RDSC 233 Unit 3

Radiography of the Upper Gastrointestinal Tract

Bontrager chapter 14

Anatomy of the stomach & duodenum

Film Critique
Radiographic anatomy

Contrast media for the alimentary tract

Exposure Factors
and examination procedures
Radiographic
Positioning of:
Pathology
Stomach
AP, PA, RAO, LPO,
Rt. lateral
What in the World?
Miscellaneous, but significant,
Motility series odds and ends
Atlas of Human Anatomy
Second edition (258) Need to know
Body habitus
relative to
position of
the stomach
and abdominal
viscera

Centering of
the stomach
is the pyloric Hypersthenic (5%)
canal/bulb.
Sthenic (50%)
Note the Hyposthenic (35%)
change in
position. Asthenic (10%)
Atlas of Human Anatomy
Second edition (258)
Need to know
Gastroesophageal junction

Cardiac part of Stomach

Fundus

Lesser and greater curvature

Body of stomach
Angular notch (incisure
angularis)
Pyloric antrum & canal
Greater omentum
Abdominal part of the esophagus
Atlas of Human Anatomy
Second edition (259)
Need to know
Cardiac oriface

Gastric (rugal) folds (rugae)

Pylorus (sphincter)

Superior (first) part of

duodenun (ampulla, cap, or
bulb)
Zigzag (Z) line
Atlas of Human Anatomy
Second edition (262)
Need to know
First (bulb), Second
(descendng), third (horizontal),
fourth (ascending), parts of
the duodenum
Duodenojejunal flexure

Duodenal papilla (vater)

Jejunum

Head of pancreas
Atlas of Human Anatomy
Second edition (263)
Need to know
Jejunum

Ileum

Mesentary

Visceral peritoneum (Serosa)

Circular folds
Mucosa
 Radiographic Anatomy

Be prepared to identify these anatomical

structures in lab.
 Radiographic Anatomy of the RAO Position
upper gastrointestinal tract
Barium in
esophagus
Rugae (rugal
Gas and barium folds)
in fundus of S.

Left
hemidiaphragm
Greater
Lesser curvature of s.
curvature of s. body of s.
Incisure angularis
Duodenal bulb
(or cap) etc. Pyloric canal Pyloric orifice
&
(surrounded by sphincter)
2nd or descending Antrum
part of d.

3rd or horizontal
part of d. Jejunum

4th or ascending part of d.

 Radiographic Anatomy of the
Distal esophagus upper gastrointestinal tract

Gastroesophageal junction (at cardiac orifice)

Cardiac zone (extends into fundus)

Area of detail

Left
hemidiaphragm

Peristalic
contraction from
distal to abdominal
part of esophagus
Anatomy
Review Know for lab
Contrast media for the alimentary tract
and examination procedures

Patient preparation (Prep)

Two kinds of Upper GIs

Fluoroscopy
Spot films Vs. Overheads

Contrast media
Barium
Water soluble iodine preparations

The Technologists role

Patient Prep for the Upper GI
For the stomach to be
visualized free of solids
or liquids that could
dilute the contrast, or
obscure pathology, the
patient should be NPO,
(Non Per Os), for 8 hrs
prior the exam.
This restriction includes
chewing gum and
cigarettes.
Two Kinds of Upper GIs
In the early years of radiology only
barium contrast was used. As the
film on the left demonstrates, a
concentration of barium entirely
attenuates the beam. Filling defects
appear as lucent shadows in the
midst of the barium, or as irregular
shapes on the edge of an organ.
Calcium or magnesium citrate
crystals produce C02 gas, and a
translucent, double contrast effect.
 Fluoroscopy Spot Films Vs. Overheads
Examinations of the Since spot films allow precise
alimentary tract begins positioning, why are overheads
under fluoroscopy to: even taken?
Short answer: Geometric
* aid in diagnosis
factors.
(peristalic activity and filling
see next screen) Using the
flouro tube
* Identify contraindications there is
to continuing (i.e. variable
fistulas, aspiration of OID, less
contrast) SID, and
* Spot filming under therefore
fluoroscopic guidance more
penumbra
Digital systems have eliminated
overhead filming some places
The effect of positions and barium
filling on the visualization of
anatomy

Identify the common anatomy on

these views
 Contrast Media for the Alimentary Tract
What you need to know

Radiopaque (vs. radiolucent) contrast media is

typically barium, a soft, metallic, alkaline earth:
atomic # 56.

Processed into barium sulfate (BaSO4). Salts of barium

are chemically pure or theyre poisonous.

Insoluble in water. Collodial suspension (shake

vigorously).

In the GI tract barium is inert. Reactions are

extremely rare.
 Contrast Media for the Alimentary Tract
What you need to know

Barium suspensions are tasteless, but rather

unpalatable. Flavorings are added to commercial
preparations, or may be added when used.

Added water changes viscosity and opacity.

Thin barium moves though the tract more
quickly. Thick barium adheres to the mucosa.
Mixtures are defined by department protocols.
Water is absorbed by the colon. If a patient is
dehydrated, water is absorbed and barium
becomes impacted. In addition to drinking
water, laxatives, such as castor oil may be given
after the exam.
 Contrast Media for the Alimentary Tract
What you need to know

Barium is contraindicated when there is a chance

of leakage (post-surgical, or perforations), and
obstruction
Water soluble, iodine preparations are absorbed
by the body, and used in such cases.
Gastroview, Gastrografin, and Oral Hypaque are
brand names. All are bitter tasting.
Iodine sensitivity is a possibility.

Water soluble contrast is also used to dilute

barium preparations s loosing opacity.
 The Technologists Role

Prepare materials for exam

Set up filming equipment

Greet the patient, explain exam, take Hx, answer

questions
Get and introduce radiologist, assist during
fluoroscopy.

Take and process overhead films

Clean up room, enter exam in computer

(Meditech at MWMC)

Dismiss the patient when radiologist okays

Radiographic Positioning of the
Upper Gastrointestinal Tract
Positioning of:

AP stomach
PA stomach

RAO stomach
LPO stomach
Right lateral stomach

and the
Motility series

including

Film Critique
 Film Critique Reminder

In addition to criteria
specific to each
projection, all films
are evaluated for:
including
* Patient ID
* Rt/Lt, special marker
* Contrast & density
* Motion
* Artifacts
 Standard UGI Positioning
Preparation
1. Evaluate the order
2. Greet the patient
3. Take History
What is pertinent Hx?
Abdominal, epigastric, or chest
pain (RO/MI), acid reflux, dyspepsia
(indigestion), ercuctation, anemia
from GI bleed, abdominal mass,
N/V, hematemesis.

4. Remove jewelry, check attire, snaps, pins, NG tubes, etc.

5. Explain the exam in laymans terms
6. Questions?
7. Set technique before positioning
Routine UGI Positioning Setup
1. 40 SID (relatively standard)
2. Reciprocating bucky
12:1, 16:1 grid
3. 100 + kVp for single, and 80
90 kVp for double contrast
(Why?)

4. 14 x 17 lengthwise for surveys, or

14 x 14 or 10 x 12 for cone down views
5. ID marker generally at bottom

6. Lt or Rt marker free of anatomy.

Routine AP Positioning
Steps

1. 14 x 17
2. Midsagittal plane
straight, no rotation

3. CR between xiphoid
tip and lower margin
of ribs (inferior costal margin)
* 1 higher for hypersthenic,
* 2 lower for asthenic.
4. Favor left side if needed.
5. Suspend breathing on
expiration.
Routine AP Positioning On a 14 x 17 film, the
Criteria entire stomach, duodenum,
and the proximal jejunum
(whatever may fill) should
be included.
In the supine position the
fundus is inferior to the
pylorus. Barium fills the
fundus, and if double
contrast, air fills the body
and duodenum.

Lateral radiograph, showing

position of fundus relative to
the pylorus.
Routine PA Positioning Steps

1. In PA position landmarks
are less accessible. In
addition to 1-2 above
lower margin of lateral
ribs (Bontrager), 6 above
the iliac crest is often
used to localize the level
of the pylorus and
duodenal bulb (center)
Higher for hypersthenic, lower for asthenic.

2. Favor left side if needed.

3. Double check Lt. marker (its a tricky
one)
Routine PA Positioning
On a 14 x 17 film, the
Criteria entire stomach, duodenum,
and the proximal jejunum
(whatever may fill) should
be included.

In the prone position the

fundus is superior to the
pylorus. Barium fills the
Pylorus, duodenum, and if
double contrast, air fills
the fundus.

Lateral radiograph, showing

position of fundus relative to
the pylorus.
The Classic Anterior Oblique Position

* Entire spine straight (head elevated)

* Coronal plane through shoulders same as
coronal plane through hips
* Placement of arms and legs like this
The Classic Posterior Oblique Position

* Entire spine straight (head elevated)

* Coronal plane through shoulders same as
coronal plane through hips
* Placement of arms and legs like this
Routine RAO Positioning
The GI Position
Steps
1. 10 x 12 lengthwise
crosswise for transverse stomach

or 11 x 14 (dependant on
department protocol)

2. 400-700 RAO (steeper for

hypersthenic habitus)
3. CR between spine and
Lt lateral border, at level
of L2. The iliac crest is
at the level of the L4-5 interspace. The
inferior costal margin of the ribs is at L2-3.
2 higher for hypersthenic, closer to
spine, & transverse film

2 lower for asthenic (Observe fluoro)

Routine RAO Positioning
The GI Position Criteria
Of the stomach
projections the
RAO is the film
of choice. In
addition to the
profile of
stomach anatomy, the duodenal
bulb and the sweep of the
duodenum must be included.

Like the PA, air rises to the

fundus, and barium settles
Note the marker in the pylorus.
placement
Routine LPO Positioning Steps
1. 10 x 12 lengthwise
crosswise for transverse stomach

or 11 x 14 (dependant on
department protocol)
2. 300-600 LPO (steeper for
hypersthenic habitus)
3. CR same as AP

4. Respiration: same as all

Note that the LPO is the corresponding

view to the RAO, and yet the degrees of
obliquity are 10 degrees less.
Routine LPO Positioning
Criteria

Like the RAO, the LPO demonstrates

the stomach in profile. The duodenal
bulb and the sweep of the duodenum
must be included.

Like the AP, air rises to the pylorus

and duodenum, and barium settles
in the fundus.
Routine Rt. Lateral Positioning Steps
1. 10 x 12 lengthwise
or 11 x 14 (dependant on
department protocol)

2. True right lateral position,

mid-coronal plane to
long axis of table
3. CR to level of inferior
costal margain, between
anterior bodies of L spine, and
muscular wall of abdomen.

4. Respiration: same as all

5. 2 both, for hyper and asthenic habitus

Routine Rt. Lateral Positioning Criteria

The Rt. lateral is unique in

demonstration of the retro-
gastic space.

Like the PA and RAO, air rises

to the fundus, and barium
settles in the pylorus and
duodenum.

For hypersthenic patients, the Rt. lateral

may demonstrate the profile view, pylorus,
bulb, and sweep of the duodenum much
like the RAO does for other body types.
Review of
If all the GI views were in
UGI Film a routine, the most efficient
Critique order would be:

1. PA
On all films 2. RAO
Patient ID
3. Rt. Lateral
Rt or Lt marker
Contrast & density 4. AP
Motion 5. LPO
Artifacts
However, for double contrast
Know where the barium exams the order may
and air will be on the: purposefully roll the patient
back and forth to keep the
1. RAO mucosal surface coated
2. PA with barium.
3. LPO
4. AP
5. Rt Lateral
 Motility Series: Chap. 15 (492-493) in Bontrager
The small intestine is studied less frequently than other
other parts of the GI tract, but when indicated, is usually
done in conjunction with the UGI.

The examination is known as a motility series

or small bowel series (SBS) or small bowel
follow through (SBFT)

Procedure: Following the UGI, 12 to 16 oz.

of thin barium is given the patient. An initial
30 min KUB is taken, the time is noted, and
a schedule of 15 to 30 minute intervals are
noted. AP KUBs are taken on this schedule
until the barium reached the terminal ilium.

The 30 min. film should be Jejunum

centered higher than a normal
KUB. Note the full stomach.
Motility Series: Chap. 15 in Bontrager
On occasion a PA KUB may be requested by the
radiologist. In this position pressure on the loops
of bowel may better demonstrate pathology Ileum

When the barium reaches the colon, KUB

filming is complete.
A small bowel series is usually completed
with fluoroscopy, and spotting the
terminal ileum.

A compression paddle is used to separate

loops of bowel. A metal ring
helps center it.
Motility Series: Chap. 15 in Bontrager

A SBFT may only take an hour or two.

When a patient is very ill, unable to
keep down much barium, and laying on
a gurney between films, it may take
many hours. If the patient must remain
recumbent, a Rt lateral or RAO position
promotes motility.
If the patient is not ill, looking at pictures
of food helps speed things along
Enteroclysis: Chapter 15 in Bontrager

A method that provides greater visibility of

the small intestine is call enteroclysis

The patient is intubated with an

enteroclysis catheter (Bilbao or Sellink
tube), through the nose, directly into the
duodenum. High density barium,
followed by air or methylcellulose is
injected
 Exposure Factors
From the Rules of Thumb

Based on: 3 phase, 100 RS film, medium speed screen, 72 SID

Compute a technique for a double contrast, and single contrast

UGI for a 26 cm abdomen in an AP position, using 400 RS system

1. (2 x 26) + 35 = 87 kVP @ 50 mAs

2. 50 mAs / 4 (RS) = 87 kVp @ 12.5 mAs (Double contrast)

3. 87 + 13 = 100 kVp @ 6 mAs (Single Contrast)

Now put the patient in an RAO (single contrast)

Up AP technique by 40 60 % = 108 kVp at 6 mAs

Now put the patient in a right lateral (double contrast)

Up AP kVp by 10, double mAs = 97 kVp @ 25 mAs
 Significant Pathologies
of the upper gastrointestinal tract
and their
Radiographic Appearances

Thoracic stomach
Diverticula
Ulcerations
Hiatal Hernia & Herniation of the stomach through the
Thoracic Stomach esophageal hiatus of the diaphragm.
The degree of herniation varys.
Sliding hiatal hernia: Small portion of the stomach protrudes though the hiatus
due to a weakening of the esophageal sphincter muscle. Herniation changes
positions, and may be demonstrated by the valsalva maneuver. Reflux,
common to hiatal hernias, may be demonstrated in the trendelenburg
position. Schatzkes ring is a radiographic sign of a sliding hernia.

Thoracic stomach:
Shown on these
images. The
majority of the
stomach
herniates into
the thoracic
cavity.
Thoracic
stomach
on CXR
Diverticula Diverticula are outpouching caused by weakness
in the wall of a hollow organ. They are benign
and generally asymptomatic, though the weakened area may
perforate, and materials in blind pouches can cause
inflammation, ulceration, or infection.
This 4 CM diverticula of
the first part of
the duodenum
contains fibrous
materials,
creating a mass
known as a
bezoar.

Accumulations
include hair,
cellulose, and
seeds

Meckels diverticulum is caused by a remnant of the yolk sac (umbilical

vesicle) found 2- 4 from the terminal ileum
Ulcerations
Ulcers occur throughout the GI tract, but are most common in the pylorus and
duodenum due to the concentration of gastric secretions. These are known
as peptic, gastric, or duodenal. A bacteria, H pylori, is a cause of ulcers
recently discovered.
Radiographically, ulcer craters are
seen when barium fills them, and
remains after position or peristalsis
has moved the rest of the barium on.
 What in the World?

Miscellaneous, but significant, odds and ends

Pathology or What in the World?
Round, radiolucent densities in the GI tract
of a boy were very puzzling. They moved,
which was good, but what could they be?

Other than motion, why

might this spot film be
so blurry?
 What in the World?
Is the barium filling
in the right
hypochondriac/epigastrium
region?

It starts
here
 Spot films, from the spot film device,
What in the World? may be difficult to identify and hang
properly. If they are always in the
Hows it hangin? device the same way the ID marker
is used for orientation. If that is
Things to look for Ribs unknown the recognition of anatomy
is the key.

Vertebral bodies
and disk spaces

Diaphragm &
lung
Esophagus
Pylorus
Cap of d.

2nd part Vertebral bodies

of d. and disk spaces
What in the World? Spot films, from the spot film
device, may be difficult to
Hows it hangin? identify and hang properly.
If they are always
in the device the
same way the ID
marker is used for
orientation. If
that is unknown
the recognition of
anatomy is the
key.
A B
On this and
the next two
screens, see
if you can
ID the spot
films hung
correctly

C D Answers follow
What in the World?
Hows it hangin?

Screen 2
A B

C D
What in the World?
Hows it hangin?

Screen 3

A B

C D
 Screen 2
What in the World?
Hows it hangin? Answers Cap of d.

Sweep of
duodenum

Cap of d. Pylorus Sweep of

duodenum
If you thought these
were fun, youll Film used
love next weeks lab for explanation
D
back 4 screens Screen 3
The End
 42. Name this position

43. If only a tube angle is used

to accomplish it, what is
the degree and direction
of the CR?

44. Name this position

45. What pathological condition

would be demonstrated
on the up side?

46. What pathological condition

would be demonstrated on
the down side?
 42. Name this position
Apical lordotic (lordotic chest)
43. If only a tube angle is used
to accomplish it, what is
the degree and direction
of the CR? 15-200 cephalad

44. Name this position (Rt) lateral

decubitus

45. What pathological condition

would be demonstrated
on the up side? Pneumothorax

46. What pathological condition

would be demonstrated on
the down side? Pleural effusion
 48.

47. In which body habitus

would the stomach lie in 50.
this extreme transverse
position? 49.
 48. 2nd or
descending
part of d.

47. In which body habitus

would the stomach lie in 50. Greater
this extreme transverse curvature of s.
position? hypersthenic 49. pyloric antrum
 1. What is the atomic number of barium?
2. True or false: Barium is Insoluble in water.

3. Is this film AP,

PA, or RAO? 4. Is this film AP, 5. Is this film AP,
PA, or RAO? PA, or RAO?

6. What is the range of obliquity for an RAO stomach?

7. What body habitus requires the steepest obliquity?
 1. What is the atomic number of barium? 56.
2. True or false: Barium is Insoluble in water. True

3. AP
4. PA 5. RAO
6. What is the range of obliquity for an RAO stomach? 40-700
7. What body habitus requires the steepest obliquity?
Hypersthenic