UPPER GASTROINTESTINAL SERIES

Radiographic examination of the distal

esophagus, stomach and duodenum.

Purpose: to study radiographically the

form and function of the distal esophagus,
stomach and duodenum and to detect
abnormal anatomic and functional
conditions.

ESOPHAGUS: STOMACH
 Muscular tube extending from  Muscular bag forming widest and
Pharynx ( at the level of cricoid most distensible part of digestive
cartilage , C6 level) to cardiac end tube.
of the stomach ( T11).  Connected: above to lower end of
 20-25cm long esophagus, and below to
 Crosses diaphragm at T10 level duodenum.
 No enzyme secreted  Act as a reservoir of food and helps
in digestion of carbohydrates,
SPHINCTER proteins and fats.

 Esophagus is surrounded at top and Location:

bottom by muscular ring, known as lies obliquely in upper left part of
upper and lower esophageal abdomen, occupy epigastric, umbilical
sphincter respectively. and hypogastric region.
 Protects esophagus and respiratory
system from acidic secretion and
regurgitation of food particle. CAPACITY:
at birth – 30ml
at puberty – 1 liter
NORMAL CONSTRICTIONS OF at adult – 1.5 to 2 liters
ESOPHAGUS SHAPE:
a. At upper esophageal sphincter J-shaped structure.

b.At the level where it crossed by arch of

aorta. EXTERNAL FEATURES:
c.At the level where it crossed by left main
bronchus. Two orifices:
d.At the CARDIAC ORIFICE (T11)
level
where it PYLORIC ORIFICE ( L1)
pierces
the
Two curvatures:
LESSER CURVATURE
 Concave from right border

diaphragm. GREATER CURVATURE

  convex and form left border. At water-soluble , iodinated contrast medium
its upper end present cardiac may be used in place of barium sulfate.
notch which separate it from
esophagus.
INDICATIONS:
The common pathologic indications for an
Two surfaces
Upper GI series include the following:
 ANTERIOR and POSTERIOR
a. BEZOAR
b. DIVERTICULA
c. EMESIS
Divided into 3 regions
d. GASTRIC CARCINOMA
 FUNDUS
e. GASTRITIS
 BODY and
 PYLORIC ANTRUM f. HIATAL HERNIA
g. ULCERS

a. BEZOAR- Describes a mass of

undigested material that becomes trapped
in the stomach. This mass usually made
up of hair ( trichobezoar) , vegetable
fibers ( phytobezoar ) , or wood products.

b. DIVERTICULA- Are pouch-like

herniation of a portion of the mucosal wall.
They can occur in the stomach or the
DUODENUM small intestines.

 Shortest, widest and the most fixed Gastric diverticula generally range
part of small intestine between 1 and 2 centimeters but may be
 Extend from pylorus to the as a few millimeters to 8 cm. in diameter.
duodenojejunal flexure. Nearly 70% to 90% of gastric diverticula
 Curved around the head of arise from posterior aspect of the fundus.
pancreas.
 Lies opposite to 1st, 2nd and 3rd
lumbar vertebrae.
c. EMESIS- Is the act of vomiting.
 Both pancreatic duct and common
bile duct opens into the duodenum Blood in vomit is called HEMATEMESIS ,
through “ampulla of vater.” which may indicate that other forms of
 25cm long and divided into 4 parts. pathologic processes are present in the GI
Tract.

CONTRAINDICATIONS
d. GASTRIC CARCINOMA- Gastric
Contraindications for Upper GI
carcinoma accounts 70% of all stomach
examinations apply primarily to the type
neoplasms.
of contrast media used. If the patient has
a history of bowel perforation, laceration, Radiographic signs include a large
or rupture of the viscus, the use barium irregular filling defect within the stomach,
sulfate may be contraindicated. An oral , marked or nodular edges of the stomach
lining, rigidity of the stomach and herniate through esophageal hiatus.
associated ulceration of the mucosa Because of the degree herniation may
vary form time to time , it is called sliding
herniation.
e. GASTRITIS- Is the inflammation of the
lining or mucosa of the stomach. Gastritis
may develop in response to various g. ULCERS- Ulcers are the erosions of the
physiologic and environmental conditions. stomach or duodenal mucosa that are
caused by various physiologic or
ACUTE GASTRITIS - presents severe
environmental conditions such as
symptoms of pain and discomfort.
excessive gastric secretions , stress, diet
or smoking. Some more recent studies
suggest that ulcers may be caused by
CHRONIC GASTRITIS – is an intermittent bacteria and thus can be treated by
condition that may be brought by changes antibiotics. If untreated, the ulcer may
in diet, stress or other factor. lead to perforation of the stomach or
f. HIATAL HERNIA- Is a condition in which duodenum.
a portion of the stomach herniates
through the diaphragmatic opening. The
herniation may be slight but in severe TYPE OF ULCER :
cases, most of the stomach is found within
the thoracic cavity above the diaphragm.
PATIENT PREPARATION
Hiatal Hernia may be due to congenital
short esophagus or weakening of the  NPO for 6- 8 hours
muscle that surrounds the diaphragmatic  Ensure that no contraindication to
opening , allowing the passage of the the contrast agent used.
esophagus.  Procedure should be explained to
patient before undergoing the
examination.
SLIDING HIATAL HERNIA  Smoking should not be allowed in
the examination day.
Is a second type of hiatal hernia that is  Diabetic patient should be
caused by weakening of a small muscle scheduled at morning.
(esophageal sphincter) located between  If the patient is female, a menstrual
the terminal esophagus and the history must be obtained .
diaphragm.
Because of aging or other factors , the
esophageal sphincter may weaken and TECHNIQUE
permit a portion of the stomach to
 SINGLE- CONTRAST + GRADED
COMPRESSION ( SCGC)
 DOUBLE – CONTRAST ( DC )
 BIPHASIC METHOD : COMBINED DC
+ SCGC.

1. SINGLE CONTRAST + GRADED

COMPRESSION
( SCGC )
  The stomach is filled and distended
with dilute barium or a water-
3. BIPHASIC-CONTRAST EXAM
soluble contrast agent ( SC )
 The stomach is compressed either • Combines the best features of the DC
manually or by positioning to allow and the SCGC techniques in one
adequate X-ray penetration in the diagnostic procedure.
evaluation of each anatomical
segment ( GC ). • Performed with a single barium
 Single contrast with graded suspension that can provide excellent
compression (SCGC) technique mucosal coating during gaseous distention
assesses thickness of the gastric in the DC phase of the study and also
folds and evaluation of gastric sufficient transparency to permit "see
emptying. through" of the contrast agent during the
 Large luminal defects can be SCGC phase.
detected. For biphasic study bubbly barium is
 The anterior gastric wall is developed. • A medium-density barium
evaluated on the prone films , an suspension which can be administered
area which may not be well simultaneously with a gas-producing
demonstrated on a routine double- agent in the form of a cold, carbonated
contrast examination. drink ("bubbly barium")

DC technique
• gives excellent definition of the lesser
and greater curvatures and the posterior
wall of the stomach;
2. DOUBLE-CONTRAST STUDY
• however, satisfactory DC images of the
Combines the principles of : anterior wall of the distal stomach and
duodenum are very hard to obtain.
 distension,
 mucosal coating and
 proper projection SCGC:
anterior wall of these structures could be
A small amount of high-density barium
demonstrated in face by filling the
suspension is used to coat the mucosal
stomach and duodenum with a low-
surface and air or CO2 gas to distend the
density barium suspension and applying
lumen.
graded compression to permit the
Both barium and air are used for contrast. examiner to "see through" these viscera.
Images are obtained as the patient rolls in Combination: takes advantages of both
various positions to coat the gastric (BIPHASIC CONTRAST )
mucosa with contrast.
Double-contrast technique provides
CONTRAST MEDIA
exquisite detail of the mucosal surface of
the stomach. • High density, low viscosity barium
sulphate for DC study.
Lesions on the dependent surface of the
stomach (the posterior wall in the supine • Low density barium for single contrast
patient) are best seen using double- study.
contrast technique
Medium density bubbly barium for
Popularized by the Japanese to diagnose biphasic study.
early gastric carcinoma.
Effervescent: The cup must be taken from the patient
• Used for double contrast study. when the table is tilted up or down.
• Carbex granules or tablets
- Composed of sodium
PROJECTION
bicarbonate, citrate and an
antifoaming agent  RAO (recumbent)
(simethicone).When swallowed  PA (recumbent)
with a small amount of water,  Right lateral (recumbent)
the granules or tablets release  LPO (recumbent)
300-500 ml of carbon dioxide  AP (recumbent)
which distends the stomach .

1. RAO ( RECUMBENT)
TECHNICAL FACTORS
Pathology Demonstrated: This is the ideal
 High kV of 100 to 125 is position for demonstrating polyps and
required to penetrate ulcers of the pylorus, duodenal bulb, and
adequately and increase C-loop of the duodenum
visibility of barium-filled
structures. --A kV below 100 will
not provide visibility of the Technical factors :
mucosa of the esophagus,
stomach, or duodenum.
 Short exposure times are  IR size-24 x 30 cm (10 x 12 inches),
needed to control peristaltic lengthwise, or 30 x 35 cm (11 x 14
motion. inches)
 With double contrast, reduction  Moving or stationary grid
of the kV to the 90 to 100 range  100 to 125 kV range
is common to provide higher- 90 to 100 kV for double-contrast
contrast images without study
overpenetrating the anatomy
(determine departmental kV
preferences). Shielding:

Place lead shield over patient's pelvic

 lodinated water-soluble contrast region to protect gonads without covering
studies often require a kV range pertinent anatomy.
of between 80 and 90 kV.

Patient Position :
PATIENT AND TABLE MOVEMENT
Various patient positions combined with Position patient recumbent, with the body
the table movements are used during the partially rotated into an RAO position;
fluoroscopic procedure. provide pillow for head.

The technologist must help the patient

with the barium cup, provide a pillow
Part Position :
when the patient is lying down, and keep
the patient adequately covered at all From a prone position, rotate 40° to 70°,
times. with right anterior body against IR or table
(more rotation sometimes required for
The barium cup should be held by the
heavy hypersthenic-type patients and less
patient in the left hand near the left
for thin asthenic types).
shoulder whenever the patient is upright.
Place right arm down and left arm flexed pertinent anatomy.. Sharp structural
at elbow and up by the patient's head. margins indicate no motion.
Flex left knee for support.

2. PA PROJECTION
Central Ray :
Pathology Demonstrated Polyps,
diverticula, bezoars, and signs of gastritis
Direct CR perpendicular to IR.
in the body and pylorus of the stomach
are shown.
Sthenic type: Center CR and IR to
duodenal bulb at level of L1 (1 to 2 inches
[2.5 to 5 cm] above lower lateral rib
margin), midway between spine and Alternate projection :
upside lateral border of abdomen, 45° to PA AXIAL:
55° oblique.
The position of the high transverse
Asthenic: Center about 2 inches (5 cm) stomach on a hypersthenic-type patient
below level of L1, 40° oblique. causes almost an end-on view, with
much overlapping of the pyloric region of
Hypersthenic: Center about 2 inches (5 the stomach and the duodenal bulb
cm) above level of L1 and nearer midline, with a PA projection.
70° oblique.
Therefore, a 35° to 45° cephalic angle of
Center cassette to CR. the central ray separates these areas for
better visualization.
Minimum SID is 40 inches (100 cm).
The greater and lesser curvatures of the
stomach also are better visualized in
Respiration: Suspend respiration profile
and expose on expiration.

Structures Shown: Structures Shown:

• Entire stomach and C-loop of duodenum Entire stomach and duodenum are visible.
are visible.

Position:
Position: Body and pylorus of the stomach are
barium filled.
• Duodenal bulb is in profile.

Collimation and CR: .

Collimation and CR: Collimation is seen along the four margins
of the radiograph..
Collimation is seen along the four margins
of the radiograph..
CR is centered to level of L2, with body
CR is centered to level of L1, with body of and pylorus of stomach and C-loop
stomach and C- loop centered on centered on radiograph.
radiograph.

Exposure Criteria:
Exposure Criteria: Appropriate Appropriate technique is used to visualize
technique is used to clearly visualize the the gastric folds without overexposing
gastric folds without overexposing other
other pertinent anatomy; sharp structural
margins indicate no motion
Part Position :
 Rotate 30° to 60° from supine
3. RIGHT LATERAL POSITION position, with left posterior against
IR or table (more rotation possibly
Pathology Demonstrated: Pathologic
required for heavy hypersthenic-
processes of the retro gastric space (space
type patients and less for thin
behind the stomach) are shown.
asthenic types).
Diverticula, tumors, gastric ulcers, and
 Flex right knee for support.
trauma to the stomach may be
 Extend left arm from body and raise
demonstrated along the posterior margin
right arm high across chest to grasp
of the stomach.
end of table for support. (Do not
pinch fingers when moving Bucky.)

Structures Shown:
Entire stomach and duodenum are visible.
Center IR at CR (bottom of cassette at
level of iliac crest).
Retrogastric space is demonstrated.
Pylorus of stomach and C-loop of
duodenum should be visualized well on
Structures Shown:
hypersthenic-type patients.
Entire stomach and duodenum are visible.

Position: An unobstructed view of the duodenal

No rotation should be present; vertebral bulb should be seen, without
bodies should be seen for reference superimposition by the pylorus of the
purposes. The intervertebral foramen stomach.
should be open, indicating a true lateral
position.
Position:
The fundus should be filled with barium.
Collimation and CR: . With a double- contrast procedure, the
Collimation is seen along the four margins body and pylorus and occasionally the
of the radiograph.. duodenal bulb are air filled.
CR is centered at level to duodenal bulb at
level of L1.
Collimation and CR:
Collimation is seen along the four margins
Exposure Criteria: of the radiograph..
Appropriate technique is used to visualize
the gastric folds without overexposing
CR is centered level to the duodenal bulb.
other pertinent anatomy; sharp structural
margins indicate no motion.

Exposure Criteria:
Appropriate technique is used to visualize
the gastric folds without overexposing
4. LPO POSITION other pertinent anatomy; sharp structural
margins indicate no motion.
Pathology Demonstrated : When a double-
contrast technique is used, the air-filled
pylorus and duodenal bulb may better
5. AP PROJECTION
demonstrate signs of gastritis and ulcers.
Pathology Demonstrated : Possible hiatal ANATOMIC CONSIDERATIONS:
hernia may be demonstrated in
The small intestine extends from the
Trendelenburg position
pyloric orifice of the stomach to the
ileocecal valve, where it joins the large
intestine at right angles.
Alternative: AP Trendelenburg:
A partial Trendelenburg (head down)
position may be necessary to fill the It averages about 22 feet in length, and its
fundus on a thin asthenic patient. diameter gradually diminishes from
approximately 1-1/2 inches in the upper
A full Trendelenburg angulation facilitates
part and approximately 1 inch to its lower
the demonstration of hiatal hernia. (Install
part.
shoulder brace for patient
safety.)
The small intestine is divided into
three portion:
Structures Shown:
Entire stomach and duodenum are visible..
1. DUODENUM – measured 8-10 inches
in length and it is the widest portion of the
small intestine. It begins at the pylorus .
Diaphragm and lower lung fields are
2. JEJUNUM – upper 2/5 of the small
included for demonstration of possible
intestine.
hiatal hernia.
3. ILEUM – lower 3/5

Position:
Fundus of the stomach is filled with The jejunum and ileum are gathered into
barium and is near center of IR. freely movable loops or convolutions and
attached to the posterior wall of the
abdomen by the mesentery. The loops lie
Collimation and CR: . in the central and lower part of the
Collimation is seen along the four margins abdominal cavity within the arc of the
of the radiograph.. large intestines.

CR is centered to duodenal bulb at level of

ANATOMICAL SUBDIVISIONS:
L1.
Duodenum = C-shaped tube which is
attached to the Stomach.
Exposure Criteria:
Jejunum = is the coiled Midportion.
Appropriate technique is used to visualize
the gastric folds without overexposing Ileum = the final section, which leads into
other pertinent anatomy. Sharp structural the large intestine.
margins indicate no motion.

Duodenum:
C-shaped tube
Joins stomach to jejunum
The first & shortest part of small
SMALL INTESTINE SERIES intestine
The widest & most fixed part
 Curves around the head ofpancreas 2. To know the physiology . Transmit or
emptying time .
Begins at pylorus on right side &
ends at duodenojejunal junction on left 3. to demonstrate the pathology in the
side. small intestines such as :
a. Regional enteritis (Crohn’s Disease)
b. Enteritis
c. Giardiasis
d. Ileus
Adynamic/paralytic
Mechanical ileus
Partially retroperitoneal
e. Meckels Diverticulum
f. Sprue
Jejunum & ileum:
g. Malabsorption syndrome

 Jejunum begins at duodenojejunal

flexure & ileum ends at ileocecal
junction.
 Coils of jejunum & ileum
aresuspended by mesentery from
posterior abdominal wall & freely
movable.
 Most jejunum lies in left upper
quadrant & most ileum lies in right
lower quadrant

PATIENT PREPARATION:
Special Radiographic Examination of the •Soft residue diet for 2 days
small intestine by administering the
barium sulfate by: •NPO after evening meal of the day before
the examination.
1.mouth
2. by complete reflux filling with a large •NPO (breakfast) on the day of the study
volume of barium enema . •Cleansing enema/cathartics
3. by direct injection into the bowel •Bladder should be empty before and
through an intestinal tube which is during the procedure
called the electrolysis .
4. Intubation method
PRELIMINARY PRELIM :
Plain AP Abdomen (KUB)
Done at timed intervals.

POSITION OF THE PATIENT:

INDICATION:
Supine
1. To know the anatomy of the small
 To take advantage of the superior
intestine.
and lateral shift of the barium-
filled stomach.
  For visualization of retrogastric
portions of the duodenum and
Prone Position: reversed the above
jejunum.
mentioned
 To prevent possible compression
overlapping loops of the intestine.
Prone: A. UGI-SB COMBINATION
( MOUTH )
 To compress the abdominal
contents ORAL or INDIRECT METHOD :
 To separate the various loops of
bowel PROCEDURES:
Barium preparation
- 33- 50% concentration. Mix the
Trendelenburg Position: preparation thoroughly.
 For final radiograph in asthenic - prepare 1 glass of barium mixture
patient ( 8oz)
Purpose:
 To unfold low lying and Tell the patient to drink the mixture slowly
superimposed loops of the ileum. and if signs of vomiting occurs, tell the
 To separate overlapping loops of patient to stop drinking and breath
ileum. through mouth , the have the patient drink
barium again until it is consumed.

LOCATIONS OF LARGE INTESTINE

PROJECTION: ALL AP PROJECTION
STRUCTURES IN RELATION TO
with time intervals
PERITONEUM
15, 30 , 45 and 60 minutes , and the end
point is when the cecum begins to be filled
Cecum: intraperitoneal up ( usually . 2 hours).

Ascending colon: retroperitoneal 1-hour interval radiographs (If more time

is needed after 2 hours )
Transverse colon: intraperitoneal
Descending colon: retroperitoneal
AP RECUMBENT :
Sigmoid colon: intraperitoneal - Patient in supine position.
Upper rectum: retroperitoneal - MSP must center to the midline of the
Lower rectum: intraperitoneal table.
- Reference point : 2 – 3 inches above iliac
crest
RELATIVE LOCATIONS OF AIR AND
BARIUM IN LARGE INTESTINE - Central Ray is perpendicular to the
image receptor.

Supine Position - Suspended respiration at the end of the

expiration.
Air: rises and fills the most anterior
structures
SMALL BOWEL SERIES ONLY
(intraperitoneal structures)
Scout: plain abdomen radiograph
Barium: sinks and fills the most posterior
structures (retroperitoneal structures) Barium: 2 cups (16 oz); noting time
First radiograph: 15-30 minute radiograph ENTEROCLYSIS PROCEDURE
- A radiographic procedures in which the
IR centered high for proximal
contrast medium is injected into the
SB
duodenum to examine the small bowel .
Second radiograph: half hour interval
- The contrast medium is injected through
radiograph
a Bilbao or Sellink tube.
IR centered to iliac crest
Finished: when barium reaches ileocecal
- Barium is given to the patient through
valve (usually 2 hours)
the tube at a rate of approx. 100ml/ min. .
1-hour interval or continuous half-hour In some patients, air is injected into the
interval radiographs small bowel after the contrast fluid has
reached the cecum.
(If more time is needed
after 2 hours)
Double contrast method:

B. COMPLETE REFLUX Barium

Filling of small intestine by a large Rate: 100 mL/minute

amount of suspension about 4,500ml
Air or methylcellulose
is required to fill the small bowel for
demonstration of colon and SI. Purpose: used to distend the lumen of
bowel

Preparation before exam:

Advantages:
Glucagon
 Enhances the visibility of the
 to relax intestine
mucosa (double contrast effect)
Diazepam/Valium  Increases the accuracy of the study

 to diminish patient discomfort

Indication: patient with

Materials:  History of small bowel ileus

 Regional enteritis (Crohn’s Disease)
 Retention tip enema  Malabsorption syndrome
 Enema bag

Disadvantages:
A retention enema tip is used and the
patient is placed in supine position for the  Increased patient discomfort
examination .  Increased possibility of bowel
perforation during catheter
The Barium suspension is allowed to flow placement
until it is observed in the duodenal bulb .
The enema bag is then lowered to the
floor to drain the colon before filming the
small bowel.

c. ENTEROCLYSIS PROCEDURE
 point of obstruction, then the Radiologist
aspirate the contents of the obstructed
Preparations:
portion of the intestine.
 Colon must be thoroughly cleansed
o Enemas not recommended
POSITIONING ROUTINES
Rationale: enema fluid may
retained in the SI
PA/AP PROJECTION

Special catheter advanced to PP: Prone/supine

duodenojejunal junction (near ligament of
RP:
Treitz)
Early Radiographs:
Thin mixture of barium sulfate instilled
L2 – Ballinger
2 in. above iliac crest - Bontrager
D. INTUBATION METHOD
Late Radiographs:
INTUBATION METHOD
Iliac crest
 This method is not utilized routinely
but in special cases to prevent or
relieve post operative
distention or to deflate or
decompress on obstructed
small bowel.
 Also known as small bowel enema.
 Uses NGT for introduction of CM
for therapeutic and diagnostic
purposes.

Materials: Nasogastric tubes

CR: Perpendicular

o Single-lumen tube SS: Barium-filled small intestine

 Site: proximal jejunum
 30-minutes radiograph: barium
 Patient: RAO position (gastric
location
peristalsis more active)
 Stomach and jejunum
 Aid in passage of tube
 1-hour radiograph: barium
location
 Jejunum
o Miller-Abbott (M-A) tube  2-hour radiograph: barium
 A double-lumen tube location
 For therapeutic intubation  Ileum and proximal
 Site: proximal jejunum colon
When barium reached ileocecal valve:
PROCEDURE: Fluoroscopy is performed

A MILLER- ABBOT tube is being Compression radiographs are obtained

inserted through the nose down to the
Exam Completed: when barium reached
cecum

-2 hours (for normal intestinal motility)