CARDIAC SERIES

- The cardiac series is a radiographic examination very similar to the barium swallow.
- It is used primarily to study heart size and configuration.

 Clinical Indications:
1. Cardiomegaly- enlargement of the heart

 Four radiographs are to be taken:

1. PA Projection at 72” SID (Source-to-image receptor distance)

*PA Projection that shows barium-filled

esophagus
* The upper arrow points to the level of aortic
coarctation, and the lower arrow marks the apex of the
enlarged LV. The arrow on the patient’s right indicates
the dilated ascending aorta.

2. Left Lateral Position

*Lateral view of a third patient with the same disease

showing a barium-filled esophagus to be pushed forward
(upper arrow) by the poststenotic dilatation of the
descending aorta and pushed backward (middle arrow) by
the enlarged left atrium (LA). The very large LV ( lower
arrow) simply casts a shadow behind the esophagus
without displacing it. The oblique arrow points to the
calcified stenotic bicuspid aortic valve.
 3. 45° RAO Position

*RAO Position
*The huge right atrium (RA) casting a triangular density
(lower horizontal arrow) behind the esophagus without
displacing it. The esophagus is deviated posteriorly by the
enlarged LA (upper horizontal arrow). The upper oblique
arrows indicate the direction of the enlarging pulmonary
trunk and right ventricle (RV). The lower oblique arrow points
to the normal LV with the undisturbed left costophrenic
sulcus.

4. 60° LAO Position

* Left anterior oblique view of a patient with valvular aortic

stenosis. The dilated ascending aorta (upper white arrow) is
immediately above the flat anterior border of a normal RV.
The black arrow points to the calcified aortic valve. The lower
white arrow marks the enlarged LV.

 Note: The difference in degree of obliquity is due to the position of the heart.

UPPER GASTRO INTESTINAL SERIES (UGIS) OR BARIUM MEAL

- Radiographic examination of the distal esophagus, stomach and duodenum.
- Usually includes the following:
1. A preliminary (scout) radiograph, usually a routine radiograph of the abdomen
is taken to delineate the organs of the abdomen and to detect any abdominal
or pelvic calcifications or tumor masses. The detection of calcifications and
tumor masses requires that the survey radiograph is taken after the preliminary
cleansing of the intestinal tract but before administration of contrast media.
2. The examination consists of fluoroscopic and serial radiographic studies of the
esophagus, stomach, and duodenum using an ingested contrast material.
3. Depending on the request or the radiologist’s preference, a small intestine
study consisting of radiographs be obtained at frequent intervals during
passage of the contrast media to the small intestine, at which time the appendix
and ileocecal region may be examined.
Purpose:
- To study radiographically the form and function of the distal esophagus, stomach
and duodenum, as well as to detect abnormal and functional conditions
Characteristics of the Stomach
- J-shaped portion of the digestive tract
- Located in the left upper quadrant (LUQ) of the abdomen below the diaphragm
- Continuous with the esophagus and above the small bowel
Opening of the Stomach
 Cardiac orifice
- The upper opening at the junction of the esophagus which is at the level of the
seventh left costal cartilage about 1 inch from the side of the sternum (level of the
tenth thoracic vertebra or T10).
- Parts:
1. Cardia
- Short, constricted region adjacent to the
gastroesophageal junction
2. Fundus
- Sac-like region that extends above and to the left
of the gastroesophageal junction (GEJ)
3. Body
- Central portion between the fundus and pylorus
4. Pylorus
- Terminal portion of the stomach
o Pyloric orifice
- The lower opening that communicates with the duodenum
- Lies about 1 inch to the right of the midline at the level of the upper
border of the first lumbar vertebra (L1)

Movement of the stomach as related to body positions

1. Upright
- If an individual is in upright position, by the force of gravity, the stomach will go
down for about 3 to 6 inches.
2. Supine
- The stomach will go up to maximum, superiorly towards the diaphragm
3. Prone
- The stomach will move slightly downward.
4. Right Lateral Recumbent
- The stomach has a tendency to swing forward, thereby placing the body of the
stomach to the abdominal wall and placing the pylorus closer to the lumbar spine
 5. Left Lateral Upright
- The body of the stomach swings backward and will go closer to the spine. The
pylorus is closer to the abdominal wall.

 Variations of patient positions may be done to demonstrate the relative position of

the stomach

Clinical Indications:
1. Ulcer
2. Hiatal Hernia
3. Acute or Chronic Gastritis
4. Tumor, carcinoma
5. Diverticulae
6. Bezoars

 Peptic Ulcer Disease

- Erosion of the stomach or duodenal mucosa to various physiological or
environmental conditions, such as:
a. Excessive gastric secretions
b. Stress
c. Diet
d. Smoking
 Two types of Peptic Ulcer
1. Duodenal Ulcer
- A peptic ulcer situated in the duodenum.
- These ulcers are frequently located in the second or third aspect of the duodenum
2. Gastric Ulcer
- A peptic ulcer disease that usually occurs on the lesser curvature of the stomach

 Hiatal Hernia
- A condition wherein a portion of the stomach will herniate (bulge) through the
diaphragmatic opening
 Gastritis
- Inflammation of the lining or mucosa of the stomach
 Tumor
- May be either malignant or benign
 Polyps
- A small mass growing from the mucosal wall
 Diverticulae
- Are weakening and outpouching of a portion of the mucosal wall
 Bezoar
- A mass of undigested material that gets trapped in the stomach.
- This mass is usually made of hair, certain vegetable fibers, or wood products. The
material builds up and may form an obstruction in time.

Contraindications
 Contraindications for UGIS apply primarily to the type of contrast media used
 If the patient has a history of bowel perforation, laceration, or viscous rupture, the
use of barium sulfate may be contraindicated since this may cause leakage of
barium to the abdominal cavity. Oral water-soluble contrast media may be used in
place of barium sulfate.

Barium Preparation
 Prepare a 2:1 (60 to 66%) or 3:1 (70 to 80%) barium mixture
 Prepare only enough amount needed in the examination about 1/3 of a glass.
Mixed thoroughly. If necessary, prepare the mixture the night prior to the
examination and refrigerate it as to minimize the unpalatable taste.

Patient Preparation
 Since UGIS is time-consuming, you should inform the patient on how long the
procedure is going to take.
 The stomach must be empty during the procedure. It is also desirable that the
colon is free of gas and fecal materials.
 If the patient is constipated, a non-gas-forming laxative may be administered a
day before the procedure.
 The patient should have soft, low-residue diet for 2 days before the examination
to prevent gas-formation.
 Cleansing enemas should be done to ensure a clean colon.
 Food and water is withheld for 8-9 hours before the procedure to empty the
stomach
 Instruct the patient not to chew gum nor smoke on the night before the procedure
since these stimulate gastric secretions and salivation

Methods of Examination
1. Single-contrast Examination
- A barium sulfate suspension is administered during the fluoroscopic examination.
The barium suspension used is 30% to 50% weight/volume average.
- The following steps are observed:
o Patient is placed in upright position.
o The radiologist may first examine the heart and lungs fluoroscopically and
observe the abdomen to determine if there are food or fluid in the stomach.
 o Give the patient a glass of barium and instruct him/her to drink it. If the
patient is in recumbent position, the suspension may be administered through
a drinking straw.
o The radiologist asks the patient to swallow two or three mouthfuls of the
suspension. During this time, examine and expose any indicated spot films of
the esophagus (spot film- radiograph which is made during a fluoroscopic
examination to permanently record conditions which exist during that
fluoroscopic procedure). By manual manipulation of the stomach through the
abdominal wall, the radiologist coats the gastric mucosa.
o Obtain additional images to demonstrate any mucosal lesions of the stomach
or duodenum
o After studying the rugae, instruct the patient to drink the rest of the barium
mixture to observe the filling of the stomach and further examine the
duodenum
- The following can be accomplished by using single-contrast examination:
a. Determine the size, shape, and position of stomach
b. Examine the changing contour of the stomach during peristalsis
c. Observe the filling and emptying of the duodenal bulb
d. Detect any abnormal alteration in the function or contour of the esophagus,
stomach, and duodenum.
e. Take spot films as indicated

 The contrast medium normally begins to pass into the duodenum almost
immediately. However, nervous tension may delay the transit of the contrast
material.
 Fluoroscopy is performed with the patient in upright or recumbent position while
the body is rotated and the table is angled so that all aspects of the esophagus,
stomach, and duodenum are demonstrated.
 Susbsequent radiographs of the stomach and duodenum should be taken
immediately after fluoroscopy before the barium mixture passes through the
duodenum.

2. Double-contrast Examination
- Its principal advantage over single-contrast examination is that small lesions are
less easily obscured and the mucosal lining of the stomach can be more clearly
visualized.
- Uses both positive and negative contrast media
- The following steps are observed for this study:
o Patient is placed in upright position
o Give the patient a gas-forming substance in the form of a powder, crystals,
pills, or a carbonated beverage. (An old method involved placing pinholes on
 the sides of the straw to that the patient can ingest air while drinking the
barium mixture.)
o For even coating of the stomach walls, the barium must flow freely and have
a low viscosity.
o Place the patient in recumbent position and instruct him/her to turn from side
to side or roll over a few times. This movement serves to coat the mucosal
lining of the stomach as the carbon dioxide continues to expand.
o Instruct the patient not to belch or burp until the end of the examination to
ensure optimum amount gas remains for the duration of the examination.
o Before the procedure, the patient may be given glucagon or other anti-
cholinergic medications to relax the GI tract. Before administering these
agents, the radiologist must consider several factors, including side effects,
contraindications, availability, and cost.

3. Biphasic Examination
- Both single-contrast and double-contrast examinations are performed on the same
day.
- The patient first undergoes double-contrast examination.
- Upon completion of the double-contrast examination, the patient is given a 15%
weight/volume suspension so that the single-contrast examination can be
performed.
- This approach increases the accuracy of diagnosis without significantly increasing
the cost of the examination.

 weight/volume- amount of substance dissolved in a measured quantity of liquid

4. Hypotonic Duodenography
- Method for showing duodenal anatomy without interference from peristaltic
activity. It involves duodenal intubation, drug-induced atony (uses certain drugs
to weaken the strength of muscles), and visualization with barium and air
- The use of this method has decreased since lesion beyond the duodenum is can
be demonstrated using double-contrast examination. When pancreatic disease is
suspected, CT or needle biopsy can be used.

Two Methods of Administering the Contrast Media

1. Double Meal Method
- The patient is required to bring home with a glassful of barium mixture and to be
ingested 5 hours prior to the examination. The second meal is being administered
during the examination.
- The disadvantage lies in the fact that there will be superimposition between the
filling of the small intestine and the stomach.
 2. Single Meal Method
- The barium mixture is administered during the actual examination.
- This is the method that is frequently employed.

Two Methods of Study Employed in UGIS

1. Overhead or Conventional Method
- This is the most frequently employed because it is less hazardous both to the
patient as well as the radiographer.
- Takes longer since delayed radiographs are to be taken to ensure filling of the GI
tract
2. Fluoroscopy and Overhead Technique
- This is more hazardous since it uses fluoroscopy, however, the length of time of
the examination is considerably reduced.
- This is also employed when taking spot filming or serial radiography for accuracy.

Ways in Determining the Reference Point for UGIS

1. By the use of SCOUT FILM
- First, trace the shadow of the stomach from the fundus down to the pylorus, then
from the pylorus, measure 4 inches to the left of it. This will be the reference point
of the stomach.
 A scout film is taken before the administration of contrast medium.
2. By utilizing two planes set at right angles
to each other
a. Addison’s Plane (transpyloric plane)
- Plane drawn transversely midway between the
manubrial notch and the upper border of the
symphysis pubis
b. Spine of the Scapula
- Plot the planes on the surface of the body of the
patient. Mark the intersection made by these 2
body planes (transpyloric plane and scapular
spine) and then measure approximately 4 inches
to the left. This will be the RP of the stomach.
3. Using imaginary line passing at the level of
the elbow joint and the right mammary
line. Get the intersection and measure 4
inches to the left of it.