TIPS FOR DR. BASHIST (and more!)

C. Tips for Dr. B, by Dr. B.

Esophagram (to evaluate for structural swallowing abnormalities, esophagitis, strictures, reflux)

1. Erect position: DOUBLE contrast/thick barium (to coat the esophagus)

Scout AP and lateral

Drink normal sips in the LAO (away from you) position, then the RAO (toward you)

TAKE PICS only when the esophagus is well-distended and the barium is coating its walls. You want to see the GE junction.

2. Tilt the table flat with the patient supine (to coat the stomach)

Turn the patient 360 degrees, with the patient first spinning to the left (to keep contrast away from the antrum) -> onto their stomach -> onto the right side -> before the patient becomes supine again, turn back in the opposite direction until

supine again (to avoid losing contrast through the pylorus). Repeat 1.5 more times.

3. TAKE PICS in the RAO then right lateral positions (to see the mucosa of the fundus and GE junction)

4. TAKE PICS in the LAO then left lateral positions (to see the mucosa of the antrum and pylorus)

5. For steps 3 and 4, if you don't have adequate visualization (i.e. barium is pooled in a certain spot or barium-filled bowel is obscuring your view of the stomach, tilt the table to semi-erect)

6. Still with the table flat: SINGLE contrast/thin barium study (to evaluate for esophageal mass effects, strictures, and for the peristaltic wave)

RAO swimmers position: Have the pt drink a single sip of contrast and follow the peristaltic wave to the proximal stomach (only take pics if something is abnormal)

Next, have the pt take multiple large swallows and once you see maximal distension of the esophagus, TAKE A PIC (should only be 2 pics, 1 at the level of the clavicles to the distal esophagus and 1 slightly below to

include the GE junction).

LAO opposite swimmers position: As above

+/- prone: per Dr. Bashist (not usually though)

7. Assess for reflux: lying supine

Have pt turn LAO (away from you) to check for spontaneous reflux, then RAO

If negative, do the same thing but with Valsalva maneuver

If negative, do the water siphon test (water with small amount of thin barium) while the patient is lying supine.

8. Cervical esophagram (thin barium) in the erect position: ONLY IF the patient c/o dysphagia or a feeling of contents being "stuck" in the throat

Ask the tech for 4 frames per second

Have the patient drink ~3 swallows in the AP and LAO (away from you) positions and while on continuous fluoro, check for delays in contrast swallowing, hang ups of contrast in the valleculae or piriform sinuses, or aspiration

TAKE PICS only if you see something abnormal

9. If there are swallowing difficulties, have the patient swallow a 12mm (critical diameter of the esophagus) barium pill

Fluoro to see the pill in the mouth

Instruct patient to swallow pill with sips of water and simply fluoro to see the pill go down. If you see it get caught up, TAKE A PIC

UGI (to evaluate for reflux, gastritis, duodenal ulcers)

1. Same as Esophagram, excluding cervical esophagram and pill

2. When taking both double contrast and single contrast pics (at the steps above), TAKE A PIC of the duodenal bulb (they love the duodenal bulb)

UGI with small bowel follow-through

1. Same as UGI but watch contrast fill up to at least ascending colon

2. This may take 10-30 minutes, so you can do something else in the meantime

UGI pre-op (patients scheduled for gastric bypass; only to look for structural abnormalities) - SINGLE CONTRAST ONLY

1. Erect position

Scout AP and lateral

Drink 1 swallow of single contrast (thin barium) in the LAO/RPO (away from you) position

Fluoro to evaluate swallow and follow contrast to the GE junction to evaluate peristalsis - DO NOT TAKE PICS here unless you see something abnormal

Drink again and with maximal distension of the distal esophagus, TAKE ONE PIC of the GE junction

Inflate the compression paddle and while fluoro-ing, compress the body of the stomach to evaluate to stomach folds - TAKE A PIC

2. Tilt the table flat with the patient supine

Generally no need to spin patient because this is single contrast only, which does not coat the gastric mucosa to evaluate ulcers, etc. Emphasis on anatomy only.

3. TAKE A PIC in LPO/RAO (toward you) position to see contrast in the fundus and the GE junction

4. TAKE A PIC in RPO/LAO (away from you) position to see contrast in the antrum, pylorus, and filling the duodenal bulb

5. For steps 3 and 4, you only need left and right laterals if something abnormal

6. RAO swimmers position

Drink 1 big sip to evaluate peristalsis while fluoro-ing down the esophagus - NO PICS (this evaluates esophageal motility without the confounding factor of gravity)

Drink repeated large sips and TAKE 1-2 PICS OF MAX DISTENSION

7. LAO opposite swimmers position: repeat step 6

8. Assess for reflux: lying supine

Have pt turn LAO (away from you) to check for spontaneous reflux, then RAO

If negative, do the same thing but with Valsalva maneuver

If negative, do the water siphon test (water with small amount of thin barium) while the patient is lying supine.

Evaluation of lap bands - SINGLE CONTRAST only

1. Erect: SCOUT IMAGE of lap band (comment on phi angle of band - 45 degrees is ideal)

2. Drink a few sips of contrast in the erect position

3. Supine: TAKE A PIC of the port

The surgeon cannulates the port

Fluoro to check position

4. Surgeon adjusts the port as needed (adds/removes fluid)

5. Erect:

Drink a sip of single contrast

TAKE A PIC of contrast going through the band

Any studies to evaluate a leak after gastric sleeve or bypass: GASTROGRAFFIN ONLY (risk of mediastinitis or peritonitis with barium)

-No template for this, as it is very situation-dependent

Hysterosalpingogram: all the attendings basically do it the same way. Watch and do the procedure 1-2 times and you'll have it down.
They'll always supervise though.

many thanks to Sumeet (tips for Dr. B from Dr. B)