Upper Gastrointestinal Series “AKA Barium Meal”

UGIS – BARIUM MEAL This is the radiographic examination of the distal

esophagus, stomach, and duodenum.

Purpose:
Study radiographically the FORM and FUNCTION of the
distal esophagus, stomach and duodenum and to detect
abnormal anatomy and functional conditions.
STOMACH It is the dilated, sac- like portion of the digestive tract
extending between the esophagus and the small
intestine.
Parts of stomach
Fundus
Corpus/Body
Pylorus

Openings of the stomach • Cardiac Orifice

• Pyloric Orifice
Curvatures • Lesser Curvature
• Greater Curvature
STOMACH HABITUS
Eutonic or normotic habitus Inscisura angularis/angular notch and pylorus are of the
same level.
Hypotonic habitus Pylorus is higher than the Inscisura angularis/angular
notch
Steer-horn Inscisura angularis/angular notch is higher than pylorus
Variations of Stomach
Infantile stomach The stomach is transversely positioned with the bulb
hidden from the view.
Cascade stomach The upper posterior wall is pushed forward, creating an
upper portion that fills until sufficient volume is
present to spill into the antrum.
Movement of the stomach as related to body position
Upright The stomach will move downward about 3-6 inches by
gravity.
Supine Stomach will go up maximum superiorly towards the
diaphragm.
Prone The stomach will move slightly downward.
Right Lateral Recumbent The stomach has the tendency to swing forward. There
by placing the body of stomach to the abdominal wall
and placing the pylorus closer to the lumbar spine.
Left Lateral Recumbent The body of the stomach swings backward and will go
closer to the spine. The pylorus is closer to the
abdominal wall.
 Body Habitus
Hypersthenic GENERAL STOMACH: HIGH AND TRANSVERSE, T9 – T12

PYLORIC PORTION: LEVEL OF T11 – T12, AT MIDLINE

DUODENAL BULB LOCATION: LEVEL OF T11- T12, TO

RIGHT OF MIDLINE
Sthenic GENERAL STOMACH: LEVEL T10 – L2

PYLORIC PORTION: LEVEL L2, NEAR MIDLINE

DUODENAL BULB LOCATION: LEVEL OF L1 – L2, AT

MIDLINE
Hyposthenic & Asthenic GENERAL STOMACH: LOW AND VERTICAL, LEVEL T11 –
L4 (L5)

PYLORIC PORTION: LEVEL OF L3 – L4, TO LEFT OF

MIDLINE
DUODENAL BULB LOCATION: LEVEL OF L3, AT MIDLINE
Physiologic Preparation of the Patient: • Inform the patient in simple terms the nature of the
procedure and why it is done.
• Tell him the approximate duration of the exam.
• It is always advisable to give verbal instructions
accompanied by actual demonstration.

Causes of Barium retention in the stomach • The barium take in, because of its neutrality, begins its
emptying almost immediately.
• The volume of barium mixture left in the stomach will
be observed in 1 to 2 hours with no residual mixtures in
3 hours.
Hypoacidity • Lack of HCI.
• It permits the retention of barium coating in the
mucosa, which in itself is not an indication of
abnormality.
Emotional Stress Like nervousness and anxiety during examination, tends
to delay gastric emptying as a result of pyloro-bulbar
spasm (closure).
Reminders to the Technologist • Attend your patient right away as he arrives in the
radiology department.
• Instruct him what things he will remove from his body
so as not to obstruct the radiograph.
• Instruct the patient to wear laboratory gown properly.
• While the patient is undressing, prepare all the
necessary things that are needed in the examination,
such as markers, cassettes, and films etc.
ileocecal valve 2 to 3hours.
last portion 4 to 5 hours.
 Three or four waves per minute occur in the filled
stomach
Two to three hours average emptying time of the normal stomach
1 to 2 hours iodinated solution clears the stomach
Exposure time: No longer than 0.2 second to 0.5 second - normal
peristaltic activity

0.1 second or less - hypermotility (Note: make exposure

at the end of expiration)
Barium Preparation: 2:1 (60 – 66%)
3:1 (70 – 80%)
• Prepare only enough for the examination, about 1/3
glass.
• Mix it thoroughly.
• Prepare a night prior to exam and refrigerate –
minimize unpalatable taste.
Patient Preparation: 1.Stomach is empty (stomach and the small intestine)
2. Colon should be free of gas and fecal material. A
non-gas forming laxative may be administered 1 day
before the examination if constipated.
3. Soft, low-residue diet for 2 days to prevent gas
formation from excessive fermentation of the intestinal
contents.
4. Cleansing enemas may be given.
5. NPO for 8 to 9 hours. Withheld food after evening
meal.
6. No smoking and/or chewing gum after midnight on
the night before the examination. This is believed to
stimulate gastric secretions and salivations that dilutes
the contrast agent.
Single meal method Administered during the actual examination.
Double meal method • Patient is required to bring home barium mixture to
be ingested 5 hours prior to examination.
• The second meal is administered during the
examination.
Ways of producing air in the stomach: • By allowing the patient to sip the barium mixture with
the use of two straws, one outside the glass and the
other is inside.
• By instructing the Px to breathe through his mouth or
swallow air after the ingestion of the barium mixture.
• By giving the patient gas-producing tablets like
“gastroluft”
• By giving the patient carbonated drinks
SINGLE- CONTRAST EXAMINATION • Size, shape, and position of the stomach.
• Changing contour of the stomach during peristalsis.
• Filling and emptying of the duodenal bulb. 
Abnormal alterations
DOUBLE- CONTRAST EXAMINATION • Small lesions
• Mucosal lining
Indications
Bezoar Mass in the stomach formed by material that does not
pass into the intestine.
Trichobezoar formed by the ingestion of hair
Phytobezoar Indigestible vegetable/fruit fibers and seeds.
Gastritis Inflammation of lining of stomach.
Pyloric Stenosis Narrowing of pyloric canal causing obstruction
Ulcer Depressed lesion on the surface of the alimentary canal.
Diverticula Pouch created by herniation of the mucous membrane
through the muscular coat.
Emesis Act of vomiting
Hematemesis blood in vomit
Hypertrophic Pyloric Stenosis (HPS) • Blockage of the passage out of the stomach due to
thickening (hypertrophy) of the muscle at the junction
between the stomach and the intestines. • The
thickened muscle creates a partial blockage
(obstruction) that interferes with the passage of
stomach contents into the small intestine.
Hiatal Hernia • Protrusion of the stomach through the esophageal
hiatus of the diaphragm.

PROCEDURES
SINGLE- CONTRAST EXAMINATION • Barium suspension used is usually in the 30% to 50%
weight/volume range.
• If there’s esophageal involvement in the examination,
thick barium suspension is used.
DOUBLE- CONTRAST EXAMINATION • Place the patient in upright position.
• Give the patient a gas-producing substance in the
form of a powder, crystals, pills, or a carbonated drink. •
Give the patient a small amount of high-density barium
suspension (weight/ volume ratio up to 250%). • Place
the patient in recumbent position and turn from side to
side to coat the organ under examination.
BIPHASIC EXAMINATION • The patient first undergoes a double-contrast
examination.
• After this, the patient is given 15% weight/ volume
barium suspension and a single- contrast examination.
HYPOTONIC DUODENOGRAPHY  First described by Liotta.
 Requires intubation
 During the atonic state when the duodenum is
distended two or three times its normal size, it
presses against and outlines any abnormality in
the contour of the head of the pancreas.
 Indications:
1. Postbulbar duodenal lesions (Alternative:
double- contrast GI series)
2. Pancreatic disease (Alternative: CT or needle
biopsy)
Projections and Positions
PA PROJECTION PATIENT POSITION: Recumbent prone or Upright (for
stomach variation)

PART POSITION: The midline of the grid coincides with

the sagittal plane passing halfway between the vertebral
column and left lateral border of the abdomen.

 Prone: Center the IR about 1- 2 inches above the

lower rib margin at the level of L1 – L2

 Upright: Center the IR 3 – 6 inches lower than L1- L2.

CENTRAL RAY: Perpendicular

(Note: The greatest visceral movement between the

prone and upright position occurs in ASTHENIC
patients.)

Structures Shown:

• UPRIGHT – size, shape, and the relative position of the

filled stomach, but it does not adequately demonstrate
the unfilled fundus.

• PRONE – the stomach moves superiorly 1.5 to 4 inches

according to the patient’s body habitus; the stomach
spread horizontally, with comparable decrease in
length.

(Note: The fundus usually fills in asthenic patients.)

 • The pyloric canal and duodenal bulb (asthenic and
hyposthenic)

(Note: The greatest visceral movement between the

prone and upright position occurs in ASTHENIC
patients.)
PA AXIAL PROJECTION PATIENT POSITION: Recumbent prone

PART POSITION:

STHENIC – Center the IR at the level of L2 (Center

higher for hypersthenic and lower for asthenic)

Note: L2 lies about 1 – 2 inches above the lower rib

margin.

CENTRAL RAY:
Gordon: 35 to 45 degrees cephalad
Gugliantini: 20 to 25 degrees cephalad

Structures Shown:
• UPRIGHT – size, shape, and the relative position of the
filled stomach, but it does not adequately demonstrate
the unfilled fundus.

• PRONE – the stomach moves superiorly 1.5 to 4

inches according to the patient’s body habitus; the
stomach spreads horizontally, with comparable
decrease in length. (Note: The fundus usually fills in
asthenic patients.)

• The pyloric canal and duodenal bulb (asthenic and

hyposthenic)

• Gugliantini Modification – infant stomach in profile

• Gordon’s Modification – ‘’open-up’’ the high,

horizontal stomach for the demonstration of the
greater and lesser curvature, the antral portion, the
pyloric canal, and the duodenal bulb in HYPERSTHENIC
patient.
PA OBLIQUE (RAO) PATIENT POSITION: Recumbent PART POSITION:
 Adjust the patient position so that a sagittal plane
passing midway between the vertebrae and the lateral
border of the elevated side coincides with the midline of
the grid.
  Center the IR about 1 – 2 inches above the lower rib
margin at the level of the L1 – L2 when the patient is
prone.

 Make the patient’s body rotate 40 to 70 degrees.

(Note: Hypersthenic patients need more body rotation
than thinner patients) CENTRAL RAY: Perpendicular
STRUCTURES SHOWN:

• Best image of the pyloric canal and duodenal bulb in

sthenic patients.

Gastric peristalsis is more active in this position.

AP OBLIQUE (LPO) PATIENT POSITION: Supine
PART POSITION:

 Adjust the patient position so that a sagittal plane

passing midway between the vertebrae and the left
lateral margin of the abdomen is centered to the grid.

 Center the IR at the level of the stomach; a point

midway the xiphoid process and the lower margin of
the ribs.

 Make the patient’s body rotate ~45 degrees (sthenic)

but can vary from 30 to 60 degrees,

CENTRAL RAY: Perpendicular

STRUCTURES SHOWN: - Fundic portion

LATERAL PROJECTION (RIGHT POSITION) PATIENT POSITION: - Upright left lateral position -
Recumbent right lateral position

PART POSITION:
- Adjust the patient position so that a plane passing
midway between the midcoronal plane and the anterior
surface of the abdomen coincides with the midline of
the grid.
- Center the IR at the level of Ll-L2 for the recumbent
position (about 1-2 inches above the lower rib margin)
and at L3 for the upright position.

CENTRAL RAY: Perpendicular

STRUCTURES SHOWN:
Upright left lateral position for left retrogastric space
  Recumbent right lateral position for right retrogastric
space, duodenal loop, and duodenojejunal junction.
 Anterior and posterior aspects of the stomach, the
pyloric canal, and the duodenal bulb.
 The right lateral projection - Best image of the
pyloric canal and the duodenal bulb in patients with a
hypersthenic habitus.
AP PROJECTION PATIENT POSITION:
-Supine
- Trendelenburg
PART POSITION: - Adjust the position of the patient so
that the midline of the grid coincides (I) with the midline
of the body or (2) with a sagittal plane passing midway
between the midline and the left lateral margin of the
abdomen.

CENTRAL RAY: Perpendicular

PATIENT POSITION: - Supine - Trendelenburg PART

POSITION: - Adjust the position of the patient so that

the midline of the grid coincides (I) with the midline of
the body or (2) with a sagittal plane passing midway
between the midline and the left lateral margin of the
abdomen.

CENTRAL RAY: Perpendicular

STRUCTURES SHOWN:

STRUCTURES SHOWN:
• Stomach - A well-filled fundic portion and usually a
double-contrast delineation of the body, pyloric portion,
and duodenum. - Best AP projection of the retrogastric
portion of the duodenum and jejunum.
• Diaphragm - An AP projection of the
abdominothoracic region demonstrates the organ or
organs involved in, and the location and extent of, any
gross hernial protrusion through the diaphragm.

PA OBLIQUE PROJECTION WOLF METHOD This method is a modification of Trendelenburg &

requires a semicylindric radiolucent compression device
 PATIENT POSITION: - Prone
PART POSITION: - Instruct the patient to assume a
modified knee-chest position during placement of the
compression device. - Adjust the patient in a 40- to 45-
degree RAO

RAO CENTRAL RAY: - Perpendicular to the long axis of

the patient's back and centered at the level of either T6
or T7. - This position usually results in a 10- to 20-
degree caudad angulation of the central ray.

STRUCTURES SHOWN:
• The Wolf method demonstrates the relationship of the
stomach to the diaphragm and is useful in diagnosing a
hiatal hernia.

This method is a modification of Trendelenburg &

requires a semicylindric radiolucent compression device
PA OBLIQUE PROJECTION RAO: SERIAL OR PATIENT POSITION: Prone
MUCOSAL STUDIES
PART POSITION:
 Under fluoroscopic control, adjust the patient so that
the area of the duodenal bulb is centered to the paddle.
 For a mucosal study, inflate the compression bladder
of the paddle to provide the desired degree of pressure.

CENTRAL RAY:  Perpendicular

STRUCTURES SHOWN:
• This method demonstrates a compression and a non-
compression study of the pyloric end of the stomach
and the duodenal bulb at different stages of filling and
emptying.
HAMPTON’S MODIFICATION Patient position: Supine

Part position: Body is rotated towards the affected side

Central ray: Perpendicular

Structures shown: Best modification to demonstrate

leaf- like pattern of the pylorus and its valve.
POPPEL’S MODIFICATION • This is used to demonstrate the right-angle view of
the stomach.
• For the evaluation of pathologies in the pancreas like
mass, cancer, and its inflammation.
• Retrogastric space is also seen.
 NOTES!
UGIS – BARIUM MEAL Study radiographically the FORM and FUNCTION of the
distal esophagus, stomach and duodenum and to detect
abnormal anatomy and functional conditions.
PA projection The pyloric canal and duodenal bulb (asthenic and
hyposthenic)
Gugliantini Modification infant stomach in profile
Gordon’s Modification ‘’open-up’’ the high, horizontal stomach for the
demonstration of the greater and lesser curvature, the
antral portion, the pyloric canal, and the duodenal bulb
in HYPERSTHENIC patient.
PA OBLIQUE (RAO) Best image of the pyloric canal and duodenal bulb in
sthenic patients. Gastric peristalsis is more active in
this position.
LPO Fundic portion
LATERAL PROJECTION (RIGHT POSITION) Best image of the pyloric canal and the duodenal bulb
in patients with a hypersthenic habitus.
PA OBLIQUE PROJECTION WOLF METHOD is useful in diagnosing a hiatal hernia.
PA OBLIQUE PROJECTION RAO: SERIAL OR This method demonstrates a compression and a non-
MUCOSAL STUDIES compression study of the pyloric end of the stomach
and the duodenal bulb at different stages of filling and
emptying.
HAMPTON’S MODIFICATION Best modification to demonstrate leaf- like pattern of
the pylorus and its valve.
POPPEL’S MODIFICATION For the evaluation of pathologies in the pancreas like
mass, cancer, and its inflammation.