GI Protocols Revised _8-09

Joshua P. Smith, M.D.
Cheri L. Canon, M.D.
UAB Department of Radiology
Revised August 2009
GUIDELINES FOR RESIDENTS IN
GASTROINTESTINAL RADIOLOGY
A
D
RRADIOLRADIOLOGY
The aim of the GI Radiology group at UAB is to provide complete and accurate studies performed in an
expeditious manner, attempting to minimize patient discomfort and delay. Achieving this depends to a large
degree on the motivation and consideration of the radiology resident. A professional and courteous manner in
your dealings with patients as well as the technical staff is an important part of your work, and you will be
evaluated accordingly.
The GI schedule begins promptly at 7:30 a.m. at University Hospital and Kirklin Clinic. You are expected to be
on time. Many of our patients have been fasting for several hours, so timely performance of studies is crucial. In
the hospital, it is helpful if you review the morning’s schedule and contact the referring clinician if there are
questions. Since studies in the hospital are seldom ready to begin at 7:30 a.m., you can preview and predictate the
abdominal radiographs from the “Unread ABD” list on the PACS.
It is standard procedure to review briefly each patient’s chart (hospital) as well as to elicit pertinent history from
the patient prior to the start of the examination. Four things should ALWAYS be determined:
1) Name on request and patient’s name coincide (check bracelet on hospitalized patients)
2) Patient’s symptoms
3) Related surgeries
4) NPO status/adequacy of bowel prep
In addition, it is wise for the resident to discuss a case with the staff radiologist if there are any questions. Always
review prior studies. This can be crucial in some cases, such as when you are about to begin a follow-up leak
study.
In some cases, examinations are ordered which are not actually needed, especially at the start of a new academic
year. For example, if a physician wants us to rule out the presence of hiatal hernia, it is not necessary for him to
order both a barium swallow and and an UGI. In such instances the resident may do the UGI and check for
gatroesophageal reflux. Check with the staff radiologists before canceling or adding on any study. If an additional
study is needed, such as a small bowel follow through after an UGI, the referring clinician must be contacted
before beginning the study so that an official order is obtained. This is a Medicare billing issue.
An attempt should be made to ascertain the possibility of pregnancy in any female patient of child-bearing
age. Radiation to the abdomen is particularly likely to be harmful between the second and sixth week postconception but unnecessary radiation should be avoided at any stage of pregnancy. You should inquire of the
patient, “Is there any possibility that you are pregnant?” If the answer is “yes” or if her menstrual period is
overdue, the patient can be sent to the lab for a urine pregnancy test. Alternatively if the procedure is elective, it
may be possible to postpone it until the onset of menses.
One of the responsibilites of the GI resident(s) is to transcribe the weekly GI Conference, which occurs at 4:30
p.m. on Wednesdays in the Tishler Conference room. The GI resident should take brief notes during the
conference and submit a transcription via email to Beth Parker (ecparker@uabmc.edu ), Dr. Canon’s Assistant.
Transcipts need to be completed by the Monday following the Wednesday conference. Residents can use voicerecognition dication system with a dummy request number to generate the report, and then cut and paste into a
word document. Dr. Canon will review the transcriptions and keep on file as part of our Quality Assurance
Program. It is the responsibilty of the GI resdient to find another resident to take notes during the conference if
they will be absent (vacation, meeting, etc.). If there are two GI residents, this responsibilty can be shared.
2
DON’T’S IN G.I. RADIOLOGY
DON’T
use a rectal balloon in a patient with known or suspected proctitis or rectal carcinoma. In our
patient population, proctitis is usually secondary to radiation therapy (cervical and prostate
carcinoma) or inflammatory bowel disease. Radiographically, the rectum may or may not be
nondistensible with loss of the normal rectal values of Houston and a granular mucosa
(Addendum A).
DON’T
inflate a rectal balloon except under fluoroscopic vision, after the rectum has been distended with
barium.
DON’T
do a barium enema examination in a patient with fulminant colitis or toxic megacolon.
Radiographically, the latter appears as a dilated colon, particularly the transverse colon, with loss
of the normal haustra and fold thickening (thumb printing).
DON’T
do a barium enema examination if a polypectomy has been performed in the last 7 days
(Addendum B).
DON’T
do a barium enema if free colonic perforation is suspected. Diluted water-soluble contrast
material (MD-Gastroview) is indicated.
DON’T
perform a rectal exam or use standard adult rectal tube in patients after J-pouch Surgery.
DON’T
give barium by mouth if a free perforation of the GI tract is suspected. Again, a water-soluble
agent is a better choice.
DON’T
begin a GI procedure in a woman of childbearing age without inquiring about the possibility of
pregnancy.
DON’T
leave an obtunded patient unattended or let them leave the radiology dept with contrast material
in their stomach. Aspiration of gastric contrast material is the most frequent cause of death
caused by fluoroscopic GI examinations.
DON’T
give orally more than 120 ml or 4 oz of undiluted MD-Gastroview.
NOTE: Water-soluble contrast media, such as MD-Gastroview, is usually supplied as 76%
solutions (66% meglumine diatrizoate and 10% sodium diatrizoate). The label states the
concentration of the drug itself. Don’t let this confuse you.
DON’T
give oral preparations of iodinated water-soluble contrast material to patients with known or
suspected aspiration or TE fistula. If a water-soluble contrast agent is desired, low-osmolar
intravenous contrast (e.g., Omnipaque) can be substituted.
DON’T
give barium by mouth to a patient who has or may have a colonic obstruction.
DON’T
vigorously insert or inflate the compression paddle under elderly patients or others with fragile
bones.
DON’T
use bicarbonate in patients after recent GI surgery.
DON’T
do a fistula or sinus tract study or a post-surgical study without a preliminary digital scout film of
the area to be studied. This should be obtained digitally.
3
FLUOROSCOPIC GI STUDIES
*
Conventional abdominal radiograph (KUB, flat and upright, lateral decubitus)
*
Barium swallow (esophagram) (BS)
*
Water-soluble esophagram
*
Modified barium swallow (with speech therapist) (MBS)
*
Upper GI examination (UGI)
*
Barium enema examination (BE)
*
Air-contrast or double-contrast barium enema examination (ACBE/DCBE)
*
Full-column or single-contrast barium enema examination (FCBE/SCBE)
*
Water-soluble contrast enema examination
*
Interactive small bowel follow-through (SBFT)
*
Fistulogram
*
T-tube cholangiogram
*
Enteral feeding tube placement
*
Endoscopic retrograde cholangiopancreatography (ERCP)
*
Tube check (PEG, PEJ)
*
Catheterogram
4
BRIEF OVERVIEW OF CONTRAST AGENTS
In general, there are two types of GI contrast agents: barium sulfate-based and iodine-based. The type of contrast
used should be determined by study requested and clinical history.
Barium sulfate is relatively inert, but it can incite an inflammatory response if spilled into the mediastinum or
peritoneal cavity with bowel contents. For this reason, a water-soluble agent is preferred if perforation is
suspected. Barium must be used cautiously when performing diagnostic enemas in patients suspected of having
mechanical obstruction of the colon. The single-contrast barium enema examination is useful in delineating the
site and nature of the obstructing lesion. Because of the danger of barium becoming inspissated above a colonic
obstruction, however, do not allow much barium to pass above a point of significant obstruction. If barium flows
freely through a narrowed area of the colon, in all likelihood it will pass just as freely in the other direction.
Barium is not contraindicated in small bowel obstruction, but an abdominal CT can demonstrate small bowel
obstruction, the point of transition, and concomitant pathology in a significantly shorter period of time.
Iodine-based contrast agents are water-soluble. There are high osmolality contrast media (HOCM) including
Reno-DIP (diatrizoate meglumine) among others, and low osmolality contrast media (LOCM) such as Omnipaque
and Isovue. LOCM include both ionic and nonionic compounds. All HOCM are ionic. The above named agents
are prepared for intravascular use, and are therefore sterile. MD-Gastroview and Gastrografin are HOCM (ionic);
they are flavored and prepared for enteric use and are not suitable for parenteral injection. Their use is limited to
the lower GI tract (water-soluble enema examination, PEJ (not PEG) studies). All other water-soluble studies
should incorporate LOCM.
HOCM can cause bronchospasm, pulmonary edema, pneumonitis, even death, and is contraindicated in
patients at risk for aspiration or with a tracheoesophageal fistula (TEF). In our adult patient population TEF
usually results from esophageal carcinoma. LOCM (Omnipaque 350, 50-100 mL) can be used more safely in
these patients. Also remember, the risk of aspiration of refluxate in obtunded patients after performing any
contrast study of the UGI tract. Residual contrast should be removed from the stomach via an NG tube in these
patients.
Gastroview and Gastrografin are limited in the volume that can safely be administered orally, 120 ml’s (4 oz).
Volumes higher than this can drastically alter fluid balance. These agents are hyperosmotic and draw fluid into
the bowel lumen. This is particularly a concern in dehydrated, elderly patients and in infants. These types of
agents are used only for evaluation of lower GI tract (water-soluble enema examination, PEJ (not PEG) study).
A final consideration is allergic or idiosyncratic reactions to iodinated contrast agents. These reactions, which are
life threatening, have been documented with intravascular iodinated contrast administration and are volumeindependent. Small amounts of water-soluble contrast can be absorbed by the GI mucosa into the bloodstream. If
significant mucosal inflammation is present, an even larger amount of absorption takes place. Therefore, history
of anaphylactoid reaction to iodinated agents is a contraindication to their administration enterally as well as
parenterally. Such procedures include cholangiograms, urethrograms, cystograms, conduitograms and
pouchograms. Thus, patients scheduled for such procedures should be screened for known risk factors for
contrast reactions (Addendum C), and resuscitation materials kept in close proximity.
5
BARIUM PRODUCTS
“Thick”
(Double-contrast BS, UGI)
Maxibar (TKC)
E-Z-HD (UH)
210% w/v
250% w/v
80% w/w
98% w/w
“Thin”
(Single-contrast BS, UGI, BE)
Liquid E-Z-Paque
60% w/v
41% w/w
SBFT
Enterobar (preferred)
50% w/v
DCBE
Liquid Polibar Plus
105% w/v
56% w/w
IODINE PRODUCTS
High Osmolar
Cysto-Conray II(Iothalamate
Meglumine)
MD Gastroview(Diatrizoate
Meglumine)
300-349 mg/ml
Urinary tract studies only
367 mg/ml
Water soluble lower GI tract
and PEJ tube studies only
Low Osmolar
Omnipaque (UH)*
Isovue (TKC)
350/300/240/180
300
*240 for myelography, 180 for cavernosograms
PATIENT POSITIONING (Relative to top of fluoro table)
Supine
Left posterior
Right posterior
AP
oblique LPO
oblique RPO
(on back)
Prone
Left anterior
Right anterior
PA
oblique LAO
oblique RAO
(on abdomen)
Left lateral
LLD
(left side down)
Right lateral
RLD
(right side down)
6
BARIUM SWALLOW/ESOPHAGRAM (BS)
The two most common indications for a barium swallow are dysphagia and odynophagia. An upper G.I. (UGI) is
indicated for most other symptoms. Particularly in patients with symptoms of gastroesophageal reflux (GER) such
as “heartburn” or epigastric pain, an UGI should be performed because these symptoms could be secondary to
ulcer disease, not just GER. We test for GER during both a BS and UGI. A biphasic study (combined double- and
single-contrast images) is usually performed for both BS and UGI.
BARIUM SWALLOW: Summary of Technique
Patient Preparation:
NPO for a minimum of 2 hours
Materials:
1 packet EZ Gas II with 10 cc water
2 oz., E-Z-HD or Maxibar, 250% and 210% w/v, respectively (“thick barium”)
7 oz., Liquid E-Z-Paque Barium, 60 % w/v (“thin barium”)
12.5 mm barium tablet
Procedure:
1. Have technologist turn on recorder. Start with the patient erect and in lateral position facing you. Have
patient swallow one mouthful of thin barium, and watch it pass through the pharynx and entire esophagus
to exclude “gross obstruction”. Watch for aspiration, leak, stricture, obstruction, or delayed emptying. If
there is significant aspiration, the study should be discontinued at this point. (Take a lateral and AP spot
view of the pharynx to document extent of aspiration). If there are abnormalities suggesting achalasia
(dilated, nonperistaltic esophagus with obstruction at the lower esophageal sphincter, and a barium
column in the esophagus), please convert to Special Protocol in Achalasia Patients (below).
2. If all goes well, center the image intensifier over the pharynx and cervical esophagus and videotape three
consecutive single swallows of thin barium in the lateral view.
3. With the patient in the AP position, record the pharynx during three more consecutive swallows. Instruct
the patient to hold the cup of barium to the side of their face with the straw in the corner of their mouth
with their chin forward. In order to accurately evaluate for symmetry of swallow, the patient must be
centered, facing forward, without head tilt or turn.
4. Place the patient in erect LPO position. Give the packet of EZ Gas II with 10 ml water followed by 2 oz.
thick barium. Obtain 3 views of the air-distended thoracic esophagus using a 3-on-1 format on a 14X14
CR cassette or digitally without magnification. The first image should include the upper thoracic
esophagus. The other two should include the lower esophageal sphincter. When using CR cassette films
(GE fluoro tower), the “Full” button on the tower should be selected or inappropriate spot film
collimation will occur (see image below). While in digital mode, this button should be changed to
“MAN” (manual).
7
1. Standing LPO thoracic esophagus
(3:1, 14 x14 CR film).
5. Obtain AP and CR lateral air-contrast views of pharynx digitally using a 6” image intensifier (II) setting.
Instruct the patient to phonate a long “E”.
2. Standing AP pharynx
(digital, 6” II).
3. Lateral pharynx
(digital, 6” II).
6. Turn patient to face table in a RAO position (prone GI position) and lower table to horizontal.
7. Record three separate, single swallows of thin barium, following the tail of each peristaltic wave with the
fluoroscope. Watch emptying at the gastroesophageal junction (GEJ) junction, and make sure the image is
not magnified.
8. Position the fluoroscope over the pharynx/upper thoracic esophagus and record three swallows. Do the
same for lower esophagus/GEJ region. You may or may not need to administer additional barium
contrast.
9. Obtain three, nonmagnified digital views, single–contrast, barium-filled, thoracic esophagus. Center the
first on over the upper thoracic esophagus. Include the open lower esophageal sphincter (LES) on the last
2 views.
8
4, 5, 6. Prone RAO thoracic esophagus
(digital, 12” II).
10. Evaluate for reflux. At this point you should make an attempt to demonstrate GER unless already been
identified during the proceeding parts of the examination. Place the patient in the supine RPO position so
that the cardia is filled with barium. Observe the GEJ fluoroscopically while the patient performs a
Valsalva maneuver and coughs. If no reflux is elicited by this maneuver, watch while the patient rolls
unassisted from the supine to the right lateral position. The straining associated with rolling over will
often elicit reflux. A fourth maneuver that can be attempted is the water siphon test. Perform this test with
the patient in the supine RPO position and have the patient drink three swallows of water. The water
serves to clear the esophagus of any residual barium and the act of swallowing may trigger the occurrence
of reflux. Lastly administering water while the patient rolls to a decubitus position may elicit reflux. Be
sure to note in your report the following (It is helpful if you jot this information on the patient’s request at
the end of the study):
1) Maneuver eliciting reflux
2) Height of the refluxed barium
3) Time it takes for the esophagus to clear the refluxate
11. BARIUM TABLET. A 12.5 cm (38 Fr) barium sulfate tablet is given to patients with:
1) Dysphagia unexplained by the findings on the routine study (i.e., the study looks normal
fluoroscopically).
2) A stricture wide enough to warrant measurement to assess clinical significance. Tight strictures
need no tablet.
This size tablet is used because strictures less than 13 mm usually cause dysphagia in most patients.
Strictures ranging from 13 to 19 mm may or may not cause dysphagia. Remember, images on films are
magnified. Refer to conversion tables for measurements.
9
ALTERNATIVE BARIUM SWALLOW EXAMINATIONS
SINGLE-CONTRAST PHARYNGEAL SPOT FILMS are occasionally obtained to demonstrate cervical
esophageal strictures or problems with the cricopharyngeal sphincter. Change the film speed on the tower to
3-4/second. Instruct the patient to hold a mouthful of barium and swallow on the count of 3. Begin obtaining
exposures on “3”, or between “2” and “3” for fast swallowers. Try to limit radiation exposure with judicious
use of this.
VARICES: If the clinical question involves the possibility of esophageal varices, recording of the distal
esophagus can be helpful. Varices are best seen in the collapsed esophagus after passage of the primary wave
when the mucosa is coated with barium. High density mucosal barium is employed. When the distal
esophagus is distended with large volume of barium, the varices can disappear. Varices empty with the
passage of a peristaltic wave and slowly refill over the next few minutes. If your clinical suspicion is high and
you do not see varices on the initial collapsed views, try coating the esophagus with high density barium and
spot filming the lower esophagus after waiting 2-5 minutes from the time of the last peristaltic wave while the
patient avoids swallowing (patient may have to spit saliva into a cup).
WATER-SOLUBLE ESOPHAGRAM: The decision concerning the use of barium vs. a water-soluble
contrast relates to the likelihood of esophageal perforation and aspiration. For most esophageal problems, a
barium suspension should be employed. If the history suggests a perforation of the esophagus or if the patient
has recently had an esophagogastrectomy, a water-soluble contrast agent should be used. Other procedures
that can result in perforations and leaks include Zenker diverticulum repair and cricopharyngeal myotomy. If
no contrast extravasation is identified with the water-soluble contrast, then “thick” barium should be given;
barium suspensions have been shown to be more sensitive in detecting perforations. Also, in cases of
suspected aspiration, a sip of water should be given to the patient prior to initiation of the study to assess for
choking.
ACHALASIA: The patient begins in the standing LPO position. Fluoroscope for air-fluid level in the
esophagus and absence of a gastric bubble. While watching with video fluoroscopy, give thin barium until the
lower esophageal sphincter opens for the first time. Make sure patient is not aspirating. Then turn recorder
off. Obtain digital images of the esophagus at 1, 2, and 5 minutes, with times denoted on the films. All images
should be obtained at the same level of the esophagus, including both the gastroesophageal junction and
above the air-fluid column. Then study the pharynx in the lateral position, specifically assessing the
cricopharyngeal relaxation. Supine imaging and provocative testing for reflux are not necessary.
MODIFIED BARIUM SWALLOW is performed in conjunction with a speech therapist. Patients are
observed with video/fluoroscopy swallowing various substances, usually in the lateral position. Laryngeal
penetration and aspiration are noted. The pharynx can be studied in the AP position if a unilateral abnormality
is suspected (e.g., stroke patient).
NOTE: Of critical importance in any patient with DYSPHAGIA is the demonstration of the cause for the
symptoms before the patient leaves the fluoroscopy room. If the routine exam fails to show an abnormality,
the patient may be able to tell you what induces their symptoms. This may be eating a particular food in a
particular way. We make it a point to observe such patients fluoroscopically while eating or drinking the food
they suggest in the way they suggest. Some of our referring clinicians arrange to have their patients bring the
offending food (biscuit, fried chicken, apple, etc.) with them on the day of their barium swallow. If, however,
this situation was not anticipated prior to the patient’s arrival to the GI suite, the technologist in charge or the
patient can obtain food samples, (e.g., sausage biscuit from cafeteria).
10
UPPER GASTROINTESTINAL (UGI) EXAMINATION
The most common indications for an UGI include epigastric pain, anemia, heme + stools, symptoms of GER, or
suspect hiatal hernia. We perform a biphasic (combined double-contrast and single-contrast) technique in most
patients. A single contrast or modified study is often needed in the following clinical situations:
Obtunded or immobile patient
Food or fluid in stomach; gastric distension (gastric outlet obstruction)
Post-surgical patient
Patient with NG tube
Upper GI: Summary of Technique
Patient Preparation:
NPO after midnight
Materials:
1 packet of EZ Gas II with 10 cc water
2 oz., E-Z-HD or Maxibar, 250% and 210% w/v, respectively (“thick barium”)
5 oz., Liquid E-Z-Paque Barium, 60% w/v (“thin barium”)
12.5mm barium tablet (optional)
Procedure:
1.
Patient standing, fluoro abdomen. Look for four things:
1) Full stomach
2) Bowel obstruction
3) Free air
4) Barium in small bowel or colon overlying UGI tract
2.
Place the patient in erect LPO position. Give EZ Gas packet with 10 ml water followed by 2 oz. “thick”
barium. Obtain 3 views of the air-distended thoracic esophagus using a 3-on-1 format on a 14X14 CR
cassette without magnification. The first image should include the upper thoracic esophagus. The other two
should include the lower esophageal sphincter. While obtaining CR images, the “Full” button on the tower
should be selected. While in digital mode, this button should be changed to “MAN” (manual). Quickly tilt
table down to horizontal before barium enters duodenum.
1. Standing LPO thoracic
esophagus
(3:1, 14 x14 CR film): first
image should center on
upper thoracic esophagus.
Next two should include the
lower esophageal sphincter.
11
3.
To coat stomach, roll patient through left lateral to prone position and back through left lateral to supine to
coat stomach. Two rolls may be necessary. (Roll to right lateral briefly only if necessary to obtain good
antral coating.) Check the lesser curve of the stomach for adequate coating. This is usually the last portion
to get coated with barium.
4.
Obtain air-contrast digital spot images in the following positions with the image intensifier setting shown.
Note, the remainder of the images should be obtained digitally.
2. LPO stomach
(9” II): This view provides
detail of the body and
antrum.
5.
3. RPO stomach
(9” II): (Check for reflux at
this time.) This view is
optimized for the lesser
curve.
4. Lateral stomach
(12” II): This view assesses
the gastric cardia (“rosette”)
and fundus as well as the
anterior wall of stomach.
Roll the patient into the left lateral decubitus position to empty the duodenal bulb. Then roll the patient
slightly back, stopping at the LPO position.
12
6.
Obtain the following spot images:
5. LPO antrum
(4.6 or 6” II).
7.
6. LPO antrum
and bulb
(4.6 or 6” II).
7. LPO bulb
(4.6 or 6” II).
8. LPO bulb
(4.6 or 6” II).
Place the table in the erect position and obtain a 6” or 9” II view of the fundus
with patient in LPO position.
9. Erect LPO fundus
(9” II).
8.
Turn patient around to face table and tilt down to horizontal, patient in prone RAO (GI position). First
observe esophageal peristalsis by watching two separate single swallows of thin barium. Obtain three,
nonmagnified views, single-contrast, barium-filled, thoracic esophagus digitally. Center the first on the
upper thoracic esophagus. Include the open LES on the last 2 views.
13
10, 11, 12. Prone RAO thoracic esophagus
(12” II).
9. Place compression paddle under patient. Obtain 3 or 4 digital images (4.5” or 6” II) of the antrum and
duodenum. Make sure compression is adequate so the barium is “see through.” To obtain adequate
compression in both regions, the paddle will have to be moved from the duodenum to the antrum in most
patients. Do not “drag” the paddle under the patient. Have them lift or “push-up.”
14
10.
Final 3 images should include as much of the stomach, duodenum, and small bowel as possible:
16. Prone RAO (12” II).
11.
17. Prone (12” II).
Roll through left lateral to supine. (If the earlier air-contrast views of the duodenal bulb were suboptimal,
another view can be obtained at this time before placing the patient supine).
18. Supine (12” II).
12.
Check for GER (see page 10) unless reflux has already been observed.
13.
If there is a question of distal esophageal stricture, give the patient a 12.5 mm barium tablet while in the
erect position.
14.
Jot reflux notes and other abnormal findings on patient request sheet.
The esophagus is certainly part of the upper gastrointestinal tract. While we do not take films of the entire
esophagus and pharynx with every UGI, a careful fluoroscopic look at the esophagus is indicated on every study,
especially if the patient has symptoms that relate to swallowing. If the patient complains of dysphagia,
odynophagia or a lump in the throat, discuss with your attending the possibility of adding on an esophagram, even
if only an upper GI was requested. Non-radiologists often have an unclear picture of the area emphasized in a
barium swallow vs. an upper GI series. We should always be on the lookout for situations where altering or
augmenting an examination may be to the patient’s benefit.
15
It should be remembered that when a barium swallow is combined with an UGI, the erect portion of the videotape
study (pharyngeal motility) should be performed last, after all films of the stomach have been obtained. Otherwise
excessive amounts of barium in the stomach will diminish the value of the UGI study.
A few words about dismissing the patient are in order. The GI attending will be involved in most of the decisions
regarding the extra spot films, additional work-up needed, and patient dismissal during your first month on GI.
However, the resident needs to quiz him/herself about these issues to develop skill in the art of declaring a study
finished. This is an important decision with outpatients especially, since they may not be able to come back to the
department in the case of an early departure. For out-of-town patients, it is crucial to check all the films and arrive
at the conclusion of the radiographic evaluation prior to letting the patient go. Important areas to evaluate are the
number and quality of spot films and overheads; critical examination of problem areas which often require
fluoroscopy to allow distinction of normal vs. pathologic; radiographic technique; and finally, does the study
answer the clinical question. Challenge yourself to go through this process even though the attending does it as
well. It is a critical step in GI radiology.
16
CONTRAST STUDIES OF THE SMALL BOWEL
The most common indications for a small bowel study are Crohn disease (known or suspected), abdominal pain,
and heme + stools and/or anemia. In the majority of cases, CT enterography is preferred over small bowel series.
The small bowel series performed at our institution is interactive with careful fluoroscopic evaluation. We do not
rely solely on the overhead radiographs, which improves examination sensitivity.
We use six methods for examining the small intestine radiographically:
1)
2)
3)
4)
5)
Interactive small bowel series
Small bowel follow-through after UGI series (SBFT)
Peroral pneumocolon
Small bowel study through indwelling tube
Water soluble contrast small bowel study (rarely)
Interactive Small Bowel Series: Summary of Technique
Patient Preparation:
NPO after midnight
Materials:
16 oz., Enterobar
Procedure:
The conventional small bowel examination is done with fluoroscopic evaluation, digital spot films and overhead
films. The overhead films are done with the patient prone to minimize radiographic magnification and
unsharpness. The diagnostic yield of the examination is clearly related to the skill and effort that goes into
the fluoroscopy. It is not enough to simply obtain films every 30 minutes and hope to spot the abnormality at the
viewbox.
1.
A scout radiograph is obtained by the technologist, particularly when there is a question of bowel
perforation or mechanical obstruction.
2.
Give 16 oz. of Enterobar by mouth. If the patient is having an UGI first, Enterobar is substituted for the
thin barium portion of the examination. Start the time clock when the patient begins drinking the barium.
Have all overhead films marked with clock time and time elapsed since the beginning of the examination.
3.
Obtain a 15-minute prone overhead radiograph.
4.
Study each film as it is taken. Additional overheads are obtained at roughly 30-minute intervals, but the
spacing needs to be adjusted to fit the rate of progress of barium through the bowel. Ideally, there will be
three or four overhead films per study.
5.
Also check each film to determine the best times to fluoroscope the patient. Two or three trips should be
made to the fluoroscopy room, at least one when the jejunum is well filled and one when the ileum is well
filled.
6.
Watch the rate of gastric emptying. Patient can drink other liquid (coffee, soda, etc.) if transit is slow, but
the stomach is empty.
7.
Once barium has reached the ascending colon and the terminal ileum is well filled, fluoro and digitally
spot the terminal ileum.
17
8.
In some cases of abdominal pain in inpatients, early spot films may show signs of obstruction. In these
cases, the patients may return to the floor and have serial abdominal images obtained at several hour
intervals to evaluate transit time.
18
MODIFIED SBFT
SMALL BOWEL FOLLOW-THROUGH (SBFT) AFTER AN UGI: This study is conducted in a fashion
similar to the conventional small bowel series. During the UGI series the patient will have been given 7 oz of
barium to drink. For the small bowel follow-through, give another 8 oz of the Enterobar and obtain the first
overhead small bowel film 15 minutes later.
PERORAL PNEUMOCOLON: This is an examination of the right colon and distal ileum. It produces very
detailed images of the distal small bowel in most patients. The study begins as an interactive small bowel series.
Once barium has reached the hepatic flexure or mid ascending colon, an enema tip is used to insufflate air per
rectum. Once the right colon and distal ileum are distended with air, digital spot films and sometimes overheads
are obtained. When you see findings in the terminal ileum on a conventional small bowel series which need
further clarification, this is a good way to augment the study and get a more detailed look.
WATER-SOLUBLE SMALL BOWEL STUDY: As useful as water-soluble contrast material is in the colon
and upper GI tract, it has relatively few applications in the small intestine. When iodinated contrast material is
given by mouth, it becomes sufficiently dilute in the small bowel, particularly if obstruction is present, that films
of the small intestine are usually not of sufficient quality to permit diagnostic evaluation. It is possible to
determine whether or not contrast eventually reaches the colon, but anatomic detail is usually not recognizable on
an examination performed in this way.
19
CONTRAST STUDIES OF THE COLON
Contrast studies of the colon can be performed in three standard ways: double-contrast barium enema (DCBE),
single-contrast barium enema (SCBE) and water-soluble contrast enema. Water-soluble contrast medium is used
whenever a colonic perforation is suspected. It is also used when it is necessary to study the portion of the colon
which lies proximal to a relatively high grade mechanical obstruction, so that barium does not become
inspissated.
The routine enema we perform is the DCBE. This examination is more sensitive for detection of polyps than is
the SCBE, which is especially important in patients over age 50, those with occult blood loss, and those with
suspected carcinoma, polyps, or colitis. SCBE is preferred, however, in certain situations, such as in patients in
whom a colonic obstruction is suspected. The demonstration of colonic fistulae such as in patients with
diverticulitis or recto-vaginal or rectovesical fistula is often best demonstrated by the single-contrast technique.
The DCBE requires that the patient lie prone during much of the examination. For this reason, the alternative
single-contrast study is preferred in patients who are unable to lie prone because of a recent or open surgical
wound or in patients whose mobility is restricted by severe arthritis, plaster casts on the extremities, etc. We
usually do a single-contrast study in patients over 70 or 75 years of age, depending upon their mobility.
Regardless of the type of enema to be performed, remember to briefly review the patient's history and indications
for the study. Be careful that you detect patients in whom colonic perforation, toxic megacolon, or fulminant
colitis are likely possibilities before you begin the exam. These are contraindications to performing a barium
enema. In cases of DCBE following incomplete colonoscopy, confirm (if necessary through direct communication
with the endoscopist) that no biopsy or polypectomy was performed during the colonoscopy. These patients
should return no sooner than seven days for their DCBE (Addendum B).
DOUBLE CONTRAST BARIUM ENEMA(DCBE)
Summary of Technique
Patient Preparation: (Instructions given to patient)
Day before barium enema:
1.
Eat no solid foods after 10:00 a.m.
2.
For lunch, take only clear liquids as listed below. NO FOOD.
3.
At 1:00 p.m. drink one full glass of water (8 oz.).
4.
At 3:00 p.m. drink one 10 oz. bottle of the Magnesium Citrate laxative. It's better chilled.
5.
At 4:00 p.m. drink one full glass of water
6.
For supper, take only clear liquids. NO FOOD.
7.
At 6:00 p.m. take the 3 laxative tablets you were given. Swallow them whole with at least one glass of
water or other clear liquid.
8.
At 8:00 p.m. drink one full glass of water.
9.
At 10:00 p.m. drink one full glass of water, Gatorade or a carbonated soft drink.
Day of barium enema:
1.
At 6:00 a.m. drink one full glass of Gatorade, apple juice or carbonated soft drink.
2.
If you are taking daily prescribed medications, take them as usual.
Materials:
Liquid Polibar, undiluted (E-Z-EM, Inc.)
Enema bag with 0.5 inch I.D. tubing and “Miller” tip with end-hole and 8 side holes
Glucagon, 0.5-1.0 mg, (if needed for spasm)
20
Procedure:
1.
A routine scout radiograph is not obtained at the Kirklin Clinic. If the patient reports to you or the
technologist that his or her bowel movements are still formed or semiformed, a scout radiograph to
determine adequacy of the bowel prep may be prudent. Examine the scout film carefully. Decide whether or
not the colon is sufficiently well prepared to allow you to proceed. In most circumstances, the patient
should receive another day's colonic preparation before the enema is done if stool is present in the colon.
Until you gain experience in how much stool or barium will preclude an adequate examination, ask the staff
radiologist to help you decide whether or not to reschedule.
2.
Next, do a careful rectal examination. Early in your experience, this will be helpful in orienting you to the
proper direction of the anal canal and rectum (these two portions of the GI tract usually lie at right angles to
one another) as a guide to inserting the enema tip. In addition, you should be able to detect the presence of a
rectal mass or stricture and can decide whether or not there is stool in the rectal ampulla. Insert the enema
tip with the patient in the left lateral decubitus position with knees drawn up toward the chest. Roll patient
to prone position and tape buttocks together tightly and tape tube in place. Turn on barium.
3.
Start with patient prone. Turn on barium. Tilt head of table down to speed flow of barium. You will also
want to squeeze the bag to get the viscous barium to flow fast enough. However, remember patient
tolerance is inversely proportional to the rate of rectal distension.
4.
Turn off barium when column reaches distal transverse colon (proximal transverse if colon is unusually
long and tortuous). This may require the addition of more barium into the enema bag in patients with a
redundant colon.
5.
Tilt table erect and place enema bag on floor to drain rectum. Clamp the tube after draining.
6.
Tilt table head down and place patient in prone RAO position. Gradually and continuously pump air into
colon.
7.
As barium column reaches proximal transverse, bring table up to horizontal and place patient in right lateral
position. Keep pumping air.
8.
As barium reaches hepatic flexure, roll patient to supine RPO. Keep pumping air.
9.
As barium enters ascending colon roll patient supine, left lateral decubitus, and prone.
10.
If there is barium left in the rectum, place table erect and drain it again and redistend rectum with air.
11.
Check one last time to make sure colon is well distended.
NOTE: When an unusual amount of colonic muscular spasm prevents filling of the colon and causes the patient
to experience undue cramping, it is helpful to administer (0.5-1.0) mg of Glucagon (Addendum C).
12.
Obtain the following digital spot radiographs:
21
1. Prone rectum
(9” II): Make sure no
residual pooled barium. If
there is, stand patient
again and drain.
13.
2. Right lateral
rectum (12” II):
Make sure acetabuli
are superimposed.
3. LPO sigmoid
(9” or 12” II):
After turning prone
to left lateral.
4. RPO sigmoid (9” or
12” II): If the sigmoid
is redundant, may need
additional spots.
Place table erect, spot both flexures. The cecum fills with barium now. Rare patients also need an erect
spot of the sigmoid.
5. RPO splenic flexure
(12” II).
6. LPO hepatic flexure
(12” II).
If the flexures are redundant, may need additional spots.
22
14.
To fill cecum with air, go to right lateral and tilt table down to horizontal, or head down if necessary, to
drain cecum. Roll back toward supine and spot cecum. If this does not adequately drain the cecum, roll the patient
supine, left lateral decubitus, prone, right lateral decubitus, and slowly down to supine (a complete 360˚ turn).
Then place in Trendelenburg position and spot.
7. Supine cecum
(9” II).
Make sure colon is adequately distended with air prior to leaving the room.
Overheads: (Obtained by the technologist)
1.
Supine (AP)
2.
Prone (PA)
3.
Prone sigmoid with 35˚ caudal angulation
4.
Right lateral decubitus
5.
Left lateral decubitus
NOTE: In rare instances when the cecum or ascending colon is inadequately studied with a double-contrast
technique, a repeat full-column enema may be necessary after the patient evacuates.
NOTE: In patients suspected of having Crohn Disease, a post-evacuation film may be helpful in assessing the
terminal ileum. Often, evacuation results in small bowel reflux.
23
SINGLE-CONTRAST (FULL COLUMN) ENEMA (SCBE)
Summary of Technique
Patient Preparation:
Same as for DCBE
Materials:
500 cc Liquid E-Z-Paque or Gastroview
Enema bag with 0.5 inch I.D. tubing and “Miller” tip with end-hole and 8 side holes
Glucagon, 0.5-1.0 mg, (if needed for spasm)
Procedure:
1.
Perform rectal exam.
2.
Insert enema tip. If anal sphincter tone is moderate to good, do not inflate the balloon. If sphincter tone is
absent or if patient loses barium during the procedure, inflate balloon unless patient has rectal pathology
(Addendum A).
To inflate balloon, first distend rectum with barium with patient supine. While watching fluoroscopically,
add enough air to balloon to bring it near but not all the way to the lateral rectal walls.
Do not inflate a retention balloon in any patient with rectal narrowing, radiation proctitis, or
ulcerative proctitis.
NOTE: Balloon inflation may also be helpful with a double contrast technique. The same directions apply.
3.
Start Supine LPO. Add barium till column reaches descending colon.
4.
Stop barium and spot rectum AP and sigmoid LPO once adequately distended (spot in two or three different
oblique projections if long and tortuous). All spot images are digital.
1. Supine rectum
(9“ II).
2. LPO sigmoid
(9 or 12” II).
5.
Add barium till column reaches transverse colon. Stop barium.
6.
Turn to supine RPO and spot splenic flexure. Alternatively, splenic flexure may be spotted in steep LPO
if that looks best*.
24
3. RPO splenic flexure
(12” II).
7.
Add barium until column reaches ascending colon. Stop barium.
8.
Turn to supine LPO and spot hepatic flexure*.
4. LPO hepatic flexure
(12” II).
9.
Add barium to fill cecum. It may help to turn table semi-erect. Stop barium as soon as terminal ileum begins
to fill.
10.
Use “banjo” paddle to obtain compression spot of cecum in supine or slight oblique position. If uncertain
whether cecum is well filled, turn patient prone and reassess.
11.
Examine the entire colon fluoroscopically while palpating it carefully with a gloved hand. It is helpful to
magnify the image while doing this (6” or 9” II setting). Check with your attending to see whether he or she
wishes to fluoroscope the colon with you. Most will.
Overheads:
1.
Supine LPO
2.
Left lateral rectum
3.
Supine AP
4.
Supine AP of sigmoid with 35˚ caudal angulation
5.
Post evacuation film
COLOSTOMY: If a patient with a diverting colostomy is sent for evaluation of the proximal portion of the
colon, a special technique must be employed to introduce the barium. There are various devices for introducing
barium through a colostomy stoma. A balloon on the end of a Bardex catheter can be inflated outside the patient.
The catheter tip is then inserted into the opening of the colostomy and the balloon is held against the skin of the
anterior abdominal wall by the patient's hand. Barium and air are introduced in retrograde fashion into the colon
and appropriate spot films are obtained. Alternatively, a plastic cone is available which will fit snugly into the
25
colostomy stoma. This also is held in place by the patient's hand. The staff radiologist will instruct you in the use
of these devices. Remember never to inflate a balloon of any type inside the colostomy stoma.
The distal limb of a colostomy can be studied either from the anus in standard fashion or from the colostomy
stoma using the methods just described. If a colonic leak is suspected in the postoperative period, water-soluble
contrast material should be used.
26
POSTSURGICAL PROCEDURES
We are often asked to evaluate post surgical patients. Examinations should be modified based upon the surgery
and clinical concern. Remember to not administer bicarbonate to patients after recent GI surgery (e.g., gastric
bypass, gastrectomy, etc.). In order to avoid certain pitfalls, a few procedures warrant discussion.
T-TUBE CHOLANGIOGRAM: SUMMARY OF TECHNIQUE
This study is most commonly performed in patients post liver transplant or post hepatico- or
choledochojejunostomy.
Preparation:
None needed unless referring clinician decides to administer prophylactic antibiotic. All transplant patients
receive oral antibiotics 1 hour prior to the study. Confirm this before beginning.
Contrast:
Sterile, injectable, ionic iodinated contrast material is used in most patients, typically Isovue in appropriate
dilution:
*Undiluted in liver transplant or other post-surgical patients with small caliber bile duct.
*40%-60% when looking for extravasation.
*15-20% when looking for calculi in a very dilated bile duct (over 1.5 cm).
Procedure:
1.
Obtain digital scout image (12” II).
2.
Inject contrast via tube using sterile technique. Be careful not to allow air bubbles to enter the duct if there
is a question of stones.
3.
Obtain a spot film after the first few ml. of contrast enters the duct to show initial pattern of flow or early
leak.
4.
Obtain AP and both oblique views of the duct. It helps to expose while injecting.
5.
Obtain one magnified view of the anastomosis.
27
PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE) STUDY:
SUMMARY OF TECHNIQUE
Whipple's operation is most often performed in patients with ductal adenocarcinoma of the pancreas. The
duodenum, part of or entire pancreas, and distal common bile duct are resected. The common bile duct, pancreas,
and proximal duodenum are anastomosed to a loop of jejunum, Roux-limb:
Pancreaticojejunostomy
Choledochojejunostomy
Duodenojejunostomy
Fig 1: Pylorus-preserving Whipple
Preparation:
NPO
Contrast:
50-100 cc Omnipaque or Isoview
Procedure:
1.
Perform t-tube cholangiogram as above, evaluating for choledochojejunostomy anastomotic patency and
lack of extravasation.
2.
A modified UGI is then performed using LOCM through the in dwelling NG tube. Again,
duodenojejunostomy patency and lack of extravasation are determined.
REMEMBER, these patients are postsurgical and may have delayed gastric emptying; residual contrast should be
removed from the stomach before the patient is sent to the floor to reduce the risk of aspiration.
28
POUCHOGRAM: SUMMARY OF TECHNIQUE
Another surgical procedure we occasionally see (usually in the outpatient setting) is the total proctocolectomy
with ileal pouch and ileo-anal anastomolis (J-pouch) after total proctocolectomy for ulcerative colitis or familial
polyposis. These patients undergo radiologic evaluation of the J-pouch before the diverting ileostomy is closed,
approximately 8 weeks after the initial surgery. You are evaluating for contrast extravasation, stenosis of the
pouch, or obstruction proximally. Two important pitfalls to avoid:
NEVER perform a rectal examination on these patients!
DO NOT use the standard rectal tube! The anastomosis at the anus is usually stenotic, and if not handled
appropriately, can be torn with the finger. (The anastomosis will be gently dilated under anesthesia at a later
time).
Ileum
Pouch
Anus
Fig 2: J Pouch
Preparation:
None needed
Contrast:
Gastroview (4oz. Diluted with 8 oz water) in BE bag w/ tubing
Blue pediatric rectal tip or 14 Fr. red rubber catheter
Procedure:
1.
Insert blue pediatric rectal tip gently into the pouch via the anus.
2.
Obtain a digital scout film (12” II).
3.
Fill pouch until contrast refluxes out the right lower quadrant ileostomy.
4.
Obtain the following digital images centered over the pouch:
1)
2)
3)
4)
Supine (9“ II)
Both obliques (9 or 12” II)
Lateral (12” II)
Supine center over proximal ileum, including the ostomy
29
GASTRIC BYPASS: SUMMARY OF TECHNIQUE
Gastric bypass is the most common bariatric surgery performed at our institution. A pouch is formed from the
cardia of the stomach, and a jejunal Roux-en-Y limb is brought through the transverse mesocolon. A side
gastrojejunostomy is created between the pouch and jejunum.
Gastrojejunostomy
Rouxlimb
Stump
Gastric bypass surgery patients are challenging. They may exceed table weight limits (GE digital: 350 lbs.,
Philips: 400 lbs.). In this case, remove the footplate and have the patient stand on the floor.
Preparation:
NPO
Contrast:
Omnipaque or Isoview
Procedure:
1. Obtain digital scout film of left upper quadrant (12” II).
2. In a standing lateral position, have the patient swallow one swallow of water-soluble contrast and fluoro
the lateral pharynx. If there is no aspiration, place patient erect AP and have them drink a few swallows of
contrast, centering over left upper quadrant. Watch for emptying and extravasation. Table spot image over
pouch.
3. If possible, place patient supine. Obtain 3 to 4 digital spot images of the gastric pouch and Roux-limb in
several obliquities. Do not magnify these images as most patients are so large that exposure time would
be long and result in motion artifact.
4. Have technologist obtain a 10-minute film of the upper abdomen to confirm contrast emptying into the
distal jejunum, beyond where the Roux-limb courses through the transverse mesocolon.
These are not aesthetically pleasing studies because of body habitus, but they can usually answer the two
clinical questions:
1.
2.
Is there a leak? This usually occurs at the gastrojejunostomy anastomosis or the blind jejunal stump.
Is there obstruction? Usually at gastrojejunostomy, as the Roux-limb traverses the mesocolon, or at
the jejunojejunostomy.
30
TUBE CHECK
Requests for evaluation of percutaneous gastrostomy and jejunostomy tubes are common. These are typically
to confirm correct tube placement and evaluate for leaks.
Preparation:
None
Contrast:
Omnipaque or Isovue
Procedure:
1.
Obtain digital scout image of upper abdomen, centered over tube.
2.
Inject 1-2 oz. LOCM through tube (usually with catheter-tip syringe).
3.
Obtain a true lateral view including the anterior abdominal wall and tube during injection.
4.
Obtain a supine view documenting contrast within the lumen of the stomach jejunum.
5.
Spot image demonstrating gastric emptying across the pylorus OR contrast in the small bowel
immediately distal to the tube tip.
6.
Always remove excess contrast (withdrawal into syringe) when possible to reduce the risk of reflux
and subsequent aspiration.
*On portable studies done on ICU patients, a lateral view may not be included. When dictating these reports,
always note in the report that an anterior leak cannot be excluded.
CATHETEROGRAM
Occasionally you may be called upon to troubleshoot malfunctioning central lines, tunneled catheters and
port-catheters. Problems include fracture of the catheter, kinking, thrombus at the tip of the line and
disconnected tubing.
Preparation:
Wipe hub with alcohol before injecting
Contrast:
Ominpaque or Isoview
1.
2.
3.
Procedure:
Obtain digital scout film of the area, including the entire length of the catheter in question.
Observe fluoroscopically while injecting and take spot images if a leak or other abnormality is detected.
Obtain images/observe injections under fluoroscopy in multiple obliquities if necessary. The technique
will vary greatly as to the problem. You may need to inject 10-20 cc of contrast under pressure with an
extension tubing to adequately opacify high flow veins (such as the SVC) to obtain diagnostic images
showing thrombus at the catheter tip, etc.
These are troubleshooting cases and a wide variety of causes of catheter dysfunction will be encountered.
Remember, ask the patient what they think the problem is, they often can help pinpoint the issue.
31
EVALUATION OF POST ESOPHAGECTOMY
(IVOR LEWIS GASTRIC PULL-UP)
Preparation:
Patient typically fasting, but not an absolute requirement.
Contrast:
40-50 cc Omnipaque or Isoview
40-50 cc High density barium
Procedure:
1. Give 40-50 cc contrast initially with patient standing (AP or RPO); then supine (AP, LPO, RPO).
2. If no leak, give 40-50 cc high-density (thick) barium by straw or catheter-tip syringe (AP, LPO, RPO).
3. Final image of stomach and filled small bowel. If no gastric emptying, take a delayed overhead
radiograph @ 20 minutes (from initial administration of contrast). If still no emptying, take a final
overhead radiography @ 40 minutes.
32
ADDENDUM A: Dr. Morgan's Top 5 Things Regarding Radiation Colitis
1.
2.
3.
4.
5.
NEVER inflate the rectal balloon in a patient who has received pelvic radiation.
Pelvic radiation is usually seen in patients with cervical or prostate carcinoma.
Barium enemas are rarely performed during the acute phase (first week after radiotherapy). Findings
would include spasm, edema, and granular mucosa.
Barium enema in chronic radiation damage reveals a smooth, featureless mucosa with absent valves of
Houston and a narrowed lumen.
The etiology of radiation colitis is progressive destruction of colonic microvasculature.
ADDENDUM B: Waiting periods before enema examination or CT colonography after endoscopic colonic
biopsy:
Barium enema examination and CT colonography should be delayed for at least seven days after:
• Forceps biopsy of colon through rigid proctoscope or anoscope
• Polypectomy (rigid or flexible scope)
• Any biopsy or polypectomy using electrocautery (“hot” forceps)
Same day barium enema examination and CT colonography are acceptable after colonoscopic biopsy of the
surface of a colonic mass (carcinoma or large polyp) without electrocautery if the patient has no clinical signs of
perforation.
While not our routine practice, at the radiologist’s discretion a barium enema examination or CT colonography
may be performed on the same day as a biopsy of a flat area of colonic mucosa performed with colonoscopic
biopsy forceps without electrocautery. Use caution in making this decision as occasional “superficial” biopsies of
this type do extend into the muscularis propria and therefore confer some risk.
ADDENDUM C: Glucagon
Glucagon is an endogenous hormone produced by pancreatic islet cells. In addition to its role in glucose
metabolism, is an antispasmotic of smooth muscle. It causes transient hypotonia of the stomach, duodenum, small
bowel, and colon. It does not alter esophageal motility, but it decreases lower esophageal sphincter pressure.
It is indicated in UGI studies in patients with partial gastric resection. It is also helpful in barium enema
examination when there is pain, spasm or increased colonic tone, manifest as inability to retain barium.
Contraindications to glucagon administration include pheochromocytoma, insulinoma, and insulin dependent
diabetes. It can cause severe hypertension secondary to catecholamine release by a pheochromocytoma and
hypoglycemia secondary to insulin release by an insulinoma. It causes hyperglycemia, but is probably safe to
administer to diabetic patients taking oral hypoglycemics if badly needed. Its effect should be explained to the
patient, so they can monitor their glucose level after completion of the study.
Glucagon must be mixed before it is injected. Dose ranges from 0.1-1.0 mg (1.0 mg=1cc=1 unit dose). Standard
dose for BE is 0.5-1.0 mg and 0.15 mg for UGI. It is injected intravenously with a 26g needle. Alternatively, it
can be given intramuscularly or subcutaneously. It can cause nausea and vomiting if a full mg is given rapidly.
This risk is decreased with slower injection and smaller doses. If unable to obtain IV access, it can be injected
intramuscularly or subcutaneously. See package insert.
Dose
0.5 mg
1.0 mg
Route
IV
IV
IM
Onset
1 min
1 min
8-10 min
Duration
9-17 min
22-25 min
12-27 min
33
Addendum C