Gambaran Defek Oesophagus pada Pemeriksaan Oesophagus Maag Duodenum (OMD) pada Pasien Hematemesis

Dibuat oleh: Miftakhul M,Modifikasi terakhir pada Wed 22 of Sep, 2010 [02:26 UTC] Abstrak

OMD (oesophagus, maag, duodenum/barium meal) didefinisikan suatu teknik radiografi untuk memeriksa oesophagus, maag dan duodenum dengan menggunakan media kontras (biasanya barium sulfat). Pemeriksaan bisa dilakukan dengan single kontras hanya barium sulfat saja, bisa juga double kontras dengan barium dan udara. Hematemisis adalah muntah darah yangterjadi karena pecahnya varises esophagus. Pemeriksaan OMD diperlukan pada kasus-kasus yang secara klinis diduga terdapat kelainan pada lambung dan duodenum, yaitu pasien denganhematemesis, melena, penurunan berat badan, nyeri epigastrium, dan tumor-tumor lambung/diluar lambung. Pada pasien ini mengalami muntah darah. Pemeriksaan radiologi OMD dilakukan sebagai pemeriksaan penunjang diagnosis.

Keywords: oesophagus maag duodenum, oesophagus, hematemesis

History

seorang wanita, usia 70 tahun, pasien mengeluh nyeri pada seluruh lapang perut, kembung, nafsu makan menurun karena perut terasa penuh , pasien juga mengeluh batuk dan badan terasa lemas, BAB sulit (merasa ingin buang air besar tetapi tdk bisa).Pasien tidak merasa pusing, mual dan muntah. sejak kurang lebih 4 hari Sebelum Masuk Rumah Sakit. Keluhan yang dirasakan semakin meningkat dan pasien mengalami muntah darah tiga kali yaitu berwarna merah segar kira-kira 1 gelas. Pasien juga masih merasakan nyeri pada seluruh lapang perut, kembung, nafsu makan menurun, batuk dan badan terasa lemas, kurang lebih 1 hari Sebelum Masuk Rumah Sakit. Kurang lebih 4 hari selama mondok di rumah saki, pasien muntah darah segar satu kali, batuk, kembung, dan nyeri perut sudah mulai berkurang. Pasien masih mengalami nafsu makan yang menurun dan lemas. Riwayat penyakit dahulu terdapat riwayat muntah darah dan menyangkal adanya keluhan serupa pada keluarga. Pemeriksaan fisik ditemukan KU baik, tanda vital hipertensi. Pemeriksaan abdomen pada inspeksi dinding perut > dinding dada dan distensi. Auskultasi dalam batas normal. Palpasi terdapatnyeri tekan seluruh lapang peru, hepar dan lien tidak teraba. Perkusi didapatkan redup diseluruh lapang perut. Dilakukan pemeriksaan penunjang OMD dengan hasiltampak multiple filling defek dengan hoineycomb appearance pada oeshopagus 1/3 distal menunjykkan adanya kelainan pada oeshopagus. Diagnosis

kesan adanya defek pada oeshopagus

Diskusi

Pada pasien ini dapat dilakukan pemeriksaan OMD. Pemeriksaan OMD diindikasikan pada kasus-kasus yang secara klinis diduga terdapat kelainan pada lambung dan duodenum, yaitu pasien dengan hematemesis, melena, penurunan berat badan, nyeri epigastrium, tumor-tumor lambung/diluar lambung. Jadi secara klinis pemeriksaan OMG dilakukan untuk mendiagnosis kelainan pada oesophagus, maag dan duodenum, baik itu karena infeksi, kongenital, trauma, neoplasia, ataupun metabolik. Contohnya ulkus gaster, gastritis, ulkus duodenum, tumor intestinum, dll. Sedangkan pemeriksaan OMD tidak dapat dilakukan pada keadaan adanya perforasi, ileus, keadaan umum yang buruk, dan hal-hal lain yang mungkin memperburuk keadaan penderita

Pemeriksaan OMD bisa dilakukan dengan single kontras hanya barium sulfat saja, bisa juga double kontras dengan barium dan udara.

Gambaran radiologi pada OMD, yaitu: a. Oesophagus yang terisi oleh kontras tampak sebagai gambaran opak memanjang dari oesophagus pars cervicalis, pars thoracica, hingga pars abdominalis. Terdapat indentasi di dua tempat, yaitu oleh arcus aorta dan oleh cabang-cabang bronkus besar. OMD setelah kontras hampir habis tampak gambaran selaput lendir oesophagus yang sejajar. b. Pada gaster posisi supine, fundus akan terlihat penuh dengan kontras, sementara antrum/bulbus terlihat kosong (sedikit kontras). Sedangkan pada foto posisi prone, fundus akan terlihat kosong, sementara antrum/bulbus terlihat penuh kontras. Pada foto posisi erek akan tampak gambaran kontras yang mengisi bagian gaster dengan permukaan cairan kontras terlihat datar, daerah fundus kosong dari kontras. c. Pada gambaran duodenum terdiri atas suatu ujung tertutup yang letaknya tepat setelah pylorus, duodenum jadi tampak seperti berujung buntu, yang disebut duodenal cap. Bagian berikutnya adalah bentuk C dari pars descenden, gambarannya terletak disebelah kanan vertebra. Bagian terakhir adalah pars horizontal, melintasi ke kiri dan menyambung dengan jejunum di fleksura duodenojejunal. Lipatan mukosa normalnya tampak pada foto double contrast. Papilla Vatter biasanya tampak lusen menonjol ke lumen di sisi medial pars descenden. Cap duodenum yang normal akan tampak simetris dan triangular. Ketika menggembung dan terlapisi barium, pola permukaan retikuler yang tampak seperti beludru mungkin dapat dilihat dengan munculnya vilii Pasien ini memenihi kriteria hematemesis dengan keluhan muntah darah segar. Sebelumnya pasien juga mengalami perut terasa penuh, mual, nafsu makan menurun, badan terasa lemas, sulit BAB yang dapat menunjukkan adanya kelainan pada saluran cerna. Serata dari hasil pemeriksaan abdomen didapatkan pada inspeksi dinding perut > dinding dada dan distensi. Auskultasi dalam batas normal. Palpasi terdapat nyeri tekan seluruh lapang peru, hepar dan lien tidak teraba. Perkusi didapatkan redup diseluruh lapang perut. Dilakukan pemeriksaan penunjang OMD dengan hasil tampak multiple filling defek dengan hoineycomb appearance pada oeshopagus 1/3 distalmenunjykkan adanya kelainan pada oeshopagus.

Patogenesis dari hematemesis dapat disebabkak dengan gagal hepar sirosis kronis, kematian sel dalam hepar mengakibatkan peningkatan tekanan vena porta. Jika sel-sel parenkim hati hancur, sel-sel tersebut digantikan oleh jaringan fibrosa yang akhirnya akan berkontraksi disekitar pembuluh darah, sehingga sangat menghambat darah porta melalui hati. Vena porta membawa darah ke hati dari lambung, usus, limpa, pankreas dan kandung empedu. Vena porta tidak mempunyai katup dan membawa sekitar tujuh puluh lima persen sirkulasi hati dan sisanya oleh arteri hepatika. Vena mesenterika superior dibentuk dari vena-vena yang berasal dari usus halus, kaput pankreas, kolon bagian kiri, rektum dan lambung. Keduanya mempunyai saluran keluar ke vena hepatika yang selanjutnya ke vena kava inferior. System porta kadang terhambat oleh gumpalan besar dalam vena porta atau cabang utamanya. Bila system porta terhambat, kembalinya darah dari usus dan limpa melalui system porta ke sirkulasi sistemik menjadi sangat terhambat, menghasilkan hipertensi porta dan tekanan kapiler dalam dinding usus meningkat 15-20 mmHg diatas normal. Sebagai akibatnya terbentuk saluran kolateral dalam submukosa esopagus dan rektum serta pada dinding abdomen anterior untuk mengalihkan darah dari sirkulasi splenik menjauhi hepar. Dengan meningkatnya tekanan dalam vena ini, maka vena tersebut menjadi mengembang dan membesar (dilatasi) oleh darah (disebut varises). Varises dapat pecah, mengakibatkan perdarahan gastrointestinal masif.

Kesimpulan

Pemeriksaan OMD (oesophagus, maag, duodenum/barium meal) dapat dilakukan pada keadan klinis seperti hematemesis, melena, penurunan berat badan,nyeri epigastrik, dan adanya tomor di dalm atau diluar lambung. Gambaran dari hasil OMD pada pasien hematemesis yaitu ditemukannya multiple filling defek dengan hoineycomb appearance pada oeshopagus 1/3 distal menunjukkan adanya kelainan pada oeshopagus. Terapi yang dapat diberikan pada hematemesis adalah konservatif dan medikamentosa. Referensi

1. Bahar., A., 2000., Buku Ajar Ilmu Penyakit Dalam., Jilid II., Balai Penerbit Fakultas Kedokteran Universitas Indonesia., Jakarta., Hal:715-719 2. 3. Medicastore 2010. Hematemesis. http://medicastore.com/penyakit/52/Hematemesis.html Indeks Penyakit. 2008. Oeshopagus maag duodenum. http://www.klikdokter.com/illness/detail/69

4. Rasad, S.,Kartoleksono.S.,Ekayuda,I.,2006.,Radiologi Diagnostik., Balai Penerbit Fakultas Kedokteran Universitas Indonesia.,Jakarta. 5. Simon, G.,2005., Diagnostik Rontgen Untuk Mahasiswa Klinik Dan Dokter Umum.,Penerbit Erlangga.,Jakarta., Hal:280-296.

Barium Meal Double Contrast

Basic Anatomy

Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London

Indications Dyspepsia Unexplained weight loss Abdominal masses Upper GI tract haemorrage or iron deficiency anaemia Assessment of perforation and or post surgery Gastrointestinal reflux Contraindications Large bowel obstruction Immediately impending gastric/abdominal surgery Contrast Media and drugs. (Typical Examples, See Contrast / Drugs Section for more information) EZEM HD 250% 100 - 150 ml Baritop 100% w/v 100 - 150 ml Gas producing mixtures, Buscopan / Glucagon Equipment Fluoroscopy with spot film capability 10 frames/second Fluoroscopy table with 90/20 tilt. Special "feeding" equipment may be required, i.e. straws and feeding cups. Injection administration equipment. Patient Preparation Patient Identification, Check Pregnancy state, General psychological preparation and examination outline. Nil by mouth for 6 hours before the examination* * Note special preparation may be needed for diabetic patients. Check sensitivity to drugs used. Technique The patient takes the gas producing agent and is requested not to burp. The patient is then positioned lying supported on the left side and drinks the barium mixture. The patient lies supine left side raised and trendelenberg tilted to induce reflux. A smooth muscle relaxant is administered. Then a series of fluoroscopically guided films is taken in a variety of positions to demonstrate the stomach, duodenal cap and first part of duodenum. Typical Film Series

Position Supine RAO Supine Supine LAO Supine Left Lateral Prone Prone,RAO,Supine,LAO Erect RAO, LAO Erect

Demonstrates Antrum and greater curve Antrum and body Lesser curve Fundus Duodenal loop Duodenal Cap series Fundus

Typical Film from Image Series

Radiation Protection Define strict referral criteria to exclude clinically unhelpful examinations Minimise fluoroscopy time and current Introduce QA programme to make regular checks on and to optimise staff and equipment performance Collimate X-ray beam to minimise size Shield sensitive organs when possible Install modern image intensifiers with sensitive (e.g. CsI) photocathodes and digital image processing Use video recorder instead of cine camera during fluoroscopy wherever possible Use spot film photofluoroscopy with modern image intensifier and 100mm camera

instead of radiography whenever appropriate Use pulsed systems with image storage devices in fluoroscopy. Aftercare Record volumes and descriptions of contrast media and drugs administered. General patient psychological aftercare Ensure the patient understands the procedure for collecting the results. Warn the patient of the possibilities of constipation and appropriate counter measures Check for any side effects of drugs used, i.e. blurred vision from muscle relaxants. Complications Aspiration of barium mixture Leakage of barium into the peritoneum with and unsuspected perforation Barium impaction and large bowel obstruction Barium induced appendicitis Side effects of drugs used Other Imaging Techniques Flexible endoscopy CT

GIT

Barium Swallow

Basic Anatomy

Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London

Indications Dyspepsia Mechanical pain on swallowing Reflux Assessment of fistulae and perforation Pre operative anatomical demonstration Speech and Language therapy studies Contraindications Non specific, however low solar water soluble contrast agents are best used in investigations where aspiration may occur. Contrast Media and drugs (Typical Examples) EZEM HD Baritop Gastromiro Volumes and concentrations are departmental / radiologist dependent. Equipment

Fluoroscopy with rapid film capability 10 frames/second Fluoroscopy table with 90/20 tilt. Special "feeding" equipment may be required, i.e. straws and feeding cups. Injection administration equipment. Patient Preparation Patient Identification, Check Pregnancy state, General psychological preparation and examination outline. The stomach should be empty if a barium meal is likely to follow. Radiation Protection Define strict referral criteria to exclude clinically unhelpful examinations Minimise fluoroscopy time and current Introduce QA programme to make regular checks on and to optimize staff and equipment performance Collimate X-ray beam to minimise size Shield sensitive organs when possible Install modern image intensifiers with sensitive (e.g. CsI) photocathodes and digital image processing Use video recorder instead of cine camera during fluoroscopy wherever possible Use spot film photofluoroscopy with modern image intensifier and 100mm camera instead of radiography whenever appropriate Use pulsed systems with image storage devices in fluoroscopy. Technique / Typical Film Series The patient stands erect and rapid film sequences are taken whilst the patient swallows the barium mixture, the series are generally taken for the full length of the oesophagus in the PA, Lateral and Right Anterior Oblique positions, with films taken prone to demonstrate oesophageal varices. Care must be taken to ensure that the patients arms and the drinking equipment are kept clear of the image field. Typical Film from Image Series

http://www.vh.org/Providers/TeachingFiles/NormalRadAnatomy/Images/

Aftercare Record volumes and descriptions of contrast media and drugs administered. General patient psychological aftercare Ensure the patient understands the procedure for receiving the results. Warn the patient of the possibilities of constipation and appropriate counter measures Complications Aspiration of barium mixture Leakage of barium into the peritoneum with and unsuspected perforation Other Imaging Techniques Flexible endoscopy CT

GIT

Barium Follow Through

Basic Anatomy Barium Follow Through is designed to demonstrate the small bowel from the duodenum to the ileo ceacal region encompassing the duodenum, jejunum and ileum including the junctions superiorly with the stomach and inferiorly with the ascending colon.

http://www.vh.org/Providers/TeachingFiles/NormalRadAnatomy/Images/

Indications Abdominal pain Diarrhoea Bleeding Partial obstruction Investigations of transit time ? Mekels diverticulum Contraindications Obstruction

Imminent surgery and or suspected perforation require water soluble contrast media. Contrast Media and drugs. (Typical Examples, See Contrast / Drugs Section for more information) Baritop 100% w/v EZHD 120 % Buscopan / Glucagon if required Metaclopramide Equipment Fluoroscopy with rapid film capability 10 frames/second Fluoroscopy table with 90/20 tilt. Special "feeding" equipment may be required, i.e. straws and feeding cups. Injection administration equipment. Patient Preparation Patient Identification, Check Pregnancy state, General psychological preparation and examination outline. * Note special preparation may be needed for diabetic patients. Check sensitivity to drugs used. Nil by mouth for 12 hours Laxative preparation 12 hours before examination Metaclopramide 20 mg orally 30 minutes before the examination Technique The technique should ensure a non fragmented dense column of contrast agent passes smoothly through the small bowel. The patient should rapidly drink about 300 ml of contrast media and then lie on their right side Typical Film Series 35 x 43 cm Films in the prone position are taken at 20 minute intervals until the contrast media passes into the colon, ensure that the early films should include the stomach, a pad under the abdomen may help to separate out the loops of bowel. The patient may need fluoroscopic spot films of areas of interest especially the terminal ileum

Typical Film from Image Series

Radiation Protection Define strict referral criteria to exclude clinically unhelpful examinations Minimise fluoroscopy time and current Introduce QA programme to make regular checks on and to optimise staff and equipment performance Collimate X-ray beam to minimise size Shield sensitive organs when possible Install modern image intensifiers with sensitive (e.g. CsI) photocathodes and digital image processing Use video recorder instead of cine camera during fluoroscopy wherever possible Use spot film photofluoroscopy with modern image intensifier and 100mm camera instead of radiography whenever appropriate Use pulsed systems with image storage devices in fluoroscopy. Aftercare Record volumes and descriptions of contrast media and drugs administered. General patient psychological aftercare Ensure the patient understands the procedure for collecting the results. Warn the patient of the possibilities of constipation and appropriate counter measures Complications Aspiration of barium mixture Leakage of barium into the peritoneum with and unsuspected perforation

Other Imaging Techniques Barium small bowel enema Radionuclide Imaging for GI Bleed CT.

Definition
Body positions in x-ray exams are based on body part, suspected defect or disease, and condition of the patient. The radiographer, also known as the x-ray tech or more formally as the radiologic technologist, uses standardized body positions in performing an x-ray exam. Positions are learned by the radiographer according to body part in relation to body habitus, anatomical position and bisecting planes, and relationship of the body to the x-ray equipment.

Purpose
Since many body parts overlay other internal structures, the radiographer uses positioning of the body part as well as specific positions of the x-ray equipment to obtain clearer views of the overlapping structures. X-ray exams usually consist of two or more radiographs, taken in orthogonal planes or variations to the relationship of body part and x-ray equipment. Exams require radiographs to be taken at 90 degrees to each other where anatomy is superimposed over important structures, where alignment of fracture ends is questioned, or for localization of foreign bodies. Exams require a minimum of three radiographs when joints or articulations are in the area of interest, although some referring physicians may ask for only two. This allows for evaluation of the bones and well as the joints.

Precautions
The radiographer applies principles of immobilization in performing the exam. The use of immobilization has two purposes. First, the patient's safety is of primary importance to the radiographer. Second, immobilization assists the patient in maintaining the applied body position during the exam. Some x-ray exams require the patient to suspend breathing during the exposure such as for chest x rays. Suspension of breathing is a method of immobilization that the patient voluntarily performs. In other cases, the radiographer assists the patient in maintaining a position with the use of radiolucent sponges or other positioning aids. Radiation protection is used to reduce or prohibit xray exposure to areas of the body that are biologically sensitive. The determinants of x-ray exposure include time spent under irradiation, distance of x-ray unit, and shielding practices. The most common practice of radiation protection is to protect the reproductive organs, especially in children and young adults. It is standard practice to question women of childbearing age if there is a possibility of pregnancy. Radiographic exams are

not usually performed on pregnant women as the developing fetus is biologically sensitive to radiation.

Description
The use of body positioning requires an understanding of terminology that refers to the relationship of the body to the x-ray equipment and to anatomical references. All body positions and exam requirements are expressed in terms of projection, position, and view. A projection refers to the path the x rays take through the body, from entrance to exit. Position describes the body and its relationship to the x-ray film device (film cassette, image intensifier, image receptor). View is not a positioning term but instead is used in discussion the radiograph. For example, the physician orders an upright chest x ray with two views of an ambulatory patient. The standard positions are P. A. (back to front) and lateral (from the side). The radiographer positions the patient standing at the xray image receptor for a posterior-anterior projection (the x rays pass from the patient's back to the front) and a left lateral projection (patient's left side closest to image receptor and x rays pass from the patient's right to left). Body positioning may also require adjacent areas be addressed, i.e., moving the arms out of the way.

Anatomical position Anatomical position is the fundamental term used in body positioning. In this position, the patient is standing and facing front. The arms are down at the sides and the palms are turned forward so that you can see them. Feet are pointed straight ahead and the toes are lying down on the floor. The surface of the body that is facing front is known as the anterior, or ventral, surface. Any anatomical structure located in the half of the body that is adjacent to the anterior surface is considered to be anterior within the body. The surface of the body facing the rear is the posterior, or dorsal, surface. Any anatomical structure located in the half of the body that is adjacent to the posterior surface is considered to be posterior within the body. The body is also discussed in right and left sides using an imaginary line dividing the sides through the body's center. Posture and relationship to x-ray equipment X-ray exams are performed with either stationary or mobile equipment. Stationary equipment may be specialized for upright exams such as a chest x-ray unit or panoramic chair unit. Some stationary equipment only allows for the patient to lie down on a table for the exam. Other stationary equipment has a rotating table that allows for upright exams in addition to having the patient lie on the table. Mobile, or portable, x-ray equipment can accommodate a variety of patient positions. Regardless of the equipment used, the same principles and terminology of positioning are applicable.
Positions for x-ray exams may require description of posture, that is, whether the patient is to be lying down, standing, or seated. The patient's physical condition or ability to cooperate may also affect the positioning procedures used for the exam. If the patient is standing, the body is referred to as upright or erect. The general term for lying down is recumbent. It is necessary to describe the position as face up or face down. Supine position of a patient describes lying on the back and facing up in anatomical position. Prone position describes the patient lying on the abdomen and facing down. For comfort, the patient may turn the head to the side unless the part to be x-rayed is the

face, head, or neck. For some exams, the patient is slanted in a head-down position known as Trendelenburg. Descriptions of the patient's position also varies by the projection. If an oblique projection is required, the body or body part (or the x-ray tube) is rotated 45 degrees from anatomical position. The side and surface closest to the image receptor describe the position. For example, a left anterior oblique describes the patient as having the left, anterior surface of the body closest to the receptor at 45 degrees from anatomical position. Another variation of position is decubitus. In the decubitus position, the patient is lying down and the x rays pass through the patient 90 degrees from the table or bed surface. In a lateral decubitus, the patient is lying on either the right or left side and the x-ray beam passes through the patient from anterior to posterior or posterior to anterior. The position is named for the side that the patient is lying on, i.e., left lateral decubitus describes the patient as lying on their left side. Lateral decubitus positions are used to image the chest or abdomen when it is necessary to demonstrate the presence of an air-fluid interface. In a dorsal decubitus, the patient is supine and the x rays pass through the body from right to left or left to right. This type of position is commonly used in lateral x rays of the spine when the patient cannot be moved into a standard lateral position.

Additional anatomical and movement terms Additional terms are used to describe relationships of body parts or directions. These terms are often paired describing opposites. Cephalic, or superior, describes a direction toward the head of the body while caudal, or inferior, refers to the feet or away from the head. Proximal describes the source or beginning, i.e., the knee is proximal to the ankle. Distal directs you away from the source or beginning. Medial refers to the middle or toward the center of the body while lateral refers to the outside or away from the center. The surfaces of the hand and foot have special anatomical terms. Plantar refers to the sole of the foot, dorsum to the top or anterior surface of the foot, and palmar to the palm of the hand.
Movements of the joints are also important in body positioning. Flexion refers to decreasing the angle between two parts such as the bending of the elbow. Its opposite movement is extension. The hyperextended joint is straightened beyond neutral or bent so as to increase the normal angle beyond neutral. In describing

A technologist positions a patient's arm for an x ray. (Photograph by Will & Deni McIntyre. Science Source/Photo Researchers. Reproduced by permission.)

flexion and extension of the spine, bending forward is flexion, neutral position is extension, and bending backward is hyperextension. Movement of the arms or legs toward the body's median line is known as adduction while moving them away from the body is abduction. Specialized movements are used to demonstrate stress on a joint. Such movements of the ankle and foot are performed without moving the leg. They are described as eversion, an outward movement, and inversion, an inward movement. Other specialized movements may be described for their effect on adjacent joints or articulations. If the hand is supinated, it is in anatomical position (palm facing up). If pronated, the palm faces down. X-ray exams of the shoulder may require views of both pronation and supination of the hand to completely evaluate structures of the head of the humerous as it articulates in the shoulder joint.

Body habitus The body habitus describes the basic body shape. Body shape is important in x-ray exams as the size, shape, and position of the organs varies by body type. The technologist should adjust the x-ray unit accordingly, in order to obtain an adequate image. There are four terms used to describe body habitus:

Hyperstenic (large to massive). Chest and abdomen are broad and deep, lungs are short, diaphragm is high. Stenic (average). Hypostenic (slender). Asthenic (very slender). Chest is narrow, shallow, and long so diaphragm is low.

In the hyperstenic patient, the stomach typically lays across the abdomen at or above waist level. The stomach of a stenic patient is shaped like a comma laying slightly skewed from left to right and centered at the waistline. The stomach of a hypostenic patient is elongated into a "J" shape and may extend into the pelvis. Since the astenic patient appears to have little abdominal space between the diaphragm and pelvis, the stomach is quite long and slender lying primarily in the pelvis. An understanding of body habitus and the relationship of the organs in the chest, abdomen, and pelvis are essential in positioning for upper and lower gastrointestinal exams. In addition, other positioning considerations are important, including posture, respiration, and stomach contents.

Preparation
Most x-ray exams require little if any preparation by the patient. In many cases, the change from street clothes to a hospital gown is all that is required. Some exams may require the patient to fast for several hours while others may require ingestion of a radiopaque liquid that will define the gastrointestional system in the radiographs. Special imaging procedures such as nuclear medicine, sonography, or magnetic resonance imaging may have additional preparation requirements.

Aftercare
Few x-ray examinations require aftercare. If the examination required an injection of medication or contrast media, instructions will be given about the contrast and care of the puncture site. Following examination of the gastrointestinal system, patients are typically instructed to drink plenty of fluids and are advised how the exam may affect bowel movements.

Complications
Complications following x-ray exams are rare. If an injection is required or catheter is used, there may be the typical complications at the puncture site-bruising, bleeding, and discomfort. Patients should be advised of the possibility of complications from their exam, preferably in writing.

Health care team roles

Although the radiographer actually performs the examination in most cases, there are other members of the health care team in the radiology department or imaging center. Many facilities have transport personnel whose job it is to move patients in and out of the imaging rooms and department. These individuals are trained in the safe handling of patients and support equipment as well as proper lifting techniques and universal precautions against infections. Many hospitals provide a radiology nurse to perform injections, assist the physician in special procedures, or provide patient care as required. The radiologist will interpret the resulting images.

KEY TERMS
Articulation joint, a connection between bones. Orthogonal planesntersecting planes, planes at right angles to each other.

Position body posture such as upright, recumbent, supine, prone, lateral, also the description of the posture of an anatomical part such as oblique. Radiograph-ray image, either physical (on film or paper) or digital. Radiographerllied health professional who performs diagnostic imaging exams using x rays, magnetic resonance imaging, computed tomography, sonography, and others.

Endoscopic Diagnosis Gastrointestinal endoscopy allows the physician to visualize and biopsy the upper gastrointestinal tract including the esophagus, stomach and duodenum. The enteroscope (a longer endoscope) allows visualization of at least 50% of the smallintestine, including most of the jejunum and different degrees of the ileum. During these procedures, the patient is given a numbing agent to help prevent gagging. Pain medication and a sedative may be administered prior to the procedure. The patient is placed in the left lateral position (Figure 11).

Figure 11. Room set-up and patient positioning for endoscopy.

An endoscope (a thin, flexible, lighted tube) is passed through the mouth and pharynx and into the esophagus. The forward-viewing scope transmits an image of the esophagus, stomach and duodenum to a monitor visible to the physician (Figure 12). Air may be introduced into the stomach, expanding the folds of tissue, and enhancing examination of the stomach.

Figure 12. Endoscope.

Esophagogastroduodenoscopy (EGD) is the most direct and most accurate method of establishing the diagnosis of peptic ulcer disease (Figures 13 and 14). In addition to identifying the ulcer, its location and size, EGD also provides an opportunity to detect subtle mucosal lesions and to biopsy lesions to establish histopathological basis. Endoscopic biopsies are indicated for all gastric ulcers at the time of diagnosis, whereas duodenal ulcers are almost always benign, not requiring biopsy in usual circumstances.

Figure 13. A, Endoscopic view of a benign gastric ulcer; B, corresponding illustration.

Figure 14. A, Benign duodenal ulcer; B, corresponding endoscopic view.

Endoscopic biopsy also appears the best and most accurate diagnostic method for H. pylori. Histological examination with standard hematoxylin and eosin staining provides an excellent means of diagnosis (Figure 15).