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Guideline Summary
Guideline Title
ACR–SPR practice guideline for the performance of contrast esophagrams and upper gastrointestinal examinations in infants and children.
Bibliographic Source(s)
American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice guideline for the performance of contrast esophagrams and upper gastrointestinal examinations in infants and children. [online publication]. Reston (VA): American College of Radiology (ACR); 2010. 6 p. [10 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Diseases of the esophagus and upper gastrointestinal tract

Note: See the "Major Recommendations" field under "Indications and Contraindications" for a detailed list of diseases and conditions considered in the guideline.

Guideline Category
Diagnosis
Evaluation
Clinical Specialty
Family Practice
Gastroenterology
Pediatrics
Radiology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To assist practitioners in providing appropriate radiologic care for patients
  • To describe principles of practice for performance and interpretation of contrast esophagrams and upper gastrointestinal examinations in infants and children
Target Population

Infants and children undergoing contrast esophagrams and upper gastrointestinal examinations

Interventions and Practices Considered
  1. Use of qualified personnel
  2. Appropriate patient selection
  3. Appropriate preliminary examination, including patient history and use of "scout" image of chest and abdomen
  4. Use of appropriate examination technique, including delivery of contrast medium in an age-appropriate manner
    • Single-contrast esophagram
    • Double-contrast (biphasic) esophagram
    • Single-contrast upper gastrointestinal (GI) examination
    • Double-contrast (biphasic) upper GI examination
    • Application of appropriate quality control indicators
  5. Equipment specifications
  6. Appropriate documentation
  7. Minimization of radiation exposure
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the Practice Guideline or Technical Standard topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

  1. Articles that have abstracts available and are concerned with humans.
  2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
  3. May restrict the search to Adults only or Pediatrics only.
  4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

Number of Source Documents

The total number of source documents identified as the result of the literature search is not known.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Recommendations are formulated through iterative review by committee, collaborating societies, and membership. Suggested recommendations are reviewed by the committee, and agreement is reached by consensus.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published costs analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Each practice guideline and technical standard, representing a policy statement by the American College of Radiology (ACR), has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council.

Recommendations

Major Recommendations

Examinations of the esophagus and the upper gastrointestinal (GI) tract by single-contrast or double-contrast technique are proven and useful procedures for evaluation of the esophagus, stomach, and duodenum. The goal of radiologic examination is to establish the presence or absence, nature, and extent of disease with a diagnostic quality study using the minimum radiation dose necessary. The following standards are for performance of single-contrast and double-contrast (biphasic) esophagrams and single-contrast and double-contrast (biphasic) upper GI examinations in infants and children. Typically, single contrast studies are used in infants and children, but occasionally double-contrast studies are indicated.

Indications and Contraindications

  1. Indications for Esophagram
    1. Pertinent history and symptoms serving as indications for an esophagram include, but are not limited to:
      1. Dysphagia
      2. Odynophagia
      3. Noncardiac chest pain
      4. Recurrent pneumonia or chronic tracheobronchial inflammation
    1. The esophagram is helpful in the diagnosis and evaluation of many conditions, including, but not limited to:
      1. Suspected or known motility disorders
      2. Strictures
      3. Varices
      4. Great vessel anomalies
      5. Esophageal obstruction
      6. Extrinsic compression
      7. Postsurgical evaluation
      8. Tracheo-esophageal fistula
      9. Esophagitis
      10. Neoplasm
  1. Indications for Upper GI Examinations
    1. Pertinent history and symptoms serving as indications for an upper GI examination include, but are not limited to:
      1. Abdominal pain
      2. Epigastric distress or discomfort
      3. Nausea
      4. Vomiting
      5. Signs and/or symptoms of upper GI bleeding
      6. Weight loss or failure to thrive
      7. Congenital syndromes or anomalies associated with intestinal malrotation
      8. Abdominal masses
      9. Chronic or recurrent respiratory disease, including cough
      10. Acute life-threatening event. The term "ALTE" infers a respiratory arrest or near arrest that has a differential diagnosis (apnea, child abuse, aspiration, etc.).
    1. The upper GI examination is helpful in diagnosing and evaluating many conditions, including, but not limited to:
      1. Intestinal malrotation anomalies
      2. Hiatal hernia
      3. Gastroesophageal reflux
      4. Suspected or known gastritis or duodenitis
      5. Pyloric stenosis
      6. Gastric outlet or upper intestinal obstruction
      7. Peptic ulcer disease
      8. Duodenal laceration or intramural hematoma
      9. Recurrent diaphragmatic hernia
      10. Neoplasms

Esophagrams and upper GI examinations may also be indicated for evaluating postsurgical patients and for detecting spontaneous, post-traumatic, or postsurgical leaks from the esophagus, stomach, or duodenum. If perforation is clinically suspected, water-soluble contrast should be used. In infants or in children in whom aspiration or esophageal-tracheal or bronchial fistula is suspected, a low osmolar agent or dilute barium should be used. (See "Examination Technique" under "Specifications of the Examination" section below.)

In reviewing indications for a contrast study of the stomach and duodenum, alternative methods of examining these structures should be considered as might be relevant to the individual case, including endoscopy, ultrasound, and computerized tomography (CT).

For the pregnant or potentially pregnant patient, see the "ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation." (See the American College of Radiology (ACR) Web site External Web Site Policy for this practice guideline and additional ones mentioned below.)

Qualifications of Personnel

For qualifications of physicians, medical physicists, radiologist assistants, and radiologic technologists, see the "ACR–SPR Practice Guideline for General Radiography."

Additionally, physicians performing this procedure should have documented formal training in the performance and interpretation of GI fluoroscopy as part of an accredited residency training program.

Qualifications of technologists performing GI radiography should be in accordance with the current ACR policy statement on fluoroscopy1 and with operating procedures or manuals at the imaging facility. Fluoroscopy technologists assisting in esophagrams or upper GI examinations should be thoroughly trained in GI radiography.

1The American College of Radiology approves of the practice of certified and/or licensed radiologic technologists performing fluoroscopy in a facility or department as a positioning or localizing procedure only, and then only if monitored by a supervising physician who is personally and immediately available*. There must be a written policy or process for the positioning or localizing procedure that is approved by the medical director of the facility or department/service and that includes written authority or policies and processes for designating radiologic technologists who may perform such procedures. (ACR Resolution 26, 1987 – revised in 2007, Resolution 12-m)

*For the purposes of this guideline, "personally and immediately available" is defined in manner of the "personal supervision" provision of the Center for Medicare & Medicaid Services (CMS)—a physician must be in attendance in the room during the performance of the procedure. Program Memorandum Carriers, DHHS, HCFA, Transmittal B-01-28, April 19, 2001.

Specifications of the Examination

The written or electronic request for a pediatric contrast – upper GI examination should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation.

Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination.

The request for the examination must be originated by a physician or other appropriately licensed health care provider. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patient's clinical problem or question and consistent with the state scope of practice requirements. (ACR Resolution 35, adopted in 2006)

  1. Patient Selection

    For a routine esophagram, the patient should not have ingested anything by mouth for a minimum of 2 hours. For upper GI examination, oral feeding should be withheld for a time period appropriate for the patient's age: approximately 2 to 3 hours for neonates and young infants, 4 hours for older infants and children. Adolescents should fast for at least 6 to 8 hours. Emergency examinations may be performed with shorter fasting times.

  1. Examination Preliminaries

    An appropriate medical history should be available, including results of laboratory tests and imaging, endoscopic, and surgical procedures as applicable.

    Use of a child life specialist and/or parent may be helpful in enabling young patients to cooperate for the examination. Immobilization devices may be helpful in patient positioning. These devices may help limit repeat radiographic exposures and unnecessary radiation dose to patients, parents, technologists, and other personnel.

    A preliminary "scout" image of the chest and/or abdomen may be useful, depending on the specific clinical concern. Preliminary images should be assessed for calcifications, skeletal abnormalities, anomalies of situs, bowel gas pattern, pneumoperitoneum, evidence of prior surgery, catheters, and monitoring electrodes. A horizontal beam image should be performed if the patient has an underlying condition that might predispose to esophageal, gastric or bowel perforation. Scout images are especially helpful in the workup of neonatal bowel obstruction, since they may influence the choice of initial fluoroscopic study (e.g., upper GI for proximal bowel obstruction and contrast enema for distal small bowel or colonic obstruction).

  1. Examination Technique

    The examination procedure should be tailored by the radiologist to the individual patient as warranted by clinical circumstances and the condition of the patient, to produce a diagnostic quality examination. Preliminary findings during the examination may indicate a need to alter technique in subsequent portions of the examination.

    A barium preparation or other contrast medium should be delivered in a manner that is appropriate for the patient's age. Flavoring agents may be added in older patients. Neonates and infants may be fed contrast from a baby bottle with a nipple. Alternatively, a device consisting of a feeding tube or orogastric tube passed through a nipple is sometimes used to deliver the contrast into the mouth; this should be done under careful fluoroscopic control to prevent aspiration. Older infants able to bottle-feed themselves may be allowed to do so. The contrast may be given by straw or taken directly from a cup by an older child. A nasogastric tube, gastrostomy tube, or jejunostomy tube may be used as appropriate. In neonates or young infants with a history of bilious emesis, a nasogastric tube can be placed with tip in the distal stomach to empty the stomach so that a controlled upper GI with a small amount of barium and air can effectively evaluate for malrotation and/or volvulus, using the least amount of barium and time.

    The amount and type of contrast material given are determined by the child's age and the indications for the study. Barium is the preferred contrast medium for most studies. Nonionic iodinated contrast media may be given to assess the integrity of an esophageal anastomosis, diagnose duodenal obstruction or perforation, or diagnose intestinal malrotation in selected critically ill patients. Iso-osmolar or near iso-osmolar solutions are important in cases in which there is risk of aspiration. Iso-osmolar contrast media are particularly important in critically ill premature neonates and infants to avoid serum electrolyte shifts. Gastrografin, a very highly osmotically active water soluble contrast agent, should not be administered orally in neonates and young infants, because this patient population has a higher risk of gastroesophageal reflux and aspiration, and aspirated hyperosmolar contrast may result in pulmonary edema and a severe chemical pneumonitis.

    1. Single-contrast esophagram
      1. The anatomic structure and motility of the entire esophagus should be evaluated fluoroscopically. Appropriate images should be obtained to document normal and abnormal findings. The examination is optimally performed in the lateral and anteroposterior projections, with visualization of the nasopharynx to the gastric fundus.
      2. Esophagrams performed in infants with suspected tracheo-esophageal fistula are optimally performed in a controlled manner, with full distension of the esophagus, which can be achieved with normal drinking in patients who drink contrast readily. In patients who do not drink sufficient contrast to distend the esophagus, the contrast can be administered in small amounts initially through a small feeding tube placed in the upper esophagus near the thoracic inlet, with the infant in a right anterior oblique or lateral position. This requires careful fluoroscopic monitoring to prevent aspiration, and monitoring of the contrast as it exits the tubes. If no fistula is identified on the early images, the study may be completed with standard oral administration of contrast. Fluoroscopic observation in the lateral view throughout contrast instillation usually will allow differentiation of contrast in the trachea due to aspiration versus a fistula.
      3. Imaging of the esophagus should include an assessment of swallowing in the lateral view, especially if the patient has symptoms suggesting swallowing dysfunction such as coughing and choking and/or gagging during feeding. This should include imaging from the base of the tongue through the upper esophageal sphincter. Modified barium swallow is a more detailed evaluation of the oral, pharyngeal, and upper esophageal phases of swallowing, usually performed in conjunction with a speech pathologist or occupational therapist. Variable thickness barium contrast may be used to assess the effect of viscosity of the fluid on swallowing function.
    1. Double-contrast (biphasic) esophagram

      Double-contrast esophagrams are seldom performed in pediatric patients, but they may help to evaluate mucosal integrity in adolescents.

      (See the "ACR Practice Guideline for the Performance of Esophagrams and Upper Gastrointestinal Examinations in Adults.")

    1. Single-contrast upper GI examination
      1. Fluoroscopic assessment of swallowing and the anatomic structure and motility of the entire esophagus, stomach, and duodenum should be performed, and appropriate images should be obtained to document normal and abnormal findings. Suggested images include frontal and lateral views of the barium-distended esophagus, stomach, and duodenum and images of the partially filled esophagus. Initial passage of contrast through the duodenum should be observed directly with fluoroscopy to confirm the position of the duodenojejunal junction (DJJ). This can be documented with serial multiple fluoro-capture images or fluoroscopy video capture, where available. On the first upper GI examination in an infant or child, the position of the DJJ should be documented on both frontal and lateral positions to diagnose or exclude malrotation. The lateral view is important to assure the retroperitoneal position of the normally rotated duodenum and the normal height of the duodenal-jejunal junction at the level of the duodenal bulb; additionally, the frontal view assures the normal position of the DJJ, at or to the left of the left pedicle of the vertebral bodies. A sufficient number of digital spot or last image hold images or fluoroscopy video captures to adequately demonstrate or exclude pathology should be obtained.
      2. Images of gastroesophageal reflux should be recorded by last image hold if reflux occurs during the examination. However, since reflux is a physiologic phenomenon and more sensitive tests exist (e.g., the pH probe), neither provocation of reflux nor prolonged fluoroscopy monitoring for detection is recommended.
      3. A final image documenting gastric emptying and the progress of contrast through small bowel loops may be obtained at the conclusion of the examination.
    1. Double-contrast (biphasic) upper GI examination

      Double contrast upper GI examinations are seldom performed in pediatric patients, but they may help to evaluate mucosal integrity in adolescents. (See the "ACR Practice Guideline for the Performance of Esophagrams and Upper Gastrointestinal Examinations in Adults.")

    1. Quality control indicators

      The following quality control indicators should be applied to all esophagram and upper GI examinations:

      1. When examinations are completed, patients should be held in the fluoroscopic area until the physician has reviewed the images.
      2. An attempt should be made to resolve questionable radiologic findings before the patient leaves. Repeat fluoroscopy should be performed as necessary.
      3. Correlation of radiologic, endoscopic, surgical, and pathologic findings is valuable for quality improvement, whenever feasible.

Documentation

An official interpretation (final report) of the examination should be included in the patient's medical record.

Reporting should be in accordance with the "ACR Practice Guideline for Communication of Diagnostic Imaging Findings."

Equipment Specifications

See the original guideline document for information about equipment specifications.

Radiation Safety in Imaging

Radiologists, medical physicists, radiologic technologists, and all supervising physicians have a responsibility to minimize radiation dose to individual patients, to staff, and to society as a whole, while maintaining the necessary diagnostic image quality. This concept is known as "as low as reasonably achievable (ALARA)."

Facilities, in consultation with the medical physicist, should have in place and should adhere to policies and procedures, in accordance with ALARA, to vary examination protocols to take into account patient body habitus, such as height and/or weight, body mass index or lateral width. The dose reduction devices that are available on imaging equipment should be active; if not manual techniques should be used to moderate the exposure while maintaining the necessary diagnostic image quality. Periodically, radiation exposures should be measured and patient radiation doses estimated by a medical physicist in accordance with the appropriate ACR Technical Standard. (ACR Resolution 17, adopted in 2006 – revised in 2009, Resolution 11)

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved performance of contrast esophagrams and upper gastrointestinal examinations in infants and children

Potential Harms

Esophagrams and upper gastrointestinal examinations expose patients to radiation.

Contraindications

Contraindications

Gastrografin, a very highly osmotically active water soluble contrast agent, should not be administered orally in neonates and young infants because this patient population has a higher risk of gastroesophageal reflux and aspiration, and aspirated hyperosmolar contrast may result in pulmonary edema and a severe chemical pneumonitis.

Qualifying Statements

Qualifying Statements
  • These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question.
  • The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from these guidelines is advised to document in the patient record information sufficient to explain the approach taken.
  • The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective.

Implementation of the Guideline

Description of Implementation Strategy

Quality Control and Improvement, Safety, Infection Control, and Patient Education

Policies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with the American College of Radiology (ACR) Policy on Quality Control and Improvement, Safety, Infection Control, and Patient Education appearing under the heading Position Statement on QC & Improvement, Safety, Infection Control, and Patient Education on the ACR Web site External Web Site Policy.

The lowest possible radiation dose consistent with acceptable diagnostic image quality should be used. Radiation doses should be determined periodically based on a reasonable sample of pediatric examinations. Technical factors should be appropriate for the size and the age of the child and should be determined with consideration of parameters such as characteristics of the imaging system, organs in the radiation field, lead shielding, etc. Guidelines concerning effective pediatric technical factors are published in the radiologic literature.

Equipment monitoring should be in accordance with the "ACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Radiographic and Fluoroscopic Equipment" (see the ACR Web site External Web Site Policy).

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Safety

Identifying Information and Availability

Bibliographic Source(s)
American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice guideline for the performance of contrast esophagrams and upper gastrointestinal examinations in infants and children. [online publication]. Reston (VA): American College of Radiology (ACR); 2010. 6 p. [10 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1997 (revised 2010)
Guideline Developer(s)
American College of Radiology - Medical Specialty Society
Society for Pediatric Radiology - Medical Specialty Society
Source(s) of Funding

American College of Radiology

Guideline Committee

Guidelines and Standards Committee of the Commission on Pediatric Radiology

Composition of Group That Authored the Guideline

Principal Reviewers: Kimberly E. Applegate, MD, MS, FACR; Susan D. John, MD, FACR; Peter J. Strouse, MD

Collaborative Committee

American College of Radiology (ACR): Kristin L. Crisci, MD; Marta Hernanz-Schulman, MD, FACR

Society for Pediatric Radiology (SPR): Brenda C. Grabb, MD; Steven J. Kraus, MD; Beverley Newman, BSc, MB, BCh, FACR

ACR Guidelines and Standards Committee – Pediatric: Marta Hernanz-Schulman, MD, FACR, Chair; Taylor Chung, MD; Brian D. Coley, MD; Seth Crapp, MD; Kristin L. Crisci, MD; Eric N. Faerber, MD, FACR; Lynn A. Fordham, MD; Lisa H. Lowe, MD; Marguerite T. Parisi, MD; Laureen M. Sena, MD; Sudha P. Singh, MB, BS; Donald P. Frush, MD, FACR, Chair, Commission

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site External Web Site Policy.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

Availability of Companion Documents

The following are available:

  • The process of developing ACR practice guidelines and technical standards. Reston (VA): American College of Radiology. Electronic copies: Available from the American College of Radiology (ACR) Web site External Web Site Policy.
  • Purpose and intended use. Reston (VA): American College of Radiology. Electronic copies: Available from the ACR Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 16, 2011.

Copyright Statement

Copyright © by the American College of Radiology, 1891 Preston White Dr., Reston, VA 20191-4397, 703-648-8900. All rights reserved. No reproduction of this material in any format, electronic or otherwise, is permitted except with prior written consent from the American College of Radiology.

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