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Two common radiographic procedures of the upper GI system involving the administration of contrast media are the esophagram, or barium swallow, as it is sometimes referred to, and the upper GI series. Each of these procedures is described in detail, beginning with the esophagram. This examination is used for the patient who have high dysphagia or definite oesophageal symptoms, or have quite often had a normal OGD but are still symptomatic, quite often a motility disorder may be the cause. Esophagram or barium swallow, is the common radiographic procedure or examination of the pharynx and esophagus, utilizing radiopaque contrast medium may be used. The purpose of an esophagram is to study radiographically the form and function of the swallowing aspects of the pharynx and esophagus. No major contraindications exist for esophagrams except possible sensitivity to the contrast media used. the technologist should determine whether the patient has a history of sensitivity to barium sulfate or water soluble contrast media. Known aspiration during ingestion (although this can be overcome by using non-ionic water soluble contrast). The contrast agent for barium swallow is barium sulphate suspension 250% w/v or water soluble contrast medium. Barium sulphate are, high atomic number, not soluble in water, used to coat the lining of organs, supplied in different thicknesses.
Used in esophogram, UGI, Small Bowel, Lower GI or BE. History of barium sulphate is starting with, lead substrate-toxic, bismuth subnitrate-toxic, thorium-radioactive, barium sulphte-inert(goes in and comes out the same – not absorbed). Barium sulphate mixture are contraindicated if any chance exists that the mixture might escape into the peritoneal cavity. This escape may occur through a perforated viscus or during surgery that follos the radiographic procedure. in either of these two cases, water soluble, iodinated contrast media should be used. Two example of this type gastrografin and Gastroview. Both of these water soluble contrast agent can be easily removed by aspiration before or during surgery. if any of this water-soluble material escape into the peritoneal cavity, the body can readily absorb it. Barium sulfate, on the other hand, is not absorbed. One drawnback to the water soluble materials is their bitter taste. Although these iodinated contrast media sometimes are mixed with carbonated soft drinks to mask the taste, they often are used “as is” or diluted with water. The patient should be forewarned that the taste may be slightly bitter. The technologist should be aware that water soluble contrast agents travel through the GI tract faster than barium sulfate. The shorter transit time of water soluble contrast agents should be kept in mind if delayed images of the stomach of duodenum are ordered. If there is any query that the patient may aspirate, the initial swallow is best carried out using a water-soluble contrast medium, although aspiration of barium has been considered by some to be relatively harmless. Aspiration may not be suspected but unsuspected ‘ silent aspiration’ may be found. The more common pathologic indications for an esophagram procedure suchas, achalasia also term cardiospasm, is a motor disorder of the oesophagus in which peristalsis is reduced along the distal two thirds of the esophagus. Achalasia is evident at the esophagogastric sphincter because of its inability to relax during swallowing. The thoracic esophagus may also lose its normal peristaltic activity become dilated (megaesophagus). Video and rapid digital fluoroscopies are most helpful in diagnosis of achalasia. Anatomic anomalies may be congenital or caused by disease, such as cancer of the esophagus. Patients suffering from a stroke often develop impaired swallowing mechanisms. certain foods and contrast agents are administered during the examination to evaluate swallowing patterns. A speech pathologist may witness the study to better understand the speech swallowing patterns of the patients. Video and digital fluoroscopy are used during these studies. Barrett’s esophagus, or barrette syndrome, is the replacement of the normal squamos epithelium with columnar-lined epithelium ulcer tissue in the lower oesophagus. This replacement may produce a structure of the distal oesophagus. In advanced cases, the development of a peptic ulcer in the distal esophagus may occurs. The esophagram may demonstrate subtle tissue change in the esophagus, but nuclear medicine is the modality of choice for this condition. the patient is injected with technetium 99m pertechnetate to demonstrate the shift in tissue types in the esophagus.
Carcinoma of the oesophagus includes one of the most common malignancies of the oesophagus, adenocarcinoma. advanced symptoms include dysphagia (difficulty in swallowing) and localized pain during meals and bleeding. Other tumors of the oesophagus include carcinosarcoma, which often produces a large, irregular polyp, and pseudocarcinoma. Dysphagia is difficulty in swallowing. This difficulty may be due to a congenital or acquired condition, a trapped bolus of food, paralysis of the pharyngeal or esophageal muscle, or inflammation. Narrowing or an enlarged, flaccid appearance of the esophagus may be seen during the esophagram, depending on the cause of the dysphagia. Video and digital fluoroscopy are the modalities of choice. Esophagram and endoscopy are performed to detect these tumors. The esophagram may demonstrate atropic changes in the mucosa due to the invasion of the tumor as well as stricture. Because the esophagus is empty most of the time, patients need no preparation for an esophagram only, all clothing and anything metallic between the mouth and the waist should be removed, and the patient should wear a hospital gown. Before the fluoroscopic procedure a pertinent history should be taken and the examination carefully explained to the patient. The first part of an esophagrams involves fluoroscopy with a positive-contrast medium. The examination room should be clean, tidy and appropriately stocked before the patient is escorted to the room. The appropriate amount and type of contrast medium should be ready. esophagrams generally use both thin and thick barium. Additional items useful in the detection of a radiolucent foreign body are cotton balls soaked in thin barium, barium pills or gelatine capsules filled with BaSO4, marshmallows. After swallowing any one of these three substance, the patient is asked to swallow an additional thin barium mixture, because the esophagram begins with the table in the vertical position, the footboard should be in place and tested for security. lead aprons, compression paddle, and lead gloves should be provided for the radiologist, as well as aprons for all other personnel in the room. proper radiation methods must be observed at all times during fluoroscopy. With the room prepared and the patient ready, the patient and radiologist are introduced and the patientis history and the reason for the exam discussed. The fluoroscopic examination usually begins with the general survey of the patient’s chest, including heart, lungs and diaphragm, and the abdomen.
During fluoroscopy, the technologist’s duties, in general, are to follow the radiologist’s instructions, assist the patient as needed, and expedite the procedure in any manner possible, because the examination is begun in the upright or erect position, a cup of thin barium is placed in the patient’s left hand close to the left shoulder. The patient then is instructed to follow the radiologist’s instructions concerning how much to drink and when. The radiologist observes the flow of barium with the fluoroscope. Swallowing (deglutition) of thin barium is observed with the patient in various positions. Similar positions may be used while the patient swallows thick barium. The used of thick barium allows better visualization of mucosal patterns and lesion within the esophagus. The type of barium mixture to be used, however is determined by the radiologist. After the upright studies, horizontal and trendelenburg positions with thick and thin barium may follow. The pharynx and cervical esophagus are usually studied fluoroscopically with the spot films, whereas the main portion of the esophagus down to the stomach is studied both with fluoroscopy and with post fluoroscopy “overhaed radiograph”. the diagnosis of possible esophageal reflux or regurgitation or gastric contents may occur during fluoroscopy or an esophagram. One or more of the following procedures may be performed to detect esophageal reflux. First, breathing exercise the various breathing exercises are all designed to increase both the intrathoracic and the intraabdominal pressures. The most common breathing exercise in the valsalva maneuver. The patient is asked to take a deep breath and, while holding the breath in, to bear down as though trying to move the bowels. This maneuver forces air against the closed glottis. A modified valsalva maneuver is accomplished as the patient pinches off the nose, closes the mouth, and tries to blow the nose. The checks should expand outward as though the patient were blowing up a balloon.
A Mueller manoeuvre can also be performed as the patient exhaled and then tries to inhale against a closed glottis. With both methods, the increase of intraabdominal pressure may produced the reflux of ingested barium that would confirm the presence of esophageal reflux. The radiologist carefully observes the esophagogastric junction during these manoeuvres. Second is water test that done with the patient in the supine position and turned up slightly on the left side. This slightly LPO position fills the fundus with barium. The patients are asked to swallow a mouthful of water through a straw. Under fluoroscopy the radiologists closely observe the esophgogastric junction. A positive water test occurs when significant amounts of barium regurgitate into the esophagus from the stomach. A compression paddle can be placed under the patient in the prone position and inflated as needed to provide pressure to the stomach region. The radiologist can demonstrate the obscure esophagogastric junction during this process to detect possible esophageal reflux. The toe-touch manoeuvre is also performed to study possible regurgitation into the esophagus from the stomach. Under fluoroscopy the cardiac orifice is observed as the patient bends over and touches the toes.
Esophageal reflux and hiatal hernias are sometimes demonstrated with the toe-touch manoeuvre. If the patient is a female, then a menstrual history must be obtained. Irradiation of an early pregnancy is one of the most hazardous situations in diagnostic radiography. X-ray examinations such as the upper GI series that include the pelvis and uterus in the primary beam and include fluoroscopy should only be done on a pregnant female when absolutely necessary. In general, abdominal radiographs of a known pregnancy should be delayed at least until the third trimester or, if patient’s condition allows (as determined by the physician), until after the pregnancy. This waiting period is especially important if fluoroscopy, which greatly increase patient exposure is involved. Potential difficulties that may arise out of a Barium Swallow is discomfort of air insufflation. Poor tolerance of swallowed gas mixture can make for poor stomach and oesophageal distension. Where buscopam injection is used to relax bowel for better pictures, patients may experience some blurring of vision. Tendency of barium to cause constipation in the days following the procedure. Need for an interpreter in non-English speaking patients.
Disadvantages of Barium Swallow
- Useful for functional assessment – allows the assessment of motility, reflux and distension.
- In comparison to gastroscopy, barium swallow is safer.
- Available resource. It is difficult to compare costs between barium studies and endoscopy and they may be of comparable costs. However is some centres barium studies are much more accessible to GPs and may be arranged with much less delay for the patient than gastroscopy.
- Not as comprehensive or accurate method for diagnosis of some conditions in comparison to gastroscopy.
- Not able to take samples or provide treatment as part of the procedure.
- Radiation exposure. Dose is 2 – 3 millisieverts compared with chest film 0.06 millisieverts and background radiation of 2millisieverts per year. Users of ionising radiation are required to inform all women of child bearing age about the risks of radiation in pregnancy. Pregnancy is a relative contraindication to the use of radiation but generally in the context of the barium enema the urgency is such that can delay or choose alternative investigation.
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