Upper GI

Question 1

Indications for an UGI

Answer 1

• Vomiting!!!
• R/O malrotation (usually in a kid with vomiting…)
• R/O pyloric stenosis (usually in a kid with vomiting…)
• R/O volvulus associated with malrotation—these kids tend to present very sick to the ER with bilious vomiting
  The NICU likes to call everything “bilious vomiting”—it usually isn’t
• Pre-op G-button (look at anatomy; most of these kids have NGT in place, use that for contrast—do not need to eval esophagus)
• Evaluate fundoplication integrity
• R/O SMA (superior mesenteric artery) Syndrome (think of this with teenagers who have recently lost a significant amount of weight in a short period of time or post-op from scoliosis surgery—more common)

Question 2

Contrast and amount used for UGI

Answer 2

• Barium for the majority
• Omnipaque 300 (not diluted) for r/o obstruction in the immediate postop period (ex: postop small bowel resection), concerns for volvulus/bilious vomiting (because may need to go to OR quickly and/or be perforated)
• Dosing—feed until we see what we need.
• If tiny preemies with high aspiration risk, I use Omni-300.
• Unless there are concerns per the ordering physician, we do not count EGD with biopsy as a post-op and these patients get barium
• Per your/MD’s discretion

Question 3

Table position for UGI

Answer 3

• Horizontal, HOB flat (some times I will raise if concerns for aspiration)
• No images in upright position or may do a quick scout
  1. Start L lateral—eval esophagus
  2. Turn AP—eval esophagus and early stomach fill
  I usually have them stop drinking here and then decide if they need more as we go
  3. Turn R lateral and/or RAO—look at pylorus and early emptying
  RAO is a good way to see the pylorus if it’s posteriorly oriented
  4. AP to see the duodenum cross midline and rise to the level of the duodenal bulb and capture the DJJ—cine loop
  5. LPO to document the posterior course of the duodenum—cine loop or last image once DJJ is seen
• Do not spend time looking for reflux even if that’s what the study is “for” (see note)
• For patients with NG tubes in place, can use NGT for contrast and not look at the esophagus (unless this is specifically requested).

Question 4

Machine settings for UGI

Answer 4

• 3 p/s, 0.5 f/s
• Save cine loops plus last-image hold
• Rarely need exposures (usually if interesting finding/concern that needs closer look)
• Grid for kids > 10-ish or adult sized; When I use the grid I still set to the “pediatrics” setting instead of “adult”—saves you radiation; unless morbidly obese or adult-sized teenagers

Question 5

Pearls for infant undergoing UGI

Answer 5

In an infant, don’t overfill the stomach because it can easily get in the way of your being able to see the DJJ well, especially on first-pass. You have to play it by ear, but some times I will give baby 10ish mL of contrast, watch the first pass and document that, then feed them more to more fully distend the stomach if needed for anything else (most of the time that’s not even important because really all they want is to r/o malro).

Question 6

Looking for GERD on UGI

Answer 6

• GERD is not an indication for an UGI or Esophagram according to the ACR-SPR nor recommended by the North American Society for Pediatric Gastroenterology. Studies have shown that barium studies are neither sensitive nor specific for the identification of GERD in cases where there is no anatomic abnormality (i.e. hiatal hernia). Therefore: I don’t spend any time looking for reflux on UGIs/esophagrams.
  Pediatricians still order them…
• IF an episode occurs spontaneously I do save it and document it in the report however I have not found any studies in the literature that support this because of the frequent occurrence of non-pathological reflux in infants…to be continued…
• When reflux is not seen on the exam and the order was “to look for reflux” I include the following in the dictation (per Dr. Putegnat): “Note is made the negative predictive value of upper GI series for clinically important gastroesophageal reflux is poor.”