Fluoroscopic Investigations Of The Gastrointestinal Tract ( Introduction)

Learning objectives With the end of this lecture the student will be able to: Describe the anatomy of the digestive system, to include the pharynx, esophagus ,stomach, , large intestine ,and accessory organs Discuss the orientation of the stomach according to body habitus, physical position and respiration Identify the function of each of the structures of the digestive system Describe room preparation and identify supplies needed for the examinations of the digestive system Identify methods of evaluating the digestive system State the criteria to evaluate the digestive system radiographs in term of positioning ,image quality, radiographic anatomy ,and pathology Explain different types of contrast media used in GIT exams Explain pharmacological agents used in GIT exams Differentiate between Retrograde and Antegrade GIT studies

References Websites http://www.e-radiography.net/ Radiographic procedures: By Stephen Chapman Positioning in Radiography: By k.C.Clarke. Text book of radiographic positioning and related anatomy; by Kenneth L.Bontrager 6th edition. Websites http://www.e-radiography.net/

Basic Anatomy The Digestive system Consists of: Mouth Pharynx Oesophagus Stomach Small Intestine Large Intestine Rectum & Anus Accessory organs include Tongue and Teeth Salivary glands Pancreas Liver Gall bladder & biliary tract

Physiology of the digestive system Ingestion Digestion Absorption Elimination

Investigations of the digestive system Plain film Investigation Barium Investigations Radionuclide Imaging Computerized Tomography Magnetic Resonance Imaging Angiography Ultrasound Non- Radiographic Investigations (Endoscopy)

Barium Investigations Wide range of investigations can be performed Can incorporate plain film & fluoroscopic equipment Involves the use of contrast media Can involve the use of pharmacological agents What is the role of the Radiographer?

Radiographic Contrast vs. Contrast Media Difference between adjacent densities in a radiograph. The films or images have different levels of density – different shades of gray Short (high) Long (low) MAJOR DIFFERENCES SLIGHT DIFFERENCES

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

Purpose of Contrast Media To enhance subject contrast or render high subject contrast in a tissue that normally has low subject contrast.

Contrast Media Properties able to show organ better physiologically no permanent alteration of organ non toxic and able to be eliminated / excreted Negative contrast Radiolucent e.g. AIR Low atomic # material Black on film Positive contrast Radiopaque e.g. BARIUM High atomic Number White on film

Contrast Media for GIT Exams Barium Sulfate: BaSO4 High atomic number Not soluble in water = suspension Used to coat the lining of organs Supplied in different thicknesses Used Esophogram, UGI, Small Bowel, Large Bowel Contraindications perforations of GI tract proximal to an obstructed bowel Precautions adequate hydration post examination

Contrast Media for GIT Exams Why use Barium Sulphate? It has a high atomic number (Z=56) Non-toxic Relatively cheap body cannot metabolize BaSO4

Gastrografin or Hypaque Contrast Media for GIT Exams Gastrografin or Hypaque High atomic # Close to iodine Water soluble Similar usage as Barium Water soluble, safe in the abdominal cavity Safe to use if perforation is suspected

Pharmacological agents Buscopan Glucagon Maxalon Carbex Methyl cellulose Why are they given?

Pharmacological agents Purpose Buscopan (20mg iv) Relax smooth muscles (Useful in barium enema examinations) Glucagon (0.3mg iv) Relax smooth muscles ( Used for patients with glaucoma & cardiovascular disease) Useful in barium enema examinations Maxalon (20mg iv/oral) Increases gastric peristalsis (useful in follow through examinations) Carbex ( Tablets) Gas producing Agent ( For double contrast Ba Meal) Methyl cellulose ( Syrup) For small bowel double contrast exams

GI Contrast Studies Antegrade studies (with the normal flow) esophagus, stomach, small bowel Contrast (Barium / barium + air /Oral iodine solution BaSO4 Only BaSO4 + Air

GI Contrast Studies Retrograde studies (against the flow) Colon ( Large Bowel) Contrast barium / barium + air Barium + Air Barium Only

GI Contrast Studies (Supplies) Esophagus Contrast media Straw and spoon Cotton balls Emesis basin Small bowel Contrast media ( 2 large glasses) Straw Gas producing substance ( carbonated drink ) Emesis basin Timer pharmacological agents Upper GIT Contrast media Straw and spoon Gas producing substance ( carbonated drink ) Emesis basin pharmacological agents Barium enema Contrast filled enema bag Enema tip Lubricant Disposable gloves Towels Sheets/blankets compression paddle pharmacological agents

GI Contrast Studies (Preparation) Common patient preparation aspects for barium investigations What would you check? Identification, request form. Pregnancy check (10 day rule) Review of previous examinations Allergy check Abdominal preparation ?Diabetic patients (adjustment in appointment time & preparation prior to examination) Psychological preparation for examination

GI Contrast Studies (Preparation) Summary of abdominal preparation ( Adults) Esophagus No preparation needed Small bowel NPO after evening meal low residue diet 1-2 days prior to exam Cleaning enema Empty bladder Upper GIT NPO after midnight ( At least 8 hours prior to exam No gum chewing No smoking Barium enema low residue diet 2-3 days prior to exam Increased fluid intake 2-3 days prior to exam Cleared liquid diet 24 hours prior to exam Cathartic the afternoon before the examination Cleaning enema Empty bladder

GI Contrast Studies (Preparation) Summary of abdominal preparation ( Paediatrics) Esophagus and Upper GIT NPO 3-4 hours prior exam 0-2 years NPO 6 hours prior exam > 2 years Esophagus and Upper GIT No preparation 0-2 years Low residue diet evening meal Mild laxative with water at bed time 2-10 years As for 2-10 years patients with doubling the dose of laxative > 10 years

GI Contrast Studies (Breathing Instructions) To reduce the stress of the abdomen that could lead to involuntary motion, all radiographs are obtained during suspended respiration. Special breathing techniques are used to increase the Intrathoracic and intra abdominal pressure Valsalva maneuver While holding the breath on deep inspiration , the patients bears down as if trying to move the bowels

GI Contrast Studies Equipment consideration Tilting table (+/-90 degrees) Rapid film recording facilities Special feeding accessories Fluoroscopic unit (normally digital) Additional over couch tube Lead aprons and gloves Sponges and other supports

GI Contrast Studies (Radiation protection) ALARA principle (Minimise dose to patient /staff) Utilise pulsed fluoroscopy where appropriate Record patient dose & imaging times Record any faults with equipment / regular QA Practical collimation Adhere to clinical protocols (minimum no of films / dose) Always read patient history / notes

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

GI Contrast Studies(Plain Films) Plain films showing Obstruction

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