinal system are generally

reserved for evaluation of mucosal abnormalities of the esophagus, stomach,
and duodenal bulb. A double contrast esophagram or double contrast upper GI

23
series may be ordered for the evaluation or detection of erosions, ulcers,
polyps, malignancy, inflammation or infection. These exams are often a
first-line evaluation for these indications, with subsequent confirmation
usually obtained via upper endoscopy. Double contrast upper GI studies
are contraindicated for patients in the immediate post-operative period
status post gastrointestinal surgery, patients with recent trauma, and for
patients with suspected aspiration, perforation, tracheoesophageal fistula,
esophageal strictures or rings.

The double contrast exam is a two part examination, with the first part of
the exam utilizing a double contrast technique and the second part of the
examination utilizing a single contrast technique. Whereas the double
contrast technique is for evaluation of mucosal detail, the single contrast
technique is for the evaluation of motility, masses, strictures, etc.

The double contrast technique utilizes gas and high density barium as the
two contrast agents. Specifically, effervescent granules (sodium
bicarbonate crystals) are swallowed by the patient and these granules
liberate gas (carbon dioxide) which distend the stomach and esophagus.
This is then followed by the administration of thick barium which coats the
surfaces of the mucosa. It is important to keep in mind that the distension
may be uncomfortable for the patient and to work quickly to obtain the
images necessary.

Preparation

Esophagram: The optimal preparation is NPO for at least 2 hours prior to

the start of the exam.

UGI Series: The optimal preparation is NPO after midnight. Medications

are okay. Water is fine but no coffee or tea.

Contrast agents

Effervescent granules (sodium bicarbonate crystals)

High density barium

Filming

Each organ should be seen in at least two views and during both
components of the examination. Collimate as necessary, to include only
the relevant organs of interest. Take single spot images during double
contrast technique.

24
N.X. Double contrast esophagram

You will need a packet of effervescent granules, a small amount of water (about 2
tablespoons), two small cups, prepared thick barium, and a large cup for this part
of the examination. Place the thick barium in a large cup. Place the effervescent
granules in one of the small cups and a small amount of water in the other small
cup.

Prior to starting this examination, describe to the patient how the granules taste
(a very sour, strong lemon taste), explain that the granules will produce a lot of
gas, and, importantly, to not let the gas escape. This can be suppressed by
telling the patient to swallow when they feel the need to belch. Explain to the
patient to take a large mouthful of barium to hold in their mouth when told and to
swallow when told. Also, explain to the patient to move the cup of barium away
from their center (away from their neck, chest, and upper abdomen).

A. The patient is placed in the upright position, standing on the footboard, in

the LPO position to offset the esophagus from the spine.

B. Mix the small amount of water and the effervescent granules (it will start
effervescing immediately) and give the mixture to the patient, having them
drink it down as quickly and completely as possible. Alternatively, have the
patient place the granules in his mouth and drink it down with a small
amount of water.

C. Take the small cup(s) away and give him the large cup of thick barium in
their left hand.

D. Center the image over as much of the esophagus as possible.

E. The patient is then asked to take one mouthful, hold it in his/her mouth, tilt
their head back, and swallow when told.

F. Follow the bolus from the mouth to the gastroesophageal junction with
fluoroscopy and look for gross abnormalities.

G. Once optimal coating is achieved, seen as a thin sheet of barium lining the
esophagus, take spot images to include the entire esophagus,
gastroesophageal junction, and distended gastric fundus.

H. Repeat E. through G. with the patient in the upright RPO positioning.

I. If a double contrast Upper GI Series is requested, then follow the

instructions below (section N.Y.). Otherwise, follow the guidelines for the
single contrast esophagram as explained in the separate section. At the end
of the single contrast esophagram, check for reflux using the described
maneuvers.

25
N.Y. Double contrast Upper GI Series

The double contrast Upper GI Series includes a double contrast

examination of the esophagus, stomach, and duodenal bulb followed by a
single contrast examination of the esophagus, stomach, and proximal small
bowel.

It is important to keep in mind the relative positions of the stomach and

duodenal bulb to achieve an optimal double contrast evaluation of the
structures of interest. For example, the gastric fundus is a relatively
posterior structure. Therefore, to obtain a double contrast examination of
the fundus, optimal positioning would be more prone, as prone imaging
traps the gas in the more superiorly located structure which, in this case,
is the gastric fundus. Anatomic variations are considerable and, ultimately,
the goal is to obtain double contrast imaging of all portions of stomach
(fundus, body, antrum) and the duodenal bulb. An exact prescription for the
spot images to obtain may not always apply and it is important to be
flexible.

A. Follow the instructions for the double contrast esophagram as

described above (N.X). It is important to complete the double contrast
esophagram as quickly as possible.

B. Once you have completed obtaining images of the esophagus in the

LPO and RPO positions, quickly lower the table into the horizontal
position with the patient lying on his/her back.

C. Once the table is completely horizontal, perform maneuvers to coat

the stomach with the thick barium as tolerated by the patient.

1. This can be achieved by rotating the patient to his/her left into the
prone position, then back to his/her right in the supine position.
2. Alternatively, rock the patient from side-to-side in the AP and PA
positions.

D. Obtain single spot images of the stomach. LPO, PA, and RAO views
should show the gastric body, fundus, and antrum adequately.

E. Watch for a double contrast view of the duodenum during evaluation

of the stomach and take spot images if it is adequately coated and
distended.

1. The LPO position is usually effective to obtain double contrast

imaging of the duodenum.
2. Sometimes the extreme RPO position may be useful.
3. Also, placing the table semi-upright may help trap gas in the
duodenal bulb if other positions dont work.

26
 F. Assess the proximal small bowel for gross abnormalities, including diverticula
and take additional spot images if necessary.

G. Follow the instructions for the single contrast Upper GI series, including
assessment for reflux using the described maneuvers.

1.G. Modified Barium Swallow (Video Fluoroscopic Swallowing

Examination)
(Performed With Speech Therapist)

The video fluoroscopic swallowing examination (modified barium swallow)

procedure is designed to study the anatomy and physiology of the oral
preparatory, oral, pharyngeal and cervical esophageal stages of deglutition,
especially in patients considered to be at risk for aspiration pneumonitis.. Small
amounts of contrast material are used to minimize the risk while evaluating the
physiology of the oral cavity and pharynx. Four consistencies of barium are used
to investigate patient complaints of variable swallowing ability: thin and thick
liquid barium, barium paste, and material requiring mastication. NOTE: This is
not the study to evaluate post-operative anatomy (e.g., following ENT
oncologic surgery), nor is this study to be used to evaluate patients with
dysphagia; the standard esophagram is to be performed in this setting.
Patients considered to be at risk for aspiration as well as having dysphagia
or post-operative swallowing problems may require both a modified as well
as a standard esophagram for complete evaluation.

Preparation
The examination is performed with a fluoroscopy unit equipped with a video
recorder (usually room 1). The speech pathologist brings the video recorder for
the examination as well as any type of "food" to be used in the examination.

Examination
The exam begins in the lateral position, with 5 cc of thin barium to assess the risk
of aspiration and the patency of the pharynx. The patient is asked to hold the
barium in his mouth while the image is centered and the video recorder is
started. The fluoroscopic field includes the oral cavity and the cervical region.
The image should be collimated to improve resolution. The patient is asked to
swallow once and the fluoroscopy image is recorded until the bolus disappears
from the field.

After laryngeal protection and patency of the pharynx are demonstrated, the
examination is continued in the same fashion with the following:

! 5 cc of thin barium
! 5 cc of thick barium. Repeat once.
! 5 cc of barium paste. Repeat once.
! 5-10 cc of barium mixed with pudding, applesauce or any other puree-like
material.

27
 ! 5 cc of barium paste mixed with a cookie or cracker. Repeat once.

The following observations are noted in the lateral and A/P planes during
the radiographic procedure:

Lateral view
! Oral and pharyngeal transit
! Analysis of patterns of lingual movement
! Gross estimate of time elapsed before swallow reflex triggers
! Estimate of amount of vallecular residue after swallow
! Amount of material aspirated per bolus and reason for aspiration
! Timing of aspiration relative to triggering of swallow reflex, i.e.
before, during or after the swallow

Anterior/Posterior View
! Asymmetries in function, i.e. pharynx and vocal folds
! Viewing residues such as collection of material in the valleculae
and residue in pyriform sinuses
! Examine the residue in pharynx after swallow, comparing the two
sides

Radiographs should be taken during the routine examination if significant findings

are noted to create a PACS record for the referring clinicians. All video recorders
will be kept by Rehabilitation Services where they will be filed as permanent
records.

2. Single-Contrast Upper GI Study

Indications for a single-contrast GI study: suspected gastritis, obstruction,
tumor. The patient drinks 60% barium preparation.

A. Begin with the patient in the upright LPO position.

B. Under fluoroscopic monitoring, the patient should be instructed to drink

four ounces of barium. Observe esophagus and spot any abnormality.
Proceed rapidly to a study of the stomach.

C. Place patient in prone RAO position. Spot antrum. Give patient large
cup of barium with a straw. Observe esophageal peristalsis with single
swallows.

D. Then obtain spots of distended esophagus while the patient drinks

barium continuously.

E. Obtain barium-filled films of the body, antrum and duodenum.

F. Turn patient to supine LPO position for air-contrast views of antrum and
duodenum.
28
 G. Turn patient RPO, take spot film of fundus.

H. Return table to upright position, take compression shots of stomach and

duodenum. Under fluoroscopy, attention should be paid to the greater and lesser
curvatures.

I. The patient should be instructed to finish the cup of barium (a second cup
of barium may be administered).

J. Technologist will obtain the following films:

1. 10" x 12" radiograph of stomach, LPO (table horizontal)

2. 10" x 12" radiograph of stomach, 45o RAO (table horizontal)
3. 14" x 17" radiograph of stomach to include all barium filled small bowel,
prone PA (table horizontal)

3. The Acute Post-Operative Stomach

The indications for an examination of the acute postoperative stomach are
generally to evaluate for leak, perforation and obstruction. Common gastric
surgical procedures include partial or complete gastrectomy (e.g. Bilroth 1 or 2),
and various bariatric procedures.

In the immediate post-operative period, a water-soluble single contrast

(Gastrografin) examination should generally be utilized especially if there is a
clinical concern about an anastomotic leak or perforation.
An exception to this is when the patient has a known or strongly suspected
tendency to aspirate into the tracheobronchial tree. Give water first then follow
with Omnipaque. Aspiration of Gastrografin can produce a fatal chemical
pneumonitis.

Spot films: Various obliquities to demonstrate the altered anatomy and any
anastomoses. Due to recent surgery, the patient may not be able to tolerate
prone positioning. Steep oblique positioning with the head of the table elevated is
often useful to facilitate gastric emptying.

Overhead films

AP, LPO and RPO

References

1. Double contrast Gastrointestinal Radiology with Endoscopic

Correlation. Igor Laufer, Chapter 8 - The Postoperative Stomach.

2. Radiology of the Postoperative Digestive Tract Bruce Javors,

Ellen Wolf, Springer , 2003
29
3.A. Evaluation of bariatric surgical procedures.

Two categories of surgery are performed: restrictive and malabsorptive.

Diagram of Surgical Options. Image credit: Walter Pories, M.D. FACS

The most common (~85%) is the Roux-en-Y gastric bypass. This consists
of formation of a 1530 mL gastric pouch attached to a segment of
jejunum with side-to-side gastrojejunostomy. At 100150 cm a
jejunojejunostomy is created. The jejunal loop from the stomach to the
jejunum is referred to as the Roux limb. It is most often now placed
antecolic. Varying the length of the Roux limb will alter the malabsorptive
component of the procedure.

Gastric banding. Purely restrictive procedure. More popular outside the

USA. Adjustable silicone band with inflatable balloon creates adjustable
stoma controlled by saline injected subcutaneous port. Look at phi
angle, vertical line to line of plane of the gastric band (normal - 4-58
degrees).

Laparoscopic sleeve gastrectomy consists of placing a staple line along the

lesser curve of the stomach. Approximately 85% of the stomach volume is
excluded and then removed. A gastric tube represents the remaining stomach.

Jejunoileal bypass, the original bariatric operation, is no longer done, but we still
see some patients who had this procedure years ago.

Radiologic evaluation

30
The patient is often examined by fluoroscopy the day after surgery. Most of
these examinations are performed with the remote controlled unit in room 1. The
patient stands for the examination with a technologist in the room behind a
barrier. It is critically important for the technologist to be with the patient at all
times, as many of these patients are unstable and susceptible to vasovagal
reactions. If the technologist needs to leave the room to process a film, then the
patient needs to return to a wheelchair.

The patient is a given a swallow of water to determine if water-soluble contrast

materials can be used for the examination. Assuming that the patient does not
aspirate, the 1st series of films is obtained in the AP position at 2 frames per
second. Try to determine on this initial set of images (or simply by asking the
patient) which of the operations has been performed. Generally, following the
Roux-en-Y configuration, the ingested contrast material will flow inferiority and to
the left whereas following the sleeve procedure, it will flow to the right. The
patient is then studied in a slight LPO and a RPO projection, also at 2 frames
per second. Once the fluoroscopic examination is completed, the technologist
obtains an upright 14x17 in the AP projection. By that time enough contrast
material has passed distally so that the jejunojejunal anastomosis can be
optimally evaluated. Images need to be reviewed before the patient is allowed to
leave the department.

Mandatory Reading: [Bariatric Surgery in STATdx; RG 2006; 26: 1355]

Imaging in Bariatric Surgery: A Guide to Postsurgical Anatomy and Common

Complications Robert C. Chandler1, Gujjarrapa Srinivas1, Kedar N.
Chintapalli1, Wayne H. Schwesinger2 and Srinivasa R. Prasad1, AJR,
January 2008, Volume 190, Number 1

Imaging in bariatric surgery: service set-up, post-operative anatomy and

complications, Shah et al, The British Journal of Radiology, 84 (2011), 101
111,Abnormal findings on routine upper GI series following laparoscopic
Roux-en-Y gastric bypass OBESITY SURGERY Raman, R., Raman, B.,
Raman, P., Rossiter, S., Curet, M. J., Mindelzun, R., Morton, J. M., 2007; 17
(3): 311-316

31
3.B. The Remote Post-Operative Stomach
These patients can be studied with barium as the contrast medium,
assuming there is no clinical concern for leak (e.g., signs of peritonitis). A
preliminary film of the abdomen is taken. Spot films and overhead films
are obtained in multiple oblique, supine and prone positions, similar to the
standard procedure for a single contrast UGI.

Use with
Patient
supine

Use with
Patient
prone

Compression devices.

4. Feeding Tube Placement

Occasionally we will be asked to assist in the placement of a feeding tube

under fluoroscopic guidance. We generally insist that the clinical team
have at least attempted to place an enteric feeding tube (EFT) on the ward,
as most of these will find their way into the duodenum without guidance.
Fluoroscopy is not of assistance if the issue is that the patient refuses to
cooperate with EFT placement or repeatedly pulls it out. Nevertheless,
under some circumstances, such as surgically altered anatomy or a large
hiatal hernia, fluoroscopy can be helpful. The patient should be sent to our
department with the EFT in the stomach or at least with him as we do not stock
these in the department.

The initial placement of the EFT is with the patient in a sitting or supine position.
Place several mL of anesthetic gel (Viscous lidocaine) in the nares for comfort
and lubrication. With the neck flexed, slowly and gently advance the EFT to the
32
 back of the throat. Tell the patient in advance that when he feels a gagging
sensation, you will pause; then have him swallow as you advance the tube. If it
has gone down the trachea, the patient will generally have spasms of coughing; if
so, withdraw. Once the tube has entered the esophagus it is usually easy to
advance it into the stomach.

Largely by trial and error, the tube should be manipulated until the tip is near the
pylorus. Hold the tip of the EFT against the pylorus until a peristaltic wave carries
it through into the duodenum. Dont jab at the pylorus! Try to advance the tip into
at least the 2nd part of the duodenum.

Troubleshooting:

It can be helpful to administer about 2 syringes of air (via Luer lock 60 cc syringe
attached to the EFT) into the stomach. This distends the stomach and stimulates
peristalsis, both helpful in advancing the EFT.

For difficult cases (HH, strictures, prior surgery) it may be helpful to administer a
small amount of barium or Gastrografin through the EFT to outline the anatomy.

The wire that comes with EFT is of little use in guiding it under fluoroscopy.
Consider removing the existing wire and replacing it with a stiffer wire of the type
used in Angiography, some of which we do keep in the Fluoroscopy suite.

Reglan (metaclopromide, 10 mg) is a medication used to stimulate peristalsis. It

is administered orally as a 10 mg tablet and is, therefore, of limited value if the
patient is unable to swallow. It also takes some minutes to have effect.

5. Small Bowel Series

(Routine Single Contrast Examination)

Except when looking for acute small bowel obstruction, the patient should have
refrained from eating and drinking since midnight. Most small bowel
examinations, frequently termed small bowel follow-through (SBFT), are done in
conjunction with UGI studies. If the patient has had a concomitant UGI, the
patient drinks one more full cup of 20% barium after the routine UGI radiographs.
If only a small bowel series (SBS) is ordered, the patient drinks two full glasses of
20% barium. Some radiologists suggest adding a capful of gastrografin in each
glass of barium the patient drinks (mix well!); this may accelerate the small bowel
transit time of the barium. During the small bowel examination, the patient
should not lie on his back or left side, as the barium will remain in the gastric
fundus. Except when routine radiographs or spot films are being taken,
the patient should either be in upright (walking, standing or sitting) or right
side down position to facilitate gastric emptying. It is important to have
solid, continuous full column filling of the small bowel with barium to
ensure adequate diagnostic visualization of all portions of the bowel. For
this reason, the stomach must remain fairly full with barium during the

33
 entire study; this may necessitate the patient having a 3rd, or even 4th,
cup of barium during the course of the examination.

NOTE: If the patient is intubated with either a nasogastric or small bowel

tube, the barium is usually injected through the tube using a 60 ml
catheter-tipped syringe.

When instilling barium through a nasogastric tube, the patient should be

placed in a head-elevated position (the X-ray table is raised) and the lower
esophagus monitored fluoroscopically during installation of barium, as
patients will invariably reflux barium around the tube. When esophageal
reflux occurs, stop injecting and ask the patient to swallow their saliva.
The resultant peristaltic wave will sweep the barium back into the
stomach.

Five minutes after the 2nd cup of barium has been ingested, a film is
obtained.

Initial - 14 X 17 radiograph of abdomen, prone, upper/mid abdomen (table

horizontal).

Subsequent - 14 x 17 radiographs of abdomen, prone, including the

rectum are obtained at 15 minute intervals for the next hour and at 1/2
hour intervals for the next two hours until barium is in the right colon.

All films should be viewed as soon as possible following their exposure.

The patient should also be fluoroscoped and the bowel palpated using a
compression device several times during the study.

NOTE: If apparent compression defects are noted on any portions of the

small bowel or if the loops appear abnormally separated, an AP supine
film is obtained immediately. Prone films give better visualization of the
small bowel loops because they tend to separate them slightly from one
another due to the compression effect of the table on the patient's
abdomen; at times, however, this compression is exaggerated (especially
in slender patients) and "abnormal" compression defects or loop
separation is observed. If the abnormalities are secondary to the patient's
prone position, they will disappear on a supine film.

If any questionable or definite abnormalities are identified on the 14 x 17

radiographs, the patient is returned to the fluoroscopic room and the bowel

is manually palpated with graded compression (using the plastic F Spoon) Spot
films are obtained of the questioned area and prone compression (using the
pneumatic compression paddle) films are also obtained. If a definite abnormality
is viewed fluoroscopically, an overhead routine radiograph (10 x 12 or 14 x 17) is
obtained of the abnormal area with the patient in the position best demonstrating
the lesion.
34
Most SBSs are completed within 1 to 1 1/2 hours post barium ingestion. Patients
in whom the study takes longer than three hours usually have ileus (including
secondary to drug therapy) or a partial or complete small bowel obstruction.
These patients are usually inpatients and further films are obtained at times
deemed clinically feasible by the radiologist; it may be necessary to follow the
study for as long as 24 hours. In these instances, the patients are returned to the
ward. They are then brought back to the fluoroscopic room for films at two to four
hour intervals during the day. The last film is obtained around 10:00 pm; if
barium still has not reached the colon, the patient is returned at 8:15 am the next
morning and is again studied. In the above cases, by the time the patient is
returned to the ward for the first time, or certainly the 2nd time, enough barium is
usually distal to the ligament of Treitz so that the patient may be put back on NG
suction if a nasogastric tube is in place.

NOTE: If a small bowel tube is in place, suction may remove a large amount of
barium from the intestinal loops.

In no instance, should a patient with an indwelling nasogastric tube be permitted

to become extremely uncomfortable, distended or nauseous; in all such
instances, suction should begin immediately and independent of the state of the
SBS examination. Giving ice water or food orally or Reglan 10 mg IV may
accelerate SBSs, but only after filled films of the jejunum have been obtained.

Because barium filled loops of small bowel are usually superimposed on each
other in the pelvis, compression films are necessary to ensure adequate
visualization of all portions of the small bowel. With the patient prone,
fluoroscopically place pneumatic compression paddle under pelvis and then
inflate balloon until bowel loops are separated.

Spot pelvic small bowel, prone (table horizontal)

When the head of the barium column is in the right colon, the patient is placed
supine and the terminal ileum, cecum and ileo-cecal valve are visualized with
several spot films taken. This will often require fluoroscopy in varying LPO and
RPO positions with graded compression over the RLQ.

14 X 17 overhead radiograph of abdomen to include all barium filled small bowel,

prone over inflated balloon (table horizontal)

5.A. Water soluble contrast challenge in patients with adhesive

SBO (Gastrografin challenge).

In the absence of signs of strangulation and following a CT scan,

patients with persistent symptoms who are deemed to have an
35
 adhesive small bowel obstruction can be given a 100cc Gastrografin
challenge. This can be administered through an NG tube or per
orally. The patient does not need to come down to the department as
the contrast can be given on the ward. Nursing personnel should be
instructed to place the patient into a right side dependent position to
facilitate gastric emptying.

Gastrografin is diagnostic and may be therapeutic because of its

high osmolality, draws fluid into SB and stimulates peristalsis.
Water-soluble contrast in the colon on a single abdominal film within
24 hours is a strong predictor of resolution. Fluoroscopy is not
necessary. A Gastrografin challenge is deemed safe and appears to
reduce surgical intervention and hospital stay, though conclusive
evidence is lacking.

6. Retrograde or Antegrade Small Bowel Series- Diagnostic or

therapeutic (Ileostomy Patient)

This study may be requested to evaluate a patient with decreased ostomy

output, suggesting SB obstruction. A Foley catheter is inserted into the
upstream portion of the SB and the 20 mL Foley balloon is gently inflated
within the bowel. Either barium or Cystografin may be used as contrast
medium, and is administered by gravity pressure with an enema bag filled
with the contrast medium. IV or IM glucagon may be given to stop
peristalsis and to allow more complete filling. A similar technique can be
utilized to evaluate the SB distal to the ostomy by directing the Foley
catheter into the distal (downstream) SB segment.

Films

! Spot films as necessary, during retrograde filling:

! 14 x 17 radiograph of the abdomen, supine, include pelvis (table

horizontal)

! 14 x 17 radiograph of the abdomen, LPO, include pelvis (table

horizontal)

! 14 x 17 radiograph of the abdomen, RPO, include pelvis (table

horizontal)

36
 ! Drain small bowel by placing enema bag on floor for 10-15 seconds. Patient
experiences relief of distension with this passive drainage. After drainage, a
quick fluoroscopic search is made for abnormalities. Small bowel loops are
separated manually utilizing a compression paddle in a gloved hand. Spot
film any definite abnormality.

7. Single-Contrast Barium or Water Soluble Enema

Common Indications: suspected colonic obstruction, volvulus, diverticular

disease (not acute).

Method

Explain examination to patient and how patient's cooperation will help. Patient
supine LPO 20-30. Have compression paddle on gloved hand as barium is
instilled.

Obtain spot films of the sigmoid colon early and in several obliquities as it is often
redundant and may be obscured later in the study by overlapping loops of
opacified colon or small bowel. Follow head of barium using paddle to separate
loops of bowel and to compress the colon. Talk to the patient as the colon is
filled - be reassuring, explain some discomfort is expected and tell the patient
he/she is doing the examination well. Do not be misled by the appearance of
undistended bowel. If contrast flow is obstructed or appears to pass through a
perforation, stop the flow of contrast and take spot films of region. When contrast
reaches splenic flexure, turn patient RPO; take spot films of the splenic flexure,
and follow barium to cecum. Take spot films of the hepatic flexure in the LPO
position (or whatever additional obliquities are necessary to unwind the twists
and turns of the colon). After the colon is completely filled, stop the flow of
contrast. Take filled and compression spot films of the cecum and ileo-cecal
valve. Cecum is filled when the appendix fills, barium refluxes into the terminal
ileum.

Overhead films

1. 14x17 films should include both rectum and flexures unless the patient is too
large when an additional film (11x14) of the pelvis should be taken.

2. With patient supine:

Abdomen, AP; 14 x 17

3. Turn patient to right to RPO:

Abdomen, 45 RPO must include splenic flexure; 14 x 17

37
 4. Turn patient to left to LPO:

Abdomen, 45 LPO must include hepatic flexure; 14 x 17

5. Keep patient LPO:

Rectosigmoid, 45 LPO with tube angled 35 cephalad and centered

on anterior superior spine; 11 x 14

6. Turn patient to left decubitus position:

Lateral rectum; 10 x 12

7. After checking and clearing the filled colon films, the patient is
instructed to completely evacuate the contrast medium (ideally, into the
toilet), and a post-evacuation AP film of the abdomen is obtained.

8. Post-Operative Contrast Enema

We evaluate many patients who have had all or a portion of their colon
removed. Many of these patients will have a temporary ileostomy or
colostomy and various anastomoses that must be evaluated prior to
surgically restoring continuity of the bowel. It is important to understand
the relevant altered anatomy and terminology in order to perform and
interpret a meaningful exam.

8.A. S/P Sigmoid Resection with End-colostomy and Hartmann Pouch.

This is the procedure usually performed for resection of sigmoid

diverticular disease or carcinoma. The surgeon will often request contrast
evaluation of the Hartmann pouch, as well as the remaining colon to
detect residual disease and to assess the length of the remaining colon
prior to planned re-anastomosis (usually several months following the
initial surgery

38
 Technique:

1. First, examine the Hartmann pouch by placing a Foley catheter into the
rectum, inflating the balloon and instilling Cystografin to opacify the remaining
recto-sigmoid colon. The surgical staple line should be identified in the
Scout film in order to anticipate the length of colon that remains. Obtain
spot films and an AP and LPO oblique of the pelvis. Then place the enema
bag on the floor, open the valve, and allow partial decompression of the
rectum for patient comfort, before proceeding to evaluation of the proximal
colon.

2. Next, place a separate Foley catheter and balloon into the colon through the
colostomy. By gravity, infuse Cystografin into the colon. As the colon fills,
utilize the same patient positioning to obtain spot and overhead films as listed
under Single ContrastEnema.

8.B. S/P Low Anterior Proctectomy with Colo-Rectal Anastomosis

The procedure is performed in patients with rectal carcinoma. Surgeons may

anastomose the remaining rectum to the sigmoid colon in an end-to-end or end-
to-side fashion, with the latter being more common. Patients will usually have a
diverting ileostomy for several months to allow complete healing of the
anastomosis.

Technique

A Scout film of the abdomen and pelvis is obtained to include the symphysis
pubis. Either a Foley catheter or a standard enema tip is inserted through the
anus. Care should be taken to not inflate a balloon at the level of the

39
anastomosis as this may disrupt a fragile staple line or occlude a potential leak.
Cystografin is infused by gravity with retrograde opacification of the entire colon.

Particular attention is paid to the colo-rectal anastomosis, with several

spot films taken during colonic filling. Other spot, overhead, and post-
evacuation films are taken as described under Single ContrastEnema.

8.C. S/P Colectomy with Ilo-Anal Pouch and Anastomosis

This procedure is performed in patients with severe colitis, usually

ulcerative. An ileal pouch is created from distal SB segments to serve as
a fecal reservoir, and the pouch is anastomosed to the rectum. All
stapled rectal anastomoses are fragile and prone to leak and
stricture. For this reason, the surgeon will usually perform a Diverting
(double-barrel) ileostomy to divert the fecal stream for several months.
We routinely perform a Cystografin enema to evaluate the pouch and
anastomoses for leak or stricture prior to take-down of the ileostomy.

Technique

A Scout film of the lower abdomen should include the symphysis. Place a
Foley catheter through the anus and inflate the 20 mL balloon within the
ileal pouch. Gravity infuse Cystografin to fill the rectum, pouch, and distal
ileum up to the ostomy site. Obtain multiple spot films in various
obliquities during filling in order to detect leak. Do not over distend the
pouch or fill the ostomy bag with contrast medium, as the latter will
obscure visualization of the bowel. Make sure the rectum is filled with
contrast; if the Foley balloon occludes the anastomosis, either partially
deflate the Foley balloon or advance the catheter farther into the ileal
pouch, as the ileo-anal anastomosis must be visualized. Obtain filled
views of the lower abdomen and pelvis in the AP, LPO and lateral rectal
positions. Then drain the contrast back into the enema bag, allow the
patient to use the bathroom, and obtain an AP Abdominal-Pelvis film post-
evacuation.

9. Therapeutic Enema.

Therapeutic enemas are used in varying clinical situations such as

patients with cystic fibrosis and obstruction (DIOS) or in patients with
intractable constipation.

Although these are ordered sometimes as Hypaque enemas or

Gastrografin enemas, these agents should not be used as they are
hypertonic to blood.. Hypertonic solutions draw excessive amounts of fluid
into the intestines and may lead to hypovolemia.

For this reason, we use Cystografin 18% which is essentially isotonic, and
does not need to be diluted.
40
 Use a large bore rectal tube (not a Foley catheter) and try to reflux as much of
the contrast into the terminal ileum as the patient can tolerate. Do not rush the
examination. The patient is usually quite cooperative and will try to accommodate
the treatment as their other option, surgery, is highly undesirable.

Often laying the patient on his right side for a significant amount of time will help
reflux. Images are generally not necessary except for a supine post evacuation
film at the end of the examination. Do not hesitate to repeat the examination if
the results are less than optimal.

Remember that contact time by the contrast agent (in the right colon and in the
ileum), when the patient has returned to their room, will often produce the desired
results.

In particularly recalcitrant clinical situations, you may add Mucomyst_- 90cc (6

gms) to the contrast enema. This would be done in consultation with a nurse
from the CF Center, who would bring the Mucomyst to Fluoroscopy.

10. Defecography

A. Patient sitting in lateral position in special chair.

B. Rectum first filled with 3 syringes of 60% barium followed by 3

syringes of barium paste (E-Z-Paste, or equipment)

C. Spot Film at rest

D. Squeeze (Kegal) maneuver

E. Bear down without allowing defecation

F. Direct patient to defecate on command and film at 2/sec until

patient feels empty.

The Following Should Be Included On All Evaluations:

1. Anorectal angle. This is the angle between the rectum and the anus at the
pubo-rectal sling.

Mean value is 92 at rest and 135 on straining.

2. Position of the pelvic floor in relation to the pubococcygeal line.

Draw a line from the lower edge of the pubis to the last coccygeal
interspace. Measure the distance from this line to the anorectal junction.
A measurement greater than 8.5 centimeters at rest is abnormal. Next,

41
measure this same during maximal strain. The difference between these
two values should not be greater than 3.5 centimeters.

3. Diameter of the anal canal.

What To Look For:

1. Increase in the anorectal angle with defecation.

2. Relaxation of the pubo-rectal muscle.

3. Opening of the anal canal.

4. Descent of the pelvic floor.

5. Significant evacuation of rectal contents.

6. Lack of bulging of the rectal vaginal septum (no rectocele).

7. Prior to evacuation, the patient should be asked to squeeze (Kegal

maneuver), which should accentuate the pubo-rectal sling, decrease
the anorectal angle, elevate the pelvic floor, and tighten the anal
canal.

Abnormalities:
1. Rectal intussusception (types)

A. Rectal intussusception

B. Intra-anal rectal intussusception

C. External rectal prolapse

D. Many intussusceptions originate from the anterior rectal wall.

E. These appear to be progressive phases of the same abnormality.

F. An enterocele is a loop of small bowel or sigmoid colon that is

enclosed in the anterior wall of the rectal prolapse.

2. Rectocele, usually from the anterior wall.

3. Dyskinetic pubo-rectal muscle. This is characterized by paradoxical

hypertonic muscle contractions and represents a lack of
coordination of the pelvic floor musculature.

4. Descending perineum syndrome.

42
 This is manifested by a descent of the pelvic floor greater then 8.5
centimeters and a greater than 3.5 centimeters change in the position of
the pelvic floor on straining.

5. Incontinence.

An enlarged anal canal and an abnormal increase in the anorectal angle.

Usually greater than 130.

6. Solitary rectal ulcer (usually anterior wall).

Commonly associated with an intussusception. Virtually never seen on def.

Study.

A. Sigmoidocele
Grades 1 ,2 or 3

References

1. Bartram, Mahieu: Radiology of the pelvic floor in Henry & Swash-

Coloproctology and the pelvic floor. 1985.

2. Mahieu: Defecography in Margulis/Burhenne 4th Edition.

Alimentary Tract Radiology.

Defecography - Worksheet
Anal/rectal angle (normal 90 at rest, 135 during straining)

Puborectalis function (normal, decreased, dyskinetic)

Anal canal measurement (less than 1.5 cm)

Pelvic floor descent (less than 3.5 cm)

43
 Supporting structures

Abnormal findings:

Rectocele

Intrarectal

Entraal

Externa rectal prolapse

Enterocele

Intussusception

Descending perineum syndrome

Dyskinetic puborectalis muscle (contraction of puborectalis muscle during

defecation)

Solitary rectal ulcer (anterior wall, 6-8 cm above the anus)

Incontinence

Fill out the above worksheet in order to help you dictate a complete report.

11. Fistulography

Catheter injections, tube injections, wound injections and sinus tract

injections all fall into this category. They are usually requested on
postoperative patients with numerous complications including wound
dehiscence, postoperative abscess, anastomotic breakdown and leak,
ulceration or perforation.

Prior to fistula injection the radiologist should review the surgical note and
chart and discuss the procedure with the patient. Any drainage from tubes
or bags should be checked for type of drainage (serous, urine, blood, bile,
feces, etc.) and volume of drainage. Such basic observations can be quite
useful in planning and interpreting a fistula injection. The toughest decision
is often which tube to inject first in a patient with multiple wounds or
catheters. Consultation with the patient's surgeon will often be useful in
such cases.

Preliminary films to include AP abdomen, lower chest (to include

diaphragm) and lower abdomen, including the pelvis and entire symphysis
pubis, are often necessary. Cross-table lateral views and obliques can be
helpful to further determine the location in three dimensions of drainage
catheters or foreign bodies.
44
Sterile, water-soluble contrast material, usually Conray 43, should be utilized.
Gloves and as sterile a technique as possible are usually indicated. Usually most
bandages and padding must be removed so that the radiologist is aware of the
location and function of all catheters and tubing in place, as well as the location
and reason for all surgical wounds and ostomies. Once this information is
available, the examination is far easier to interpret. If a wound injection is being
performed, usually gently inserting a small catheter into the wound as far as it will
go easily is helpful to prevent leakage of contrast material out through the wound
onto the skin. Generally, the largest catheter (e.g., Foley) that will fit into the tract
should be used to minimize leakage around the catheter. Frequent checking
under the fluoroscopic carriage is necessary to see leakage from a wound or to
spot sites of communication to other skin openings.

Contrast injection should be performed under fluoroscopic observation at all

times. Gentle pressure should always be used. The injection should be
discontinued if resistance is encountered or if the patient complains of pain
thought to be due to the injection. Water-soluble contrast may cause a transient
burning sensation, especially in recent wounds or abraded, inflamed tissues.
Many fistulous tracts are poorly communicating, being obstructed by debris or
edema. Passive filling is often the rule and, therefore, rotation of the patient
through as much of a 360 arc as possible is desirable in an attempt to fill such
fistula. Often it is not possible to roll the patient prone due to the presence of
wounds or tubing. However, even the worst cases can often be rolled onto one
side with assistance.

Films

After preliminary films are obtained and satisfactorily reviewed, spot films should
be obtained during fluoroscopy.

Key:

Early films are often the most diagnostic. Spot films must have a sufficient field of
view to recognize relevant anatomy and location (e.g., filling of proximal or distal
SB, colon, vagina or bladder.

If an enterocutaneous fistula is identified (by recognizing luminal filling and

mucosal pattern) identify specifically which bowel segment is involved (proximal
vs distal SB or colon) as this has important clinical implications. Subsequently, it
may be impossible to determine where a fistula tract started without early films.
Continue to inject until all diagnostic information necessary has been obtained.
Usually spot films in the supine, LPO and RPO views are obtained. Overhead
views, including AP and cross-table lateral should also be done.

45
12. Endoscopic Retrograde Choledochopancreatography
(ERCP)

This examination has been radically altered by the introduction of MRCP,

3D rendered CT and Ultrasound. Whereas previously most examinations
were for diagnostic purposes, most today are done for intervention.
Nonetheless it is important for the radiologist to understand how the
examination is performed and optimized. Currently in our hospital ERCPs
are performed away from the main department and we have less
involvement with the procedures. You may practice in a center where the
approach is different from that currently done at Stanford. Common
indications are for identification and removal of common duct stones, as
well as diagnosis, dilation and stenting of biliary strictures (malignant,
inflammation, and post-surgical).

ERCP studies to be dictated are found under GI Fluoroscopy, unread.

Most can and should be interpreted soon after the study is completed. On
rare occasions, it may be necessary to delay interpretation until the
endoscopists procedure note is available for review in EPIC. Comparison
with prior ERCPs (and other imaging studies) and dictated reports will often
allow quick and accurate interpretation (e.g., follow-up dilation of an
anastomotic stricture following liver transplant; or stent replacement in a
patient with pancreatic carcinoma) without requiring extensive EPIC review,
nor waiting for the transcribed report from the endoscopist.

13. Post-operative Cholangiography

This procedure usually follows surgical intervention of the biliary tree (e.g.,
common duct stone extraction, liver transplantation with duct-duct
anastomosis). A T-tube or some other indwelling biliary catheter will be in
place.

Technique

Scout film of right upper quadrant.

Transplant recipients and other immunesuppressed patients should have

prophylactic antibiotic coverage (to be determined by the referring MD), as
cholangiography may cause transient broad spectrum bacteremia. (Note:
This can be minimized by using only low pressure injection of contrast
material.)

The external portion of the biliary catheter is cleaned with Betadine and/or
alcohol. If the catheter has a Luer Lock end, that is used for connection to
the injection tubing, which is a 30-50 cm in length of clear tubing. A 50 mL
syringe is filled with Conray 43 and the connecting tubing is filled with
46
 contrast medium (cm). Following connection to the biliary catheter, suction is
applied to withdraw bile into the connecting tubing and to rid the tubing of air
bubbles. (Note: Air bubbles must not be injected as these may simulate common
duct stones or prevent filling of intrahepatic ducts).

With low pressure injection of CM and fluoroscopy monitoring, the biliary tree is
opacified. Contrast will normally flow through the CBD to the duodenum quite
readily. To visualize the intrahepatic ducts optimally, the patient may be placed
into a 10 Trendelenberg (head down) position. Take several AP and oblique spot
films of the entire biliary tree. Raise the head of the table 10, if necessary, to fill
the CBD and demonstrate flow into the duodenum ( or Roux limb, in the case of a
choledocho-enteric anastomosis. Get a post-procedure overhead film of the
right upper quadrant in RPO position. Consider re-injecting CM to fill the biliary
tree just before the overhead film is taken.

14. Hysterosalpingography.

Get history, allergies, prior surgery. Most patients will have started on tetracyclines
as the American College of Obstetricians and Gynecologists recommends empiric
antibiotic treatment for women with a history of pelvic infection or when
hydrosalpinx is diagnosed at the time of the study.

Done 2-5 days after end of period- late follicular phase.

Known contrast allergy, pregnancy, and active pelvic infection are absolute
contraindications to the procedure.

Encourage bladder emptying prior to procedure.

Explain procedure. Be supportive and reassuring.

Support the patients hips on a stack of towels to aid visualization of the cervix.

Drape lower body as possible, female chaperone

Clean vulva and cervix well with Betadine multiple times

6.8 F Shalkoff catheter with 1.4 ml balloon and 14 F 16cm stiffener. Occasionally
may have to use tenaculum with Cohen acorn cannula.

Place stiffener against cervical os, not in canal. Fill catheter with Omnipaque,
eliminating air bubbles from tubing.

Inflate balloon within the cervix or uterine lumen and inject CM slowly to
decrease discomfort and tubal spasm.

In presence of tubal spasm, wait, will often relax. Use Glucagon if needed.

47
 Scout radiograph. At least 4 images. 1. Early for small filling defects 2.full
filling 3. both obliques 4. Any other including prone to resolve any
questions. Have a preliminary impression from the fluoroscopy so that you
can get all the proper images. For example, prone may differentiate free
spill versus large hydrosalpinx.

At the end of the procedure, deflate balloon, inject additional contrast

medium (if necessary) to visualize the uterine isthmus.

After procedure, explain what to expect, sticky contrast material, slight

bleeding, be aware of possible infection etc.

Ref; Diagnostic imaging in infertility, Winfield, 1992

15. Cystography and Voiding cystourethrography (VCUG)

Get history, indications for examination, infection history, allergies and

prior contrast reactions (Weese DL, Greenberg HM, Zimmern PE.
Contrast media reactions during voiding cystourethrography or retrograde
pyelography. Urology. Jan 1993;41(1):81-4).

Also be aware that during urodynamic evaluation, patients may have a

vasovagal response and even syncope. Stop bladder filling, lay patient
down, to correct situation.

1 cc sterile Neomycin sulfate ampule added to 300 mL Cystografin (or

Cystoconray. (According to the American Urological Associations Best
Practice Policy Statement on Antimicrobial Prophylaxis, prophylactic
antibiotics for cystourethrography or urodynamic studies are
recommended only for patients with risk factors (Wolf JS Jr, et al Best
practice policy statement on urologic surgery antimicrobial prophylaxis. J
Urol. Apr 2008;179(4):1379-90.)

Scout film of the abdomen and pelvis.

Catheterize and drain the bladder using aseptic technique and materials in
the Foley Catheterization kit.

Instill the Cystografin through the catheter via gravity.

For adults instill 300 to 400 mL of contrast material; false-negative

examinations can occur with inadequate distention of the bladder. Some
patients, especially those with neurogenic or post-operative bladders, may
tolerate less volume.

48
 Obtain early filling and fully distended AP, obliques and lateral fluoroscopic views.
Check for reflux. Get supine 14x17 films covering kidneys and bladder.

If VCUG is requested, ask the patient to try to tolerate maximal distention as this
will help them urinate on demand. Many patients find it difficult to void on
command and with an audience. It may help them to place their hand in warm
water or to hear running water.

For the VCUG, rotate the patient to the right 45 degrees.It is best to personally
speak with a referring urologist as to whether the Foley catheter should remain in
place or be removed. Some patients will be able to urinate around the catheter,
while many cannot. Urethral strictures are often best visualized with the Foley
catheter out.. Fluoro over bladder base and take multiple spots at 3 films/sec.
Check for refluxGet 14x17 AP supine post void film of pelvis.

Autonomic dysreflexia

In patients with spinal cord injuries, bladder filling during cystography may be
associated with vasovagal or even more severe neurologic and systemic
reactions. Prior to undertaking such procedures, the radiologist should consult
with the referring physician and read the relevant section of Uptodate on
prophylaxis and treatment of autonomic dysreflexia.

In spinal cord injury patients with lesions above the splanchnic sympathetic
outflow tract (T5-T6), bladder filling during cystourethrography or urodynamics
may trigger a life-threatening imbalance in reflexive sympathetic discharge. Signs
of autonomic dysreflexia include piloerection, skin pallor, sudden and severe
hypertension with compensatory bradycardia, and profuse sweating and flushing
above the level of the injury. Autonomic dysreflexia is a potential life-threatening
complication. The bladder should be drained and if the blood pressure is
significantly elevated a short-acting antihypertensive medication (nifedipine or a
nitrate) may be given. These medications may also be given prophylactically to
patients prior to cystography. Blood pressure should be monitored throughout
the cystogram.

16. Retrograde Urethrography (RUG).

Urethrography is performed by the retrograde injection of Cystografin into the
urethra. Common indications are trauma and stricture. Patients with blood at the
urethral meatus after blunt or penetrating trauma and patients with a so called
floating prostate on digital rectal examination should undergo a RUG. The
examination may also be ordered in surgical patients who have undergone a
urethroplasty for treatment of stricture.

Get a scout film. Place the patient supine turned 45 degrees to the right.

Clean the glans and urethral meatus with Betadine.

Inject 2 % lidocaine jelly into the urethra (Lidocaine Hydrochloride Jelly USP, 2%
49
STERILE PAK URO-JET). Wait a couple of minutes.

Place the tip of a pediatric catheter at the fossa navicularis (about 2 cm

from the urethral meatus). Inject 1.5 cc of air into the balloon slowly. Do
not over inject especially in patient with impeded sensorium.

Pull the penis laterally to straighten the urethra. Inject contrast slowly. Take
images as urethra fills. Contrast may or may not pass beyond the prostatic
urethra.

50
 GI CURRICULUM & READING ASSIGNMENTS

1. During the 1st and 2nd year Fluoro rotations, the resident will access the
Curriculum section of RADPrimer and will read the Basic Gastrointestinal and
Genitourinary Lessons with specific attention to the following: Basic Diagnoses
and Differential Diagnoses for the Esophagus, Stomach, Duodenum, Small
Bowel, Colon, Biliary System, Urethra and Bladder.

During the 3rd Fluoro rotations, the resident will access the Intermediate GI & GU
Lessons.

2. The resident will also access the Radiology Department Med Wiki and review the
Resident Educational Resources. Among these are excellent review articles on
common surgical procedures that are encountered frequently on the fluoroscopy
service. These must be understood in order to recognize expected alterations in
anatomy, as well as unexpected complications of these procedures.

A. Cystectomy [RadioGraphics 2009; 29: 461]

B. Esophagectomy [RG 2001; 21: 1119] [RG 2007; 27: 409]
C. Gastrectomy [RG 2002; 22: 323]
D. Bariatric Surgery [RG 2006; 26: 1355] [RG 2013; 32: 1161]
E. Ileo-anal Anastomosis [RG 1997; 17: 81] [RG 2010; 30: 221]
F. Liver Transplantation [RG 2007; 27: 1401]
G. Anti-reflux Surgery [RG 2005; 25: 1485]
H. Whipple Procedure [RG 2012; 32: 743]
I. Hysterosalpingography [RG 2006;26:419-431]
J. Ano-rectal Disease [RG 2006; 26: 1391-1407]

3. By the end of his/her 2nd fluoro rotation, the resident will also take and must
achieve a passing (> 90%) score on the Stanford Radiography and Fluoroscopy
Inservice Exam. By the end of his/her 3rd Fluoro rotation, the resident must
achieve a passing score (>80%) on the RADPrimer Basic and Intermediate level
GI & GU Exams.

4. At the end of the 2nd week on service, the resident should seek feedback from the
Abdominal Imaging faculty on service as to his/her progress. A composite written
review based on the Inservice Exam results and input from all faculty who have
had contact with the resident on service, will be entered into MedHub shortly after
completion of the Fluoro rotation.

* A large number of reference textbooks dealing with all aspects of abdominal

imaging are available in the Fluoroscopy reading room, the resident on-call room,
Lane Library and on loan from any of the Abdominal Imaging faculty.

51
 ADDITIONAL REFERENCE LIST

1. Laufer, Igor. Double-contrast Gastrointestinal Radiology with Endoscopic

Correlation, W.B. Saunders, Philadelphia, 1992. Book is available in
Resident Library. Best images and our techniques.

2. Diagnostic Imaging: Abdomen (2nd Ed): Published by Amirsys [Hardcover]

Michael P. Federle, R. Brooke Jeffrey, Paula J. Woodward MD, Amir
Borhani MD

3. Eisenberg, Ronald. GI Radiology. Book is in Resident Library.

4. Alimentary Tract Roentgenology edited by Margulis & Burhenne, Vol. 1 & 2.

4th ed., 1989

5. Practical Alimentary Tract Radiology. Same authors but much shorter.

6. McCort, Mindelzun, Filpi, Rennell. Abdominal Radiology, 1981.

7. McCort, Mindelzun, Trauma Radiology. Abdominal Chapter, 1990.

8. Diagnostic and Surgical Imaging Anatomy: Chest, Abdomen, Pelvis:

Published by Amirsys by Michael P. Federle, Melissa L. Rosado-de-
Christenson MD FACR, Paula J. Woodward MD and Gerald F. Abbott MD

9. Meyers, Morton. Dynamic Radiology of the Abdomen, 6th ed. Springer-

Verlag.

10. Levine. Radiology of the esophagus, 1990.

11. 1990.

12. Stewart, Edward. Atlas of Endoscopic Retrograde Cholangio-

Pancreatography, 1977. On permanent reserve in Lane Medical Library
and Reading Room.

13. Radiology of the Postoperative Digestive Tract Bruce Javors,

Ellen Wolf, Springer , 2003

14. Diagnostic imaging in infertility, Winfield, 1992

15. GI Radiology The requisites, Halper and Goodman, 1993

16. The abdominal plain film, S. Baker, 1992

52
 The following developed by the Society of Gastrointestinal Radiology
(Dennis Balfe, M.D., Spencer Gay, M.D., Duane Mezwa, M.D.) will serve to
give you an outline of the many entities which you are likely to encounter
during your rotations in the Abdominal section. All of these topics are
covered in STATdx and in the RADPrimer GI curriculum. Similarly, a
complete GU curriculum is covered in STATdx and RADPrimer, in addition
to Diagnostic Imaging: Abdomen (Federle et al).

CURRICULUM IN GASTROINTESTINAL RADIOLOGY

I. Physics
A. Composition of standard contrast agents
B. KVp setting for standard studies

II. Pharynx
A. Technique of examination
B. Normal anatomy
C. Benign diseases
1. Congenital disorders
a. Branchial cleft cysts
b. Thyroglossal duct cysts
2. Webs
3. Diverticula
4. Foreign bodies
5. Trauma
D. Malignant tumors
1. Primary squamous cancer
2. Salivary gland tumors
3. Lymphoma
4. Metastases
E. Motility disorders
1. Normal pharyngeal motion
2. The modified barium swallow
F. The postoperative pharynx
1. Total laryngectomy
2. Partial laryngectomies

53
III. Esophagus
A. Technique of examination
B. Normal anatomy
C. Benign diseases
1. Congenital abnormalities
2. Diverticula
3. Trauma
4. Esophagitis
a. Reflux
b. Infectious
c. Caustic
d. Drug-induced
5. Barretts esophagus
6. Rings, webs, strictures
7. Varices
8. Benign tumors and tumor-like conditions
9. Extrinsic processes affecting the esophagus
a. Vascular structures
b. Mediastinal structures
c. Pulmonary abnormalities
d. Vertebral and paravertebral structures
D. Malignant tumors
1. Squamous
2. Adenocarcinomas
3. Other malignant tumors
E. Motility disorders
1. Normal esophageal motility
2. Primary motility disorders
3. Secondary motility disorders
F. The postoperative esophagus

IV. Stomach
A. Normal anatomy and variations
B. Technique of examination
C. Benign diseases
1. Congenital
2. Diverticula
3. Gastritis
a. Erosive
b. Hemorrhagic
c. Atrophic
d. Granulomatous and gummatous
i. Sarcoidosis
ii. Crohns
iii. Syphilis

54
 e. Infectious
f. Miscellaneous
i. Eosinophilic
ii. Amyloidosis
4. Peptic ulcer disease
a. Epidemiology
b. Etiology
c. Healing of peptic ulcers
d. Complications
5. Hypertrophic gastropathy
6. Varices
7. Motility disturbances
D. Malignant diseases
1. Primary
a. Adenocarcinoma
b. Lymphoma
c. GI stromal tumors
d. Carcinoid
2. Metastatic
a. Hematogenous
b. Lymphatic
c. Peritoneal
E. The postoperative stomach
3. Technique of examination
4. Expected surgical appearance
5. Complications

V. Duodenum
A. Benign diseases
1. Congenital abnormalities
2. Diverticula
3. Hernia
4. Trauma
5. Inflammation
a. Duodenitis
b. Duodenal ulcers
c. Crohns
6. Varices
7. Aortoduodenal fistula
8. Systemic diseases
a. Sprue
b. Whipples
c. Scleroderma

55
 Benign tumors
B. Malignant diseases
1. Adenocarcinoma
2. Lymphoma
3. Metastatic disease

VI. Small Intestine

A. Technique of examination
B. Normal anatomy and variants
C. Benign diseases
1. Congenital disorders
2. Diverticula
3. Trauma
4. Vascular diseases
a. Intestinal ischemia and infarction
b. Radiation enteritis
c. Scleroderma
d. Vasculitides
i. Henoch-Schonlein purpura
ii. Polyarteritis nodosa
iii. Systemic lupus erythematosis
iv. NSAIDS enteritis
e. Varices
5. Malabsorption
a. Sprue
b. Lymphangiectasia

Inflammatory diseases
c. Crohns
d. Infectious and parasitic diseases

Benign tumors
e. Sporadic
f. Associated with polyposis syndromes
D. Malignant tumors
1. Adenocarcinoma
2. Lymphoma
3. Carcinoid
4. GI stromal tumors
5. Metastases
a. Hematogenous
b. Peritoneal

VII. Colon and Appendix

A. Technique of examination
B. Normal anatomy
C. Benign diseases
1. Congenital abnormalities
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 2. Diverticular disease
a. Demographics
b. Pathogenesis
c. Diverticulitis
3. Inflammatory diseases
a. Crohns
b. Ulcerative colitis
c. Infectious colitis
i. Pseudomembranous
ii. Viral
iii. Bacterial
iv. Colitis in AIDS
d. Appendicitis
e. Ischemic colitis
4. Benign neoplasms
a. Adenoma
b. Mesenchymal tumors
c. Polyposis syndromes
5. Motility disorders
a. Demographics
b. Etiology
c. Dynamic proctography
i. Technique
ii. Findings
iii. Surgical decision-making
D. Malignant diseases
1. Adenocarcinoma
a. Demography
b. Etiology and risk factors
c. Biologic behavior
d. Staging
e. Surgical decision-making
2. Other malignant tumors
a. Lymphoma
b. Metastases

VIII. Pancreas
A. Normal anatomy
B. Congenital abnormalities and variants
C. Imaging methods
D. Pancreatitis
1. Etiology
2. Clinical staging
E. Pancreatic neoplasms
1. Duct cell adenocarcinoma
2. Cystic pancreatic neoplasms
3. Islet cell tumors

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IX. Liver
A. Normal anatomy
1. Classical gross anatomy
2. Couinaud segmentation
B. Congenital abnormalities
C. Imaging methods
D. Diffuse diseases of the liver
1. Cirrhosis
2. Diseases associated with infiltration
a. Fatty infiltration
b. Hemochromatosis
c. Storage diseases
3. Vascular diseases
a. Portal hypertension
b. Portal vein occlusion
c. Hepatic venous hypertension
E. Focal diseases of the liver
1. Benign
a. Focal fatty infiltration
b. Cavernous hemangioma
c. Liver cell adenoma
d. Focal nodular hyperplasia
e. Regenerating nodules in cirrhosis
2. Malignant
a. Hepatocellular carcinoma
i. Epidemiology
ii. Etiology and risk factors
iii. Surgical decision-making
b. Metastases
i. Variation in appearance
ii. Pitfalls in diagnosis
iii. Surgical metastasectomy
c. Other malignant liver lesions
F. Liver transplantation
1. Surgical candidates
2. Exected postoperative appearance
3. Complications

X. Spleen
A. Normal anatomy and variants
B. Congenital abnormalities
C. Splenomegaly

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 D. Focal lesions
1. Cysts
2. Hemangioma
3. Infarction
4. Abscess
5. Granulomatous disease

XI. Bile Ducts and Gallbladder

A. Normal anatomy and variants
B. Techniques of examination
C. Congenital abnormalities
1. Choledochal cysts
2. Carolis disease
D. Inflammatory diseases
1. Gallbladder
a. Acute cholecystitis
i. Calculous
ii. Acalculous
b. Chronic cholecystitis
2. Biliary ducts
a. Primary sclerosing cholangitis
b. Ascending cholangitis
c. Recurrent pyogenic cholangitis
d. AIDS cholangiopathy
e. Ischemic injury
f. Surgical injury
i. Mechanisms
ii. Bismuth classification
iii. Surgical decision-making

XII. Peritoneal Spaces

A. Normal anatomy and embryology
B. Distribution of fluid collections
C. Diseases of the peritoneum
1. Inflammatory diseases
a. Bacterial peritonitis
b. Sclerosing peritonitis
2. Primary tumors
3. Metastatic tumors

XIII. Retroperitoneum
A. Normal anatomy and embryology
B. Retroperitoneal spaces
C. Retroperitoneal planes
D. Benign diseases
1. Fibrosis
2. Inflammatory diseases
E. Malignant tumors
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XIV. Mesenteries
A. Normal anatomy and embryology
B. Relationship to retroperitoneum
C. Pathologic conditions
1. Primary
2. Arising in the bowel
3. Arising in the retroperitoneum
4. Arising in the peritoneum
5. Systemic diseases

XV. Percutaneous Biopsy and Fluid Aspiration

XVI. Multisystem Disorders

A. Acute abdomen
B. Trauma to the abdomen
C. Collagen vascular diseases
D. Syndromes involving the Gastrointestinal Tract

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