ESOPHAGRAM:

 

how to do an esophagram:

 

First look up pt. to see why esophagram ordered.

 

typical indication:  r/o HH in a patient prior to bariatric surgery.  upon discussion with surgery, they want ot know if ther eis signicant HH so that can repair that at same time.

 

Check pt. chart, exclude barium allergy

should be fasting 8 hrs prior

Get scout films:  lateral neck and PA chest

Look at PA chest to exclude possible HH on basis of chest xray

Look at lateral neck to evaluate soft tissues of pharynx

 

Procedure:

use thick barium with fizzy tabs or thin barium

Single contrast:  Thin Barium

Double Contrast:  Thick barium with "fizzies"  For evaluation of the mucosa, subtle mucosal disaese (backup is direct camera vis"

Leak studY " rule out esophageal perf":  Use gastrografin or other water soluble contrast

 

Cervical esophagram:
Some attendings want, some dont;

 

easy to do

 

Sequence:  3 Frames/ sec

Image straight AP and straigh lateral, centered at the neck, cone down and mag if needed

instruct patient to take a large gulp and image the whole time

same thing AP and lateral

 

want to visuzlie structures like piriform sinuses and valleculuae

 

can make diagnosis of pulsion diverticula or cricopharngeas, among other

 

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Start off in standing LPO.  Basically standing on table but obliqued slightly approx 45 deg to get espohagrus off the spine (the esophagus is anterior).  get better picture of esophagus if obliqued off the spine

 

Set the parametsrs on the machine:  go to sequence and set 2-3 frames / sec.  This will occur when pressing yellow button

 

Get in position with fluoro unit.  Move machine up to patients cervicothoracic junction.  Cone down to get long rectangle.  Be comfortable going up and down in this position to obtain images of the entire esophagus to the GEJ.

 

Instruct pt. to hold barium cup and straw off to side, so as to not obscure the image of the esophagus

 

Instruction:  when i say, take 2-3 large gulps of barium and swallow.  

IF using fizzies, instruct to take fizzies "like a shot" and "chase" with small amt water.  Do not burp.  Want air to keep esophagus distended so can see "through" the thick barium aka mucosal relief.

 

Time the swallow so when press yellow button, there is delay and then pictures start shooting and will cover upper, middle, and lower third esophagus in LPO view.

 

Second portion of study:

 

take ppt off table.

 

change table to 90 degree (flat)

 

Ask technologist to place pt. RPO / swimmers position

 

Now take shots in similar fashion with yellow button.  Now that gravity is out of the equation, can assess esophageal motility.  What this means is that every bolus sohldu propagate straight caudal.  

 

Now in this position, very good to exclude HH.  Scan at the level of the diaphragms.  You should not see gastric rugae above the diaphragms.  If you do, you have a HH.  Characterize size

Do some limited imaging of the stomach if nesc.

 

For reflux:  Image pt. esophagus and ensure it has cleared the already given barium.  Now try to elicit reflux.  This can be after pt. rotates around table (does a 360 pirouette) or after applying pressure to epigastric region.  Image before and after

 

Send pictures to PACS (Archive-> File -> Save image -> PACS)

 

Discuss images with attending prior to discharging pt.

 

PROCEDURE COMPLETE.