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FLUOROSCOPY
Stomach and DuodenumDemonstration data

Upper GI Series

The upper gastrointestinal series evaluates the stomach and duodenum, and often the distal oesophagus, using combined double- and single-contrast fluoroscopy. In adults it demonstrates ulcers, masses, outlet obstruction and post-surgical anatomy; in infants it is the reference standard for confirming the position of the duodeno-jejunal junction and excluding malrotation with midgut volvulus.

Indications

  • Epigastric pain, dyspepsia and suspected gastric or duodenal peptic ulceration
  • Suspected gastric outlet obstruction, gastric mass or linitis plastica
  • Assessment of post-surgical anatomy after gastrectomy, fundoplication or bariatric surgery
  • Suspected leak or gastric emptying disorder when endoscopy is contraindicated or non-diagnostic
  • Paediatric bilious vomiting to evaluate for malrotation and midgut volvulus

Contraindications & Cautions

  • Suspected perforation or post-operative anastomotic leak: use water-soluble iodinated contrast first, not barium
  • High aspiration risk in infants: use low-osmolar non-ionic contrast rather than hyperosmolar ionic agents
  • Complete distal obstruction where retained barium may inspissate
  • Recent surgery without surgical clearance for oral contrast

Patient Preparation

  • Adults nil by mouth from midnight or at least 6 hours to empty the stomach
  • Infants fasted for one feed cycle (approximately 3 hours) before the study
  • Withhold agents that alter motility where possible
  • Explain effervescent granules and the manoeuvres to coat the mucosa
  • Confirm no suspected perforation before selecting barium

Technique & Parameters

  • Scout image then effervescent granules with a small amount of water to distend the stomach with gas
  • High-density barium swallowed and the patient rotated to coat the gastric mucosa for double-contrast views
  • Single-contrast phase with low-density barium to assess distension, contour and gastric emptying
  • Compression and prone/oblique views of the antrum and duodenal bulb to profile ulcers
  • In infants a small volume of contrast is given through the nasogastric tube or bottle and the duodeno-jejunal junction is imaged in a true AP projection
  • Follow the contrast to confirm the duodeno-jejunal junction lies left of the spine at the level of the duodenal bulb

Systematic Review

  • Assess gastric distensibility, fold pattern and areae gastricae for infiltration
  • Profile the antrum and duodenal bulb for ulcer craters and deformity
  • Evaluate the position and configuration of the duodenal C-loop
  • In paediatrics confirm the duodeno-jejunal junction position and the course of the third part of the duodenum
  • Assess gastric emptying and look for extrinsic compression or mass effect
  • Inspect the distal oesophagus and gastro-oesophageal junction

Key Findings & Significance

  • Benign gastric ulcer: rounded crater projecting beyond the lumen with smooth radiating folds reaching the edge
  • Malignant ulcer: crater within a mass, nodular rolled edges and folds that stop short of the crater
  • Linitis plastica: rigid, non-distensible narrowed stomach from diffuse infiltration
  • Gastric outlet obstruction: dilated stomach with delayed emptying and antral or duodenal narrowing
  • Malrotation: duodeno-jejunal junction displaced to the right of the midline and low
  • Midgut volvulus: corkscrew spiralling of the duodenum and proximal jejunum

Differential Considerations

  • Gastric mass: adenocarcinoma, lymphoma, GIST, or benign polyp
  • Thickened gastric folds: hypertrophic gastritis, Menetrier disease, lymphoma or infiltrating carcinoma
  • Duodenal narrowing: peptic stricture, annular pancreas, superior mesenteric artery syndrome or tumour
  • Filling defect in the bulb: ulcer-related oedema, Brunner gland hyperplasia or polyp
  • Paediatric bilious vomiting: malrotation, duodenal web, atresia or annular pancreas

Pearls & Pitfalls

  • A right-sided duodeno-jejunal junction in an infant with bilious vomiting mandates urgent surgical referral
  • Folds radiating to a smooth ulcer crater favour benign disease; nodular converging folds favour malignancy
  • Use water-soluble contrast first whenever a leak or perforation is possible
  • Adequate gaseous distension is essential to demonstrate the areae gastricae and small mucosal lesions
  • A normal upper GI does not exclude intermittent malrotation; correlate with clinical suspicion

Structured Report

  • State the contrast agent and phases performed
  • Describe the stomach, duodenum and distal oesophagus with any ulcers, masses or narrowing
  • Characterise ulcers as benign or malignant by morphology
  • In paediatrics explicitly state the position of the duodeno-jejunal junction and whether malrotation is present or excluded
  • Give an impression and recommend endoscopy or CT where appropriate

References

  • ACR-SPR Practice Parameter for the Performance of Esophagography and Upper Gastrointestinal Examinations
  • Applegate KE et al. Malrotation and Midgut Volvulus: Radiographic Evaluation. RadioGraphics
  • Levine MS, Rubesin SE. Diseases of the Stomach and Duodenum. Textbook of Gastrointestinal Radiology
  • Royal College of Radiologists iRefer: Making the Best Use of Clinical Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.