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The Gastrointestinal Exam

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Upper GI Exam

Definition

An upper GI examination is a fluoroscopic examination (a type of x ray imaging) of the upper gastrointestinal tract, including the esophagus, stomach, and upper small intestine (duodenum).

Purpose

An upper GI series is frequently requested when a patient experiences unexplained symptoms of abdominal pain, difficulty in swallowing (dysphagia), regurgitation, diarrhea, or unexplained weight loss. It is used to help diagnose disorders and diseases of, or related to, the upper gastrointestinal tract. Some of these conditions are: hiatal hernia, diverticula, tumors, obstruction, gastroesophageal reflux disease, pulmonary aspiration, and inflammation (e.g., ulcers, enteritis, and Crohn's disease).

Glucagon, a medication sometimes given prior to an upper GI procedure, may cause nausea and dizziness. It is used to relax the natural movements of the stomach, which will enhance the overall study.

Description

An upper GI series takes place in a hospital or clinic setting, and is performed by an x ray technologist and a radiologist. Before the test begins, the patient is sometimes given a glucagon injection, a medication that slows stomach and bowel activity, to provide the radiologist with a clear picture of the gastrointestinal tract. In order to further improve the upper GI picture clarity, the patient may be given a cup of fizzing crystals to swallow, which distends the esophagus and stomach by producing gas.

Once these preparatory steps are complete, the patient stands against an upright x ray table, and a fluoroscopic screen is placed in front of him or her. The patient will be asked to drink from a cup of flavored barium sulfate, a thick and chalky-tasting liquid, while the radiologist views the esophagus, stomach, and duodenum on the fluoroscopic screen. The patient will be asked to change positions frequently to coat the entire surface of the gastrointestinal tract with barium, move overlapping loops of bowel to isolate each segment, and provide multiple views of each segment. The technician or radiologist may press on the patient's abdomen to spread the barium throughout the folds within the lining of the stomach. The x ray table will also be moved several times throughout the procedure. The radiologist will ask the patient to hold his or her breath periodically while exposures are taken. After the radiologist completes his or her portion of the exam, the technologist takes three to six additional films of the GI tract. The entire procedure takes approximately 15–30 minutes.

In addition to the standard upper GI series, a physician may request a detailed small bowel follow-through (SBFT), which is a timed series of films. After the preliminary upper GI series is complete, the patient will drink additional barium sulfate, and will be escorted to a waiting area while the barium moves through the small intestines. X rays are initially taken at 15-minute intervals until the barium reaches the colon (the only way to be sure the terminal ileum is fully seen is to see the colon or ileocecal valve). The interval may be increased to 30 minutes, or even one hour if the barium passes slowly. Then the radiologist will obtain additional views of the terminal ileum (the most distal segment of the small bowel, just before the colon). This procedure can take from one to four hours.

Esophageal radiography, also called a barium esophagram or a barium swallow, is a study of the esophagus only, and is usually performed as part of the upper GI series (sometimes only a barium swallow is done). It is commonly used to diagnose the cause of difficulty in swallowing (dysphagia), and to detect a hiatal hernia. The patient drinks a barium sulfate liquid, and sometimes eats barium-coated food while the radiologist examines the swallowing mechanism on a fluoroscopic screen. The test takes approximately 30 minutes.

Preparation

Patients must not eat, drink, or smoke for eight hours prior to undergoing an upper GI examination. Longer dietary restrictions may be required, depending on the type and diagnostic purpose of the test. Patients undergoing a small bowel follow-through exam may be asked to take laxatives the day before to the test. Patients are required to wear a hospital gown, or similar attire, and to remove all jewelry, to provide the camera with an unobstructed view of the abdomen.

Aftercare

No special aftercare treatment or regimen is required for an upper GI series. The patient may eat and drink as soon as the test is completed. The barium sulfate may make the patient's stool white for several days, and can cause constipation; therefore patients are encouraged to drink plenty of water to eliminate it from their system.

Risks

Because the upper GI series is an x ray procedure, it does involve minor exposure to ionizing radiation. Unless the patient is pregnant, or multiple radiological or fluoroscopic studies are required, the small dose of radiation incurred during a single procedure poses little risk. However, multiple studies requiring fluoroscopic exposure that are conducted in a short time period have been known, on very rare occasions, to cause skin death (necrosis) in some individuals. This risk can be minimized by careful monitoring and documentation of cumulative radiation doses.

Normal Results

A normal upper GI series shows a healthy, normally functioning, and unobstructed digestive tract. Hiatal hernia, obstructions, inflammation (including ulcers or polyps of the esophagus, stomach, or small intestine), or irregularities in the swallowing mechanism are just a few of the possible abnormalities that may appear on an upper GI series. Additionally, abnormal peristalsis, or digestive movements of the esophagus, stomach, and small intestine can often be visualized on the fluoroscopic part of the exam, and in the interpretation of the SBFT.

Barium Enema

Definition

A barium enema, also known as a lower GI (gastrointestinal) exam, is a test that uses x-ray examination to view the large intestine. There are two types of tests: the single-contrast technique, where barium sulfate is injected into the rectum to gain a profile view of the large intestine, and the double-contrast (or "air contrast") technique, where air and barium are inserted into the rectum.

Purpose

A barium enema may be performed for a variety of reasons. One reason may be to help in the diagnosis of colon and rectal cancer (or colorectal cancer), and inflammatory disease. Detection of polyps (benign growths in the tissue lining the colon and rectum), diverticula (pouches pushing out from the colon), and structural changes in the large intestine can also be confirmed by the barium enema. The double-contrast barium enema is the best method for detecting small tumors (such as polyps), early inflammatory disease, and bleeding caused by ulcers.

A doctor's decision to perform a barium enema is based on a patient's history of altered bowel habits. These can include diarrhea, constipation, lower abdominal pain, or patient reports of blood, mucus, or pus in the stools. It is recommended that healthy people have a colorectal cancer screening colonoscopy every five to 10 years, because this form of cancer is the second most deadly type in the United States. Those who have a close relative with colorectal cancer, or who have had a precancerous polyp, are considered to be at an increased risk for the disease and should be screened more frequently by their doctor for possible abnormalities.

Description

To begin a barium enema, the doctor will have the patient lie with their back down on a tilting radiographic table so that x rays can of the abdomen can be taken. The film is then reviewed by a radiologist, who assesses if the colon has been adequately cleansed of stool during the prep process. After being assisted into a different position, a well-lubricated rectal tube is inserted through the anus. This tube allows the physician or the assisting health care provider to slowly administer the barium into the intestine. While this filling process is closely monitored, the patient must keep the anus tightly contracted against the rectal tube so that the position is maintained and the barium is prevented from leaking. This step is emphasized to the patient because inaccuracy may occur if the barium leaks. A rectal balloon may also be inflated to help the patient retain the barium. The table may be tilted or the patient may be moved to different positions to aid in the filling process.

As the barium fills the intestine, x rays of the abdomen are taken to distinguish significant findings. There are many ways to perform a barium enema. One way is that shortly after filling, the rectal tube is removed and the patient expels as much of the barium as possible. Alternatively, the tube will remain in place, and the barium will move through that tube. A thin film of barium remains in the intestine, and air is then slowly injected through the rectum and to expand the bowel lumen. Usually no films will be taken until after the air is injected. Multiple films are generally obtained by a radiologist; then, additional films are made by a technologist.

Preparation

To conduct the most accurate barium enema test, the patient must follow a prescribed diet and bowel preparation instructions prior to the test. This preparation commonly includes restricted intake of diary products and a liquid diet for 24 hours prior to the test, in addition to drinking large amounts of water or clear liquids 12–24 hours before the test. Patients may also be given laxatives and asked to give themselves a cleansing enema.

In addition to the prescribed diet and bowel preparation prior to the test, the patient can expect the following during a barium enema:

  • They will be well draped with a gown as they are placed on a tilting x-ray table.

  • As the barium or air is injected into the intestine, they may experience cramping pains or the urge to defecate.

  • The patient will be instructed to take slow, deep breaths through the mouth to ease any discomfort.

Aftercare

Patients should follow several steps immediately after undergoing a barium enema, including:

  • Drinking plenty of fluids to help counteract the dehydrating effects of bowel preparation and the test.

  • Taking time to rest. A barium enema and the bowel preparation taken before it can be exhausting.

  • A cleansing enema may be given to eliminate any remaining barium. Lightly colored stools will be prevalent for the next 24–72 hours following the test.

Risks

While a barium enema is considered a safe screening test used on a routine basis, it can cause complications in certain people. The following indications should be kept in mind before a barium enema is performed:

  • Those who have a rapid heart rate, severe ulcerative colitis, toxic megacolon, or a presumed perforation in the intestine should not undergo a barium enema.

  • The test can be performed cautiously if the patient has a blocked intestine, ulcerative colitis, diverticulitis, or severe bloody diarrhea.

  • Complications that may be caused by the test include perforation of the colon, water intoxication, barium granulomas (inflamed nodules), and allergic reaction. However, these conditions are all very rare.

Normal Results

When patients undergo single-contrast enemas, their intestines are steadily filled with barium to differentiate markings of the colon markings. Normal results display uniform filling of the colon.

As the barium is expelled, the intestinal walls collapse. A normal result on the x ray after defecation will show the intestinal lining as having a standard, feathery appearance.

The double-contrast enema expands the intestine, which is already lined with a thin layer of barium, using air to display a detailed image of the mucosal pattern. Varying positions taken by the patient allow the barium to collect on the dependent walls of the intestine by way of gravity.

A barium enema allows abnormalities to appear on an x ray that may aid in the diagnosis of several different conditions. Most colon cancers occur in the rectosigmoid region, or on the upper part of the rectum and adjoining portion of the sigmoid colon. However, they can also be detected with a proctosigmoidoscopy. Further, an enema can identify other early signs of cancer.

Identification of polyps, diverticulosis, and inflammatory disease (such as diverticulitis and ulcerative colitis) is attainable through a barium x ray. Some cases of acute appendicitis may also be apparent by viewing this x ray, though acute appendicitis is usually diagnosed clinically, or by CT scan.

    
       

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