PEDS - ON CALL

Pediatric Fluoroscopic Exam
(Quick Reference)

Infant UGI

Refer to handout

1. Preparation: NPO for 3 hours

2. Materials:

        a. Chux under patient

        b. 4 oz bottle and nipple, or patient's regular bottle and nipple

        c. Routine single contrast liquid barium or aqueous contrast (Omnipaque 180 in infant) (aqueous contrast preferred in patients who may potentially go to the OR)

3. Shield table

4. Infant restraining device

5. Film sequence

    a. Preliminary AP supine chest/abdomen on one film. Obtain left lateral decubitus radiograph of abdomen as needed.

    b. Fluoroscopic portion of examination:

        i. Minimize radiation exposure by using “pulsed” fluoro, keeping the tower as close to the patient as possible, collimating as tightly as possible, and using a “tap” fluoro technique. Take advantage of the last image hold feature to examine the image without prolonged exposure!

        ii. Minimize radiation exposure by obtaining saved spot images and reserve actual spot filming for images in which it is determined that more definition is necessary to maximize detail as well as to clarify confusing fluoroscopic findings.

    a. To evaluate the esophagus:

        i. Place infant into straight left lateral decubitus position.*

        ii. Observe and image first swallow in the left lateral projection.

            1. Evaluate the swallowing mechanism.

           2. Look for evidence of nasopharyngeal reflux, laryngeal penetration, and tracheal aspiration

        iii. Evaluate esophageal peristalsis.

        iv. Look for position of esophagus, vascular rings, strictures, varices, mucosal abnormalities, hiatal hernia.

        v. Turn infant into supine position and evaluate esophagus 

        vi. Do not allow the patient to drink too much contrast as the overdistended contrast filled stomach may obscure the C-loop and interfere with the evaluation for malrotation!!!!!

* Please note that if you begin the examination with the patient in a right lateral decubitus position that you must be very careful not to miss imaging the C-loop and the duodenal-jejunal junction, as gravity will hasten it to fill out more quickly in this position.

b. To evaluate for malrotation (must call pediatric radiologist on call to review the history and the preliminary scout films:

          i. Turn the baby RPO or, if necessary, prone oblique with right side down, in relationship to the table.

          ii. As soon as the first and second parts of the duodenum are visualized, turn the infant into an absolutely straight supine AP position and obtain an image of the entire C-loop including the region of the ligament of Treitz. The duodenal-jejunal junction should be to the left of the spine at the level of the duodenal bulb, at about the level of L1.

          iii. Be sure to open up the shutters over the lower chest so you can see the cardiac silhouette and the rib case in order to be certain that the baby is absolutely straight, as patient rotation can lead to an error in assessing the position of the duodenal-jejunal junction (ligament of Treitz).

c. To further evaluate for hiatal hernia:

Obtain images of the esophagus either supine or LPO to the table with the infant crying (induce Valsalva maneuver by removing bottle as infant is drinking or the pacifier) and with infant calm (pacifier may be used).

e. To evaluate the stomach and duodenum:

Obtain prone barium/air contrast spots of the fundus, prone obliques of the barium filled duodenum, supine and oblique air filled gastric antrum and duodenal bulb and loop.

f. To evaluate for gastroesophageal reflux (GER):

Remove the baby from the immobilization board and have the accompanying person hold the baby and feed him/her (without fluoroscopic observation) an equivalent amount of his/her usual feeding. The infant should be burped and then put back on the fluoroscopic table for assessment of GER with the infant in various positions and document presence and extent of reflux, if present.

g. Overhead films:

            i. At the discretion of the radiologist (e.g. supine chest/abdomen)

h. When infant has enteric tube and cannot drink by mouth:

            i. Fill 60 cc syringe with routine single contrast barium that is compatible with the baby’s enteric tube. Do not administer more contrast than required to answer the question at hand or an amount equivalent to the amount usually offered to the baby during a feeding.

            ii. Begin with the infant in a prone oblique position with the right side down and obtain images of the gastric antrum and descending duodenum, a supine view of C-loop, and contrast and air-filled views of the stomach and duodenum.

            iii. Check for GER after the stomach is filled to the amount of the infant's usual feeding. 

            iv. Overhead films at the discretion of the radiologist: (e.g. supine chest/abdomen)