Aliementary Canal

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Emptying Times for the stomach

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in 2-3 hours

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Food reaches the ileocecal valve:

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in 2-3 hours

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Food entirely passes the alimentary canal in

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4 to 5 hours

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Food reaches and exits the rectum in

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24 hours

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When you do a study of the alimentary canal you will be using a combination of the

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fluoro machine + radiography

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Because you are examining hollow organs

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contrast media must be used:

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There are two types of contrast media:

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Water soluble-Gastrografin

Water insoluble- Barium Sulfate

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Barium Sulfate is made of

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water insoluble salt made of metallic barium

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Barium may come either

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1. powdered or liquid

2. different concentrations/for different parts and physician prefrence

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Barium has a high Z number so we need to use the

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15 percent rule, when we increase the kvp the film becomes darker so we have to compensate by decreasing the mAs by 1/2

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When you use water soluble contrast like gastrogafin

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the technique will not have to change

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For example during an Esophogram you normally use 75 KvP at 20 mAs, same with gastrografin but

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90 kvp and 10 mAs if you use water insoluble contrast like barium sulfate

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A Hypaque enema is one which is given for

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therapeutic value for severe impaction

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Before you start any fluoro exam remember bring the

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bucky on the table all the way down

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To prepare a bag of barium

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1. Usually add water (follow manufacturer's instructions)

2. Shake thoroughly

3. Put upside down

4. CHECK FOR EXPIRATION DATE

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Water-Soluble contrasts like gastrografin are

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Iodinated contrasts derived from intravenous contrasts.

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Gastrografin and the like move

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faster through the alimentary canal than Ba

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In addition to it's speed water soluble contrast

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does not adhere to the mucosa

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The difference between thick and thin barium is in the different levels of

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concentration.

1. Thick to show structure

2. Thin to show movement and function

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We always use water soluble contrast when there is a suspected

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perforation

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Water soluble contrast is okay for use in the stomach and duodenum but dilutes

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in the small intestine which gives you (no detail of anatomy)

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Water soluble contrast is good for colon when given

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antegrade (water absorbed in colon contrast gets more concentrated) or retrograde

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The advantages of water soluble contrast

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1. Easily removed by suction

2. Reabsorbed if there is perforation

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Disadvantages

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1. Bitter taste

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Modern Fluoro (invented by edison in 1898) uses an

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image intensifier

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Fluoro comes from

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underneath the table so you should shield the patient from behind (wrap around shield)

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During fluoro we use

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compression devices such as the compression paddle

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During fluoro we prefer to use very short

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exposure times

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During fluoro of the alimentary canal we do it at the end of

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expiration

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The amount of KvP typically used for single contrast is somewhere between

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100-125 KvP

Front 31

Double contrast (contrast + air) uses a KvP of

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80-90kvp

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Esophagus

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1. Full column, single contrast, Ba only

30-50% BA

2. Double contrast-Fizzies (carbon dioxide crystals) and Ba

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Double contrast of the esophagus has

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Low viscosity, and high density

Is received mixed with the Ba or given before the Ba is drank by the patient

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CR for esophagus

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T7

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General Overheads taken for Esophagram

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1.Start with scout before fluoro just like AP T-spine

2. AP

3. RAO

4. Lateral

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There is no

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preparation for an esphogram diet wise

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Always start the patient

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upright whenever possible

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The patient holds the cup of contrast in the

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left hand and drinks upon request

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The patient will swallow many mouthfuls of Ba and be given different breathing instructions the first of which is not to

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belch

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Trouble swallowing is known as

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Dysphagia

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The marker is placed on the

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top of the film

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For the overheads we use a

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14 X 17 lengthwise cassette

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The top of the film should be at the level of the

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mouth to include entire esophagus (centered between t5-t6)

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Overheads are done

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recumbent because the Ba stays in the patient longer (peristalisis and gravity makes the Ba travel through the esophagus quickly)

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Have the patient swallow several mouthfuls of Ba and hold a mouthful until

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immediately before and exposure

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Its required that the esophagus is full

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of Ba and that we see it in its entirety

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The Ba must be penetrated so use the

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15 percent rule, somewhere around 90 KvP at 16 mAs should work

Front 48

Esophagus AP or Pa projection

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Supine or Prone, MSP centered to cassette

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AP or PA oblique Projection (RAO or LPO)

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1. 30-45 degree oblique

2. center 2" lateral to MSP on elevated side

3. The esophagus will be projected between the heart and vertebrae

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Lateral Projection requires a jump in

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10kvp and 2 steps in time

so 100 kvp at 25 MaS

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The patient can face either right or left

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whichever way the radiographer is positioned closest

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for the lateral Esophagus center along the

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MCP

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Don't forget to take

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earrings, necklaces, glasses off

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Upper GastroIntestinal Series will include

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1. Distal Esophagus

2. Stomach

3. All or part of small intestine

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UGI starts with a

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Scout KUB

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Then there will be

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ingestion of contrast medium and fluoro

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Then the tech begins taking timed films until the Ba reaches the ileocecal valve

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Usually 20 minute increments

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The O min film is always a

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High KUB centered 3 inches above the crest

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Preperation for SBS/UGI

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1. Inform patient on LENGTH of procedure

2. Stomach must be empty

3. May have more extensive preperation

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Normally the contrast is

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Ba sulfate suspension with water

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Good technique is again

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90 kvp at 16 mAs

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UGI

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Single contrast exam-30-50% Barium Sulfate suspension given under Fluoro

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Patient starts

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upright

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Patient drinks and the rad

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takes films of esophagus

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At this time the stomach mucosa is becoming

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coated

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Sometimes a compression paddle is used to

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take spot films of the stomach ( so have one ready)

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UGI shows

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1. size and shape of stomach

2. Changing contour of stomach during peristalisis

3. The filling and emptying of the duodenal bulb and any abnormalities from esophagus to bulb

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UGI fluoro is done in the

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upright position as well as recumbent

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Overheads must be taken immediately

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so stomach doesnt empty

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Table may be placed trandelenberg to show

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Hiatal hernia (stomach through esophogeal hiatus)

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UGI: Double Contrast Exam

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Small lesions are better visualized, musosal lining is coated better. Patient needs to be mobile

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UGI: Double Contrast

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1. Start Upright

2. Give Fizzies normally with water

3. Small amount of Ba given (thick)-250% wt/volume concentration

4. Have patient lie down and roll to coat stomach

5. No belching

6. Fluoro done/the overheads

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Overheads for UGI

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1. AP or PA

2. RAO or LPO

3. Right Lateral

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For AP films the Ba is in the top of the stomach also known as the

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Fundus and air is in the body of the stomach, pyloric part, and duodenum

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For PA films Ba is in the

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body, pyloric region, and and duodenum, and AIR is in the FUNDUS

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An anterior oblique RAO is preferred over and LPO

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because as you see the BA tends to stay in the duodenal cup which is a common place for cancer

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Then you can take a right Lateral with a

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10 X 12 cassette

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Centered at the

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MCP

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UGI PA projection

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14 X 17 cassette

High KUB (L1 L2) look for where elbows are

Sagittal plane should run between MSP and lateral border

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If you do an upright PA

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drop the cassette 3" to 6"

Ba-fill the body and bulb air in the fundus

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Structures Shown

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Stomach, duodenal loop (sweep) (a 14 X 17 is preferred to show lower lungs for any chance of hiatal hernia)

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PA Axial Projection

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14 X 17 lengthwise

Prone

35-45 degrees cephalad at L2 for hypersthenic patients to open up the greater and lesser curves of the stomach

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PA oblique (RAO)

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10 X 12 cassette

Right arm along body, left arm up, and left knee bent

40 to 70 degree oblique (more oblique for hypersthenic patients)

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Structures Shown

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Pyloric canal and Duodenal Bulb

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CR

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midway between spine and elevated lat side of body at L1-L2

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AP Oblique (LPO)

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10 x 12

30 to 60 degree oblique

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CR

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between spine and left lateral side of patients body @L1-L2

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Structures Shown

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Fundus filled with BA, pylorus and bulb filled with air this is why RAO is preferred method

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UGI Lateral Projection

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10 x 12

Recumbent (Rt)

Go up 2 steps in mas 1 in kvp

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Structures shown

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retro gastric space, duodenal loop, duodenum-jejunum junction

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CR

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between MCP at L1-L2 and anterior surface of abdomen

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Zanker Diverticulitum

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a pouch created that makes food feel like it is getting stuck

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If you do an upright lateral do

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a left lateral

try to see where the duodenal sweep is while rad fluoros

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Shows

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Retro gastric space

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Center

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@L3 midway b/w MCP and anterior of abdomen

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UGI AP projection

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shows fundus filed with Ba

Center at L1-L2

14 x 17

between MSP and left border of patient

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So UGI Normal Protocol

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AP SCOUT- AB Technique 75 kvp 32 mas

AP or PA done with 14 X 17 @ 90kvp at 16 mas

RAO and Rt Lateral 10 X 12 cassette

Oblique one step in time

Lateral one step in KVP and two steps in time

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SBS Fills 3 ways

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1. Ingestion

2. Reflux (retrograde through rectum)

3. Enteroclysis (bypassing of stomach and esophagus-patient has NG tube thru pyloric)

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Preperation for patient

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1. Low residue diet 2 days prior

2. cleansing enemas

3. Empty Bladdder ( may displace loops of bowel)

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Start with a

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KUB Scout to make sure clean

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1. Oral Method

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Scout fim taken

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Supine film shows

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Stomach moved so it doesnt superimpose over bulb and jejunum. Prevents loops of bowel from overlapping and compressing each other

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Prone films show

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compressed abdominal contents for better film quality

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A O min film is taken immediately after patient ingests

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2 bottles of either water-soluble or water-insoluble contrast, if already had UGI one bottle is usually fine

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Take timed KUBS

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until contrast reach ileocecal valve then get rad to spot the TI

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Always use

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time markers

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Each rad and each patient differs in times of films taken and

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length of actual procedure (EXPLAIN TO PATIENT)

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You may give a patient a food stimulant

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3 to 4 hours after drinking to aid in peristalisis (coffee, water, walking around) only with outpatients

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Never feed

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inpatient you would need docs permission

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Last Resort

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lay on right side and this sometimes help empty the stomach contents

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Purpose of SBFT

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Post Abdominal Surgery (ex abendectomy, c-section)

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SBS AP or PA Projection

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14 X 17

First couple of films high KUBS

then third and fourth regular KUBS

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Center

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@ L2 within first 30 minutes, then at level of crest thereafter

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SBS Reflux Exam

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Ba given after patient recieves glucagon (relaxes muscles in colon) and or valium

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Ba is given until

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duodenal bulb is filled then bag is lowered to drain colon

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Films taken of

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Small intestine

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SBS Enteroclysis procedure

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Contrast injected under fluoro into a tube in the small intestine

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Then,

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Fluoro spot films are taken

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Overheads are taken as requested by the

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physician

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Ba may also be injected into a tube into the

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stomach and timed films are taken much like the oral exam

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Barium Enema can be either

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1. Single contrast BaSo4 only (or water soluble iodinated contrast)

2. Double-contrast-BaSo4 and air

3. Two-Stage double contrast-single given then air

4. Single-stage double contrast- air selectively injected during fluoro

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The reason we give air during a BE

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helps to destend the lumen by pumping air and circulating the contrast

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BE demonstrates

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anatomy and tonus of colon, air distends the lumen and shows small lesions

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High Density

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Ba is used in BE double contrast studies because it absorbs more radiation

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Air is usually the

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gaseous medium, but carbon dioxide can also be used (more expensive but more easily absorbed by the body)

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Preperation

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1. Large intestine must be fully emptied ( light broth diet, going to the bathroom before hand)

2. Feces can appear as pathology

3. Always ask last time NPO

4. Dietary restrictions: laxatives, cleansing enemas-Whole GI tract needs to be cleaned

Front 127

The bags and enema tips used are

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disposable

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The retention tips with the double lumen are

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flexible rubber tip with balloon on the tip

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Limit of air-one puff

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90ml or 90cc of air (anymore could rupture the rectum)

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Tip is inflated JUST before the exam

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under fluoro

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Bags hold

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3000ml but you usually only use half

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Tubes are

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6 feet long

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Single Contrast BE

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12-25% Ba is used

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Double Contrast BE

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75-95% BA is used

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Water should be

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COLD-soothing, sphincter contracts to help contain enema

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Warm water can

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irritate and even injure the mucosal lining

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Prep for BE

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1. Explain procedure to patient

2. Have them relax

3. Take Scout to show to rad

4. Keep them covered as to not embarass them

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Insertion of tip

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1. Patient in Sims position

2. Left side lean forward 30-45 degrees and flex right knee on table above and in front of left

3. IV pole 18-24 inches above rectum

4. Run barium through to free tube of air

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Always remember to

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CLAMP the tube the fill with about 1000cc of Ba

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Hemostat

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is like a double clamp

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Have KY Jelly lubricant and lubricate

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tip of retention tube

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Have patient

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relax and take deep breaths`

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Hold up right buttocks

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to open gluteal fold

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ON EXPIRATION

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insert tip 1- 1 1/2" anteriorly and then superiorly

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Total length insertion should never be more than

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3 1/2 " to 4 "

Front 146

NEVER FORCE THE TIP

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Hold the tip in place and position patient for fluoro

Front 147

SINGLE CONTRAST BE PROCEDURE

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1. Get Rad

2. Open clip for enema flow when rad asks

3. Open and close tip as rad asks (stopping helps avoid patient cramping)

4. Patient will roll so rad can inspect all parts of colon

Front 148

SINGLE CONTRAST BE Continued

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5. Spot films taken during fluoro

6. Overheads taken

7. Patient goes to restroom

8. Post-evacuation film taken

Front 149

BE DOUBLE CONTRAST PROCEDURE

Back 149

Single Stage Procedure:

1. Very clean colon, dense Ba, doesn't flake or clump

2. 200%wt/volume-must be able to flow freely

3. Overhead radiographs-all done on expiration, center slightly higher for hypersthenic patients

Front 150

BE PA projection

Back 150

14 X 17 lengthwise

MSP @ level of crests

Front 151

BE PA projection structures shown

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entire colon (may need 2 films crosswise-upper to include lower lungs, lower to include entire rectum

Front 152

BE PA Axial Projection

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14 X 17 or 10 X 12

Front 153

Cassette centered at

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crests

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CR

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30 to 40 degree caudad, cephalad if AP entering at level of ASIS

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Shows

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Recto Sigmoid area

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Make the collimation

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more like 14 X 14 and put bottom of cassette at top of butt crack

Front 157

BE RAO Position-PA oblique Projection

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14 x 17 lengthwise

35-45 degree rotation

CR- 1-2 " lateral to midline of body on elevated side at level of crest

Front 158

Structures shown

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right colic flexure, cecum, ascending and sigmoid colon

Front 159

Opposite view

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LPO

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In the RAO view the

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right hepatic flexure more anterior on transverse colon (hepatic opens up)

Front 161

The LAO position for the BE

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14 x 17 lengthwise

35-45 degree rotation

CR 1 to 2 inches lateral to midline of elevated side at level of crests

Front 162

Structures shown

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left colic flexure opened, descending colon (splenic opens up)

Front 163

Opposite view

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RPO

Front 164

BE Lateral Projection

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10 x 12 LW

Right or Left

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CR

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MCP @ ASIS

Front 166

Structures Shown

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rectum and distal sigmoid

Front 167

Hips should be

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superimposed (Praying with knees on top)

Front 168

BE AP Projection

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2 14 x 17 crosswise

top at xiphoid tip

bottom has to include symphisis

Front 169

BE RIght lateral decubitus

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14 X 17 LW

Front 170

CR

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horizontal and perpendicular to MSP @ crests

Front 171

Structures Shown

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AP or PA projection of the entire colon

Front 172

Demonstrates

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medial side of ascending colon and lateral side of descending colon

Front 173

Do not over penetrate

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air filled portions of the colon

Front 174

Assure

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no rotation of the patient

Front 175

BE LEft Lateral Decubitus

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14 x 17 LW

Front 176

CR horizontal and perpendicular to

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MSP at crests

Front 177

Shows

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Projection of entire colon

Front 178

Demonstrates

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lateral portion of ascending and medial portion of descending

Front 179

Markers should be placed

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on top or on both top and bottom CYA

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Make sure to

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turn it and flip it before annotating it

Front 181

AP Axial Projection

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14 x 17 LW or 10 X 12 LW

Front 182

Cassette centered

Back 182

2" above crest

Front 183

CR

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30 to 40 degrees cephalad @ 2 inches below ASIS at MSP

Front 184

shows

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rectosigmoid

Front 185

BE Decubs

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Needs a grid cassette or upright bucky

place radiolucent support under side down

Place back or abdomen directly against grid

Front 186

BE Lateral Projection

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Right or Left Ventral Decubs

Front 187

14 X 17 LW and

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Patient Prone

Front 188

CR

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horizontal and perp to MCP at level of crests

Front 189

shows

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posterior portion of colon

Front 190

include entire colon

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flexures to rectum

Front 191

BE upright projections

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same as recumbent, center a little lower

Front 192

Chassard Lapine

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Patient sits and bends, CR at level of greater trochanters and perpendicular

Front 193

Colostomy Studies

Back 193

Same prep and contrast

Front 194

Different

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tip

Front 195

Fluoro/spots/overheads

Front 196

Defocography

Back 196

evacuation proctography, or dynamic rectal examination

1. No prep

2. Ba paste injected with special injector

3. Pt seated in lateral position in radiolucent commode. Fluoro spots during defocation

4. Angle between rectum and anal canal compared to normal values

Front 197

Last Overhead

Back 197

Post evacuation of BE and label it so on right crest