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
- Indications for Esophagram
- Pertinent history and symptoms serving as indications for an esophagram include, but are not limited to:
- Noncardiac chest pain
- Recurrent pneumonia or chronic tracheobronchial inflammation
- The esophagram is helpful in the diagnosis and evaluation of many conditions, including, but not limited to:
- Suspected or known motility disorders
- Great vessel anomalies
- Esophageal obstruction
- Extrinsic compression
- Postsurgical evaluation
- Tracheo-esophageal fistula
- Indications for Upper GI Examinations
- Pertinent history and symptoms serving as indications for an upper GI examination include, but are not limited to:
- Abdominal pain
- Epigastric distress or discomfort
- Signs and/or symptoms of upper GI bleeding
- Weight loss or failure to thrive
- Congenital syndromes or anomalies associated with intestinal malrotation
- Abdominal masses
- Chronic or recurrent respiratory disease, including cough
- Acute life-threatening event. The term "ALTE" infers a respiratory arrest or near arrest that has a differential diagnosis (apnea, child abuse, aspiration, etc.).
- The upper GI examination is helpful in diagnosing and evaluating many conditions, including, but not limited to:
- Intestinal malrotation anomalies
- Hiatal hernia
- Gastroesophageal reflux
- Suspected or known gastritis or duodenitis
- Pyloric stenosis
- Gastric outlet or upper intestinal obstruction
- Peptic ulcer disease
- Duodenal laceration or intramural hematoma
- Recurrent diaphragmatic hernia
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 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)
- 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.
- 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).
- 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.
- Single-contrast esophagram
- 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.
- 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.
- 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.
- 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.")
- Single-contrast upper GI examination
- 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.
- 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.
- A final image documenting gastric emptying and the progress of contrast through small bowel loops may be obtained at the conclusion of the examination.
- 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.")
- Quality control indicators
The following quality control indicators should be applied to all esophagram and upper GI examinations:
- When examinations are completed, patients should be held in the fluoroscopic area until the physician has reviewed the images.
- An attempt should be made to resolve questionable radiologic findings before the patient leaves. Repeat fluoroscopy should be performed as necessary.
- Correlation of radiologic, endoscopic, surgical, and pathologic findings is valuable for quality improvement, whenever feasible.
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."
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)