Upper Gastrointestinal and Small Bowel Series

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Upper Gastrointestinal and Small Bowel Series

Synonym/acronym: Gastric radiography, stomach series, small bowel study, upper GI series, UGI.

Common use

To assess the esophagus, stomach, and small bowel for disorders related to obstruction, perforation, weight loss, swallowing, pain, cancer, reflux disease, ulcers, and structural anomalies.

Area of application

Esophagus, stomach, and small intestine.

Contrast

Barium sulfate.

Description

The upper gastrointestinal (GI) series is a radiological examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate, which is a milkshake-like, radiopaque substance. A combination of x-ray and fluoroscopy techniques are used to record the study. Air or gas may be instilled to provide double contrast and better visualization of the lumen of the esophagus, stomach, and duodenum. If perforation or obstruction is suspected, a water-soluble iodinated contrast medium is used. This test is especially useful in the evaluation of patients experiencing dysphagia, regurgitation, gastroesophageal reflux (GER), epigastric pain, hematemesis, melena, and unexplained weight loss. This test is also used to evaluate the results of gastric surgery, especially when an anastomotic leak is suspected. When a small bowel series is included, the test detects disorders of the jejunum and ileum. The patient’s position is changed during the examination to allow visualization of the various structures and their function. Images of the swallowed contrast medium as it moves through the digestive system are visualized on a fluoroscopic screen, recorded, and stored electronically for review. Drugs such as glucagon may be given during an upper GI series to relax the GI tract; drugs such as metoclopramide (Reglan) may be given to accelerate the passage of the barium through the stomach and small intestine.

When the small bowel series is performed separately, the patient may be asked to drink several glasses of barium, or enteroclysis may be used to instill the barium. With enteroclysis, a catheter is passed through the nose or mouth and advanced past the pylorus and into the duodenum. Barium, followed by methylcellulose solution, is instilled via the catheter directly into the small bowel.

Pediatrics An upper GI series is usually done in the pediatric population to diagnose the cause of recurrent GI signs (bleeding) and symptoms. The etiology is often related to age. In infants, recurrent symptoms such as vomiting after feeding, poor feeding, poor weight gain, and abdominal pain (evidenced by frequent crying during or after a feeding) may trigger an investigation. The most common causes of upper or lower GI bleeding in infants up to 1 mo include allergies to milk proteins, anorectal fissures, bacterial enteritis, coagulopathy, esophagitis, Hirschsprung’s disease, intussusception, peptic ulcer, stenosis, varices, or Meckel’s diverticulum. Children between 2 to 23 mo are most commonly diagnosed with allergies to milk proteins, anorectal fissures, esophagitis caused by gastroesophageal reflux (GER), gastritis, intussusception, Meckel’s diverticulum, NSAID-induced ulcer, and ingested foreign body. Pediatric patients 24 mo and older are most commonly diagnosed with esophageal varices, Mallory Weiss tears, peptic ulcer, related to Helicobacter pylori infection or peptic ulcer secondary to some other type of systemic disease (e.g., Crohn’s disease or IBD). Other abnormal findings in this age group include IBD, polyps, malignancy, sepsis, and Meckel’s diverticulum.

This procedure is contraindicated for

  • high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alert Patients suspected of having upper GI perforation, unless water-soluble iodinated contrast medium, such as Gastrografin, is used.
  • high alert Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
  • high alert Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs) because iodinated contrast is nephrotoxic.
  • high alert Elderly and compromised patients who are chronically dehydrated before the test, because of their risk of contrast-induced renal failure.
  • high alert Patients with an intestinal obstruction because the barium or water from the enema may make the condition worse.

Indications

  • Determine the cause of regurgitation or epigastric pain
  • Determine the presence of neoplasms, ulcers, diverticula, obstruction, foreign body, and hiatal hernia
  • Evaluate suspected GER, inflammatory process, congenital anomaly, motility disorder, or structural change
  • Evaluate unexplained weight loss or anemia
  • Identify and locate the origin of hematemesis

Potential diagnosis

Normal findings

  • Normal size, shape, position, and functioning of the esophagus, stomach, and small bowel

Abnormal findings related to

  • Achalasia
  • Cancer of the esophagus
  • Chalasis
  • Congenital abnormalities
  • Duodenal cancer, and ulcers
  • Esophageal diverticula, motility disorders, ulcers, varices, and inflammation
  • Foreign body
  • Gastric cancer or tumors, and ulcers
  • Gastritis
  • Hiatal hernia
  • Perforation of the esophagus, stomach, or small bowel
  • Polyps
  • Small bowel tumors
  • Strictures

Critical findings

  • Foreign body
  • Perforated bowel
  • Tumor with significant mass effect
  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Factors that may impair clear imaging

    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
  • Other considerations

    • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
    • Patients with swallowing problems may aspirate the barium, which could interfere with the procedure and cause patient complications.
    • Possible constipation or partial bowel obstruction caused by retained barium in the small bowel or colon may affect test results.
    • This procedure should be done after a kidney x-ray (IV pyelography) or computed tomography of the abdomen or pelvis.
    • Consultation with the appropriate HCP should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the esophagus, stomach, and small intestine.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s gastrointestinal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Ensure that this procedure is performed before a barium swallow.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect coagulation (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • If iodinated contrast medium (e.g., Gastrografin) is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the procedure. Inform the patient that the procedure is usually performed in a radiology department by an HCP, with support staff, and takes approximately 30 to 60 min. Pediatric Considerations Preparing children for an upper GI examination depends on the age of the child. Encourage parents to be truthful about unpleasant sensations the child may experience during the procedure and to use words that they know their child will understand. Toddlers and preschool-age children have a very short attention span, so the best time to talk about the test is right before the procedure. The child should be assured that he or she will be allowed to bring a favorite comfort item into the examination room, and if appropriate, that a parent will be with the child during the procedure.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain to the patient that he or she will be asked to drink a milkshake-like solution that has an unpleasant chalky taste.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure. Protocols may vary among facilities. Pediatric Considerations The fasting period prior to the time of the examination depends on the child’s age. General guidelines are that the patient should not eat for the period of time between normal meals: newborn 2 to 3 hr; infants to 4 yr: 3 to 4 hr; 5 yr through adolescence: 6 to 8 hr.

Intratest

  • Potential complications:
  • Complications include allergic reaction to the contrast medium, aspiration of the barium, significant diarrhea related to use of Gastrografin, and partial bowel obstruction caused by thickened or congealed barium.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has complied with dietary and fluid restrictions for 8 hr prior to the procedure.
  • Ensure that the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still throughout the procedure because movement produces unreliable results.
  • Upper Gastrointestinal Series

  • Place the patient on the x-ray table in a supine position, or ask the patient to stand in front of a fluoroscopy screen.
  • Instruct the patient to take several swallows of the barium mixture through a straw while images are taken of the pharyngeal motion. An effervescent agent may also be administered to introduce air into the stomach. Pediatric Considerations For infants, barium contrast may be mixed with a small amount of the infant’s feeding to take in a bottle. If the patient is unable to drink the barium, a thin, flexible tube may be placed through his or her nose to get the barium into the esophagus.
  • Small Bowel Series

  • If the small bowel is to be examined after the upper GI series, instruct the patient to drink an additional glass of barium while the small intestine is observed for passage of barium. Images are taken at 30- to 60-min intervals until the barium reaches the ileocecal valve. This process can last up to 5 hr, with follow-up images taken at 24 hr.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet and fluids, as directed by the HCP.
  • Monitor for reaction to iodinated contrast medium, including rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting, if iodine is used.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Instruct the patient to take a mild laxative and increase fluid intake (four glasses) to aid in the elimination of barium unless contraindicated. Pediatric Considerations Instruct the parents of pediatric patients to hydrate the child with electrolyte fluid post barium enema. Geriatric Considerations Chronic dehydration can also result in frequent bouts of constipation. Therefore, after the procedure, elderly patients should be encouraged to hydrate with fluids containing electrolytes (e.g., Gatorade, Gatorade low calorie, for diabetics, or Pedialyte) and to use a mild laxative daily until the stool is back to normal color.
  • Inform the patient that his or her stool will be white or light in color for 2 to 3 days. If the patient is unable to eliminate the barium, or if the stool does not return to normal color, the patient should notify the HCP.
  • Recognize anxiety related to test results, and be supportive of perceived loss of independence and fear of shortened life expectancy. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include barium enema, barium swallow, capsule endoscopy, CT abdomen, endoscopic retrograde cholangiopancreatography, esophageal manometry, fecal analysis, gastric acid stimulation test, gastric emptying scan, gastrin stimulation test, gastroesophageal reflux scan, H. pylori antibody, KUB study, Meckel’s diverticulum scan, MRI abdomen, and US pelvis.
  • Refer to the Gastrointestinal System table at the end of the book for related tests by body system.