Treat Acute Esophageal Impaction

Contraindications:

  1. Impaction of longer than 24 hr duration.
  2. Recent instrumentation of esophagus in past week
  3. Obstruction caused by a known sharp foreign body such as a bone, plastic utensil, etc.
  4. Obstruction caused by a known rigid obstruction such as esophageal carcinoma or fixed stricture
    1. Note this does not include esophageal rings (e.g. Schatzki rings are not a contraindication).
  5. Location in the proximal third of the esophagus.
  6. The history or presence of an esophageal diverticulum or prominent cricopharyngeus muscle noted on initial fluoroscopy is a contraindication to combination therapy.
  7. Contraindication to glucagon therapy (known sensitivity or patients with suspected insulinoma or pheochromocyloma).

Procedure:

  1. The patient should swallow 5cc of a non-ionic contrast agent, such as Omnipaque 160. Fluoroscope with the patient standing in the LPO position to determine the presence, location andi configuration of the foreign body. Have a basin handy.
  2. Make table horizontal and give glucagon 1 mg IV over 30 sec, then immediately return table to upright position. Glucagon relaxes the LES and possibly the smooth muscle of the distal esophagus.
  3. Two minutes after the glucagon, give the patient one packet of EZ Gas (the effervescent agent distends the esophagus) in 30cc of H20 followed by one cup (240 cc) of H20. If successful, the patient will experience immediate symptomatic relief. If this fails, endoscopy must be considered.
  4. A limited esophagogram is then performed with 50cc of non-ionic contrast to confirm passage of the foreign body and ensure that no perforation has occurred.
  5. Follow-up double-contrast esophagography should be performed electively to diagnose the underlying cause of the esophageal obstruction. This should be done 7-14 days post-disimpaction to allow edema or mucosal irritation to subside.

Robbins MI, Shortsleeve MJ. Treatment of Acute Esophageal Food Impaction with Glucagon, an Effervescent Agent, and Water. AJR 1994: 162:325-328

Double-Contrast Upper GI Series

The following technique is just one example of an UGI and you will find many variations in practice.

Upright Left Posterior Oblique:

  1. If indicated, fluoro chest to exclude pulmonary nodules.
  2. Give a small sip of HD barium and fluoro for position.
  3. Give EZ gas crystals followed by 30 cc of water and then have the patient take three or four rapid swallows of HD barium, holding the cup in their left hand.
  4. Obtain air esophagram views to include the gastroesophageal junction. Have the patient finish the remainder of the HD barium (if any).
  5. Bring the table to a horizontal position with the patient in LPO or supine position. Roll patient three times, if possible, to coat stomach.

Supine:

Obtain a spot film of the stomach.

Right Posterior Oblique:

Obtain a spot film (Schatzki's view) of the gastric fundus, body and lesser curvature.

Right Lateral:

Obtain a spot film focusing on the anterior gastric wall, the gastroesophageal junction, and the duodenal bulb.

Left Posterior Oblique:

  1. Obtain a spot film centered on the gastric antrum.
  2. Obtain a spot film of the duodenal bulb (wait for air within a noncontracted bulb).

Prone:

Obtain a film of the gastric body and antrum.

Right Anterior Oblique:

  1. Obtain a film of the duodenal bulb, duodenal C-sweep, and distal gastric antrum.
  2. Use thin barium to obtain imaging of the drinking esophagus. This view should include the gastroesophageal junction. Document esophageal ring if present.

Supine:

Perform a fluoroscopic evaluation checking for reflux (using cough, Valsalva, swallowing or H20 siphon test, or straight-leg-raise techniques).

Overhead Films

Obtain LPO, PA, AP, and RAO (however, these are attending preferences)

Notes:

  1. If an air-filled duodenal bulb is difficult to obtain, try turning the patient to a left anterior oblique position from the LPO position (to empty the barium from the duodenal bulb) and then back to the LPO position for the spot film.
  2. Glucagon (0.1 mg IV push over 30 seconds) can be given prior to the exam to slow gastric emptying.

Double-Contrast Barium Enema

The following technique is just one example of a BE and you will find many variations in practice. At Mount Auburn, biphasic enemas are performed. On call, you will usually be doing single contrast, water soluble enemas.

Left Lateral: The following is usually done by the tech.

  1. Do a rectal exam making sure to use copious amounts of gel lubrication.
  2. Insert the enema tube tip carefully and inflate the balloon if no palpable abnormalities were present on the rectal exam.
  3. If rectal disease is present, the tube can be secured in place with tape.

Prone:

  1. Introduce the barium into the colon and run it gently to the splenic flexure.
  2. When the barium passes into the proximal most portion of the transverse colon, clamp the enema tube and drain the excess barium (if needed).
  3. Pump air into the colon gently and watch for the barium to cross the spine. At this point, check to make sure no air is leaking back into the enema bag.

Right Lateral:

  1. Place the patient in a right lateral position while continuing to pump air into the colon as gently as possible.
  2. When the barium reaches the distal-most point of the ascending colon, turn the patient to a supine position.

Supine:

Check to make sure the colon is adequately coated with barium,

Left Posterior Oblique:

Obtain an image of the sigmoid colon before the cecum fills with barium.

Right Anterior Oblique:

Obtain another image of the sigmoid colon or go directly to overhead views if there is substantial reflux through the ileocecal valve or if the patient is having substantial difficulty holding the barium.

Upright:

  1. Make sure that the barium drains into the cecum.
  2. Obtain a film of the splenic flexure (right posterior oblique).
  3. Obtain a film of the transverse colon (anteroposterior).
  4. Obtain a film of the hepatic flexure (left posterior oblique).

Supine:

Obtain a 1-on-l view of the cecum. Attempt to fill the cecum with air by putting the patient in a right posterior oblique position and/or by placing them in the Trendelenburg position.

Left Lateral:

Drain excess barium from the rectum, pump additional air back into the rectum, and obtain a film of this region.

Prone:

Obtain a view of the rectum.

Overhead Films (optional):

AP, PA, PA angled rectum, Prone cross table rectum, bilateral decubitus views, if redundant colon add bilateral obliques, and postevacuation view only needed when right colon is a problem.

Notes:

Glucagon (1.0 mg I.V. push over 30 seconds) can be given if colonic spasm is present. mini