Tips for Dr. B (and more!)

A. Practical Fluoroscopy of the GI and GU Tracts (2012)

-Mt. Sinai library:
-This is all you'll need, especially the 2nd chapter.  It explains what low-density/thin and high-density/thick barium is, as well as what the difference is between single and double contrast studies
-All steps for esophagrams and UGI studies are laid out very well here, which could be used for any attending except Dr. B

B. Procedures on the rotation
-Modified barium swallows
-Cine esophagrams (recorded swallows, usually only preferred by Dr. Bashist)
-UGI studies +/- small bowel follow through
-Hysterosalpingograms (speculum, yeah!)
-S/p gastric bypass or sleeve - r/o leak

C. 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)