Fluoroscopy Barium Meal
Indications
1. High or low dysphagia.
2. Gastro-esophageal reflux disease
(GERD)
3. Assessment of a hiatus hernia.
4. Generalized epigastric pain.
5. Globus pharyngeus.
6. Persistent vomiting.
7. Assessment of fistula.
8. Inability to pass the endoscope during
UGIE.
Methods of Barium Meal
- Double Contrast ( গ্যাস তৈরী হয় এমন খাবার + Barium Sulphate)
- Single Contrast (Barium Sulphate)
Contrast Media Requirement:
- 130 gm Barium
Sulphate+750 ml water.
- 7 UP/ Sprite
(Double Contrast)
Patient Requirement:
- কম পক্ষে ৬ ঘন্টা খালি পেটে থাকতে হবে।
- সুতি কাপড় পরিধান করতে হবে।
- রোগীর গায়ে Metallic কোন জিনিস থাকলে তা খুলে দিতে হবে
Produce Technique:
- প্রথমে Barium Sulphate ১ টি মগে বা গ্লাসে ভালো করে মিশাতে হবে।
- রোগীকে Bucky টেবিলে বসায়ে ২ ঢোক পরিমাণ Barium Sulphate খাওয়াতে হবে এবং টেবিলের রোগীকে বাম দিকে ২বার ঘুড়াতে হবে তারপর Supine এবং Prone Position এর ছবি নিতে হবে।
- তারপর রোগীকে Machine এর Foot Stand এ দাঁড় করাই।
- গোলানো Barium Sulphate এর অর্ধেক গ্লাস খাইয়ে দিতে হবে।
- Machine এ রোগীকে ঠিকমতো Position করে Monitor এ Stomach লক্ষ করি এবং Full Stomach এর একটি ছবি নেই।
- গ্লাসে রাখা বাকি অর্ধেক Barium Sulphate রোগীকে খাইয়ে দিই।
- Machine এর Screen এ Stomach এর Duodenum লক্ষ করি। Barium Sulphate Duodenum area তে গমন করলে Erect Position এ দুটি Duodenum Cap এর Spot Film নিই। ( একটি Pressure দিয়ে অপরটি Pressure ছাড়া)।
- তারপর মেশিনসহ রোগীকে শোয়াইয়া Right Anterior Oblique এবং Left Anterior Oblique Position এ Duodenum Cap এর আরও দুটি Spot Film নিতে হবে।
- Hiatus hernia (পাকস্থলী বৃদ্ধি প্রাপ্ত) দেখার প্রয়োজন হলে রোগীকে Head Down করে Stomach এর Fundus include করে একটি ছবি নিতে হবে।
- এখানে উল্লেখ্য যে, কখনও কখনও Stomach এর Lateral ছবি নেওয়ার প্রয়োজন হতে পারে।
- সব গুলি ছবি রেডিওলজিষ্ট কে দেখাতে হবে এবং প্রয়োজন হলে রেডিওলজিষ্ট এর Advice অনুযায়ী ছবি নিতে হবে।
Anatomy stomach
The stomach, is an intraperitoneal digestive organ located between the oesophagus and the duodenum.
It has a ‘J’ shape, and features a lesser and greater curvature. The anterior and posterior surfaces are smoothly rounded with a peritoneal covering.
In this article, we shall look at the anatomy of the stomach – its position, structure and neurovascular supply.
Anatomical Position
The stomach lies within the superior aspect of the abdomen. It primarily lies in the epigastric and umbilical regions, however, the exact size, shape and position of the stomach can vary from person to person and with position and respiration.
Anatomical Structure
Fig 1 – The parts of the stomach.
The stomach has four main anatomical divisions; the cardia, fundus, body and pylorus:
Cardia – surrounds the superior opening of the stomach at the T11 level.
Fundus – the rounded, often gas filled portion superior to and left of the cardia.
Body – the large central portion inferior to the fundus.
Pylorus – This area connects the stomach to the duodenum. It is divided into the pyloric antrum, pyloric canal and pyloric sphincter. The pyloric sphincter demarcates the transpyloric plane at the level of L1.
Greater and Lesser Curvatures
The medial and lateral borders of the stomach are curved, forming the lesser and greater curvatures:
Greater curvature – forms the long, convex, lateral border of the stomach. Arising at the cardiac notch, it arches backwards and passes inferiorly to the left. It curves to the right as it continues medially to reach the pyloric antrum. The short gastric arteries and the right and left gastro-omental arteries supply branches to the greater curvature.
Lesser curvature – forms the shorter, concave, medial surface of the stomach. The most inferior part of the lesser curvature, the angular notch, indicates the junction of the body and pyloric region. The lesser curvature gives attachment to the hepatogastric ligament and is supplied by the left gastric artery and right gastric branch of the hepatic artery.
Fig 2 – The greater and lesser curvatures of the stomach
Anatomical Relations
The anatomical relations of the stomach are given in the table below:
Anatomical Relation | Structures |
Superior | Oesophagus and left dome of the diaphragm |
Anterior | Diaphragm, greater omentum, anterior abdominal wall, left lobe of liver, gall bladder |
Posterior | Lesser sac, pancreas, left kidney, left adrenal gland, spleen, splenic artery, transverse mesocolon |
Sphincters of the Stomach
There are two sphincters of the stomach, located at each orifice. They control the passage of material entering and exiting the stomach.
Inferior Oesophageal Sphincter
The oesophagus passes through the diaphragm through the oesophageal hiatus at the level of T10. It descends a short distance to the inferior oesophageal sphincter at the T11 level which marks the transition point between the oesophagus and stomach (in contrast to the superior oesophageal sphincter, located in the pharynx). It allows food to pass through the cardiac orifice and into the stomach and is not under voluntary control.
Pyloric Sphincter
The pyloric sphincter lies between the pylorus and the first part of the duodenum. It controls of the exit of chyme (food and gastric acid mixture) from the stomach.
In contrast to the inferior oesophageal sphincter, this is an anatomical sphincter. It contains smooth muscle, which constricts to limit the discharge of stomach contents through the orifice.
Emptying of the stomach occurs intermittently when intragastric pressure overcomes the resistance of the pylorus. The pylorus is normally contracted so that the orifice is small and food can stay in the stomach for a suitable period. Gastric peristalsis pushes the chyme through the pyloric canal into the duodenum for further digestion.
Fig 3 – The peristaltic ejection waves of the stomach
Greater and Lesser Omenta
Within the abdominal cavity, a double layered membrane called the peritoneum. supports most of the abdominal viscera and assists with their attachment to the abdominal wall.
The greater and lesser omenta are two structures that consist of peritoneum folded over itself (two layers of peritoneum – four membrane layers). Both omenta attach to the stomach, and are useful anatomical landmarks:
Greater omentum – hangs down from the greater curvature of the stomach and folds back upon itself where it attaches to the transverse colon It contains many lymph nodes and may adhere to inflamed areas , therefore playing a key role in gastrointestinal immunity and minimising the spread of intraperitoneal infections.
Lesser omentum– continuous with peritoneal layers of the stomach and duodenum, this smaller peritoneal fold arises at the lesser curvature and ascend to attach to the liver. The main function of the lesser omentum is to attach the stomach and duodenum to the liver.
Together, the greater and lesser omenta divide the abdominal cavity into two; the greater and lesser sac. The stomach lies immediately anterior to the lesser sac. The greater and lesser sacs communicate via the epiploic foramen, a hole in the lesser omentum.
Fig 4 – The greater and lesser omenta.
Neurovascular Supply
The arterial supply to the stomach comes from the celiac trunk and its branches. Anastomoses form along the lesser curvature by the right and left gastric arteries and along the greater curvature by the right and left gastro-omental arteries:
Right gastric – branch of the common hepatic artery, which arises from the coeliac trunk.
Left gastric – arises directly from the coeliac trunk.
Right gastro-omental – terminal branch of the gastroduodenal artery, which arises from the common hepatic artery.
Left gastro-omental – branch of the splenic artery, which arises from the coeliac trunk.
The veins of the stomach run parallel to the arteries. The right and left gastric veins drain into the hepatic portal vein. The short gastric vein, left and right gastro-omental veins ultimately drain into the superior mesenteric vein.
Fig 5 – Arterial supply to the stomach
Innervation
The stomach receives innervation from the autonomic nervous system:
Parasympathetic nerve supply arises from the anterior and posterior vagal trunks, derived from the vagus nerve.
Sympathetic nerve supply arises from the T6-T9 spinal cord segments and passes to the coeliac plexus via the greater splanchnic nerve. It also carries some pain transmitting fibres.
Lymphatics
The gastric lymphatic vessels travel with the arteries along the greater and lesser curvatures of the stomach. Lymph fluid drains into the gastric and gastro-omental lymph nodes found at the curvatures.
Efferent lymphatic vessels from these nodes connect to the coeliac lymph nodes, located on the posterior abdominal wall.
Clinical Relevance: Disorders of the Stomach
Gastro-Oesophageal Reflux Disease
This is a digestive disorder affecting the lower oesophageal sphincter. It refers to the movement of gastric acid and food into the oesophagus.
GORD is a common condition, affecting 5-7% of the population. Symptoms include dyspepsia, dysphagia, and an unpleasant sour taste in the mouth.
There are three main causes of reflux disease:
Dysfunction of the lower oesophageal sphincter
Delayed gastric emptying
Hiatal hernia (see below)
Treatment involves lifestyle changes, medication such as a PPI to reduce stomach acid, and as a last resort, surgery.
Hiatus Hernia
A hiatus hernia occurs when a part of the stomach protrudes into the chest through the oesophageal hiatus in the diaphragm. There are two main types of hiatal hernias; sliding and rolling:
Sliding hiatus hernia – The lower oesophageal sphincter slides superiorly. Reflux is a common complication, as the diaphragm is no longer reinforcing the sphincter.
Rolling Hiatus Hernia – The lower oesophageal sphincter remains in place, but a part of the stomach herniates into the chest next to it. This type of hiatus hernia is more likely to require surgical correction to prevent strangulation of the herniated pouch.
Fig 6 – Classifications of hiatus hernias. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a rolling type.
Anatomy small intestine
The small intestine is an organ located within the gastrointestinal tract. It is approximately 6.5m in the average person and assists in the digestion and absorption of ingested food.
It extends from the pylorus of the stomach to the ileocaecal junction, where it meets the large intestine at the ileocaecal valve. Anatomically, the small bowel can be divided into three parts: the duodenum, jejunum, and ileum.
In this article, we shall examine the anatomy of the small intestine – its structure, neurovascular supply, and clinical correlations.
Fig 1 – The anatomical divisions of the small intestine.
The Duodenum
The most proximal portion of the small intestine is the duodenum. Its name is derived from the Latin ‘duodenum digitorum’, meaning twelve fingers length. It runs from the pylorus of the stomach to the duodenojejunal junction.
The duodenum can be divided into four parts: superior, descending, inferior and ascending. Together these parts form a ‘C’ shape, that is around 25cm long, and which wraps around the head of the pancreas.
D1 – Superior (Spinal level L1)
The first section of the duodenum is known as ‘the cap’. It ascends upwards from the pylorus of the stomach, and is connected to the liver by the hepatoduodenal ligament. This area is most common site of duodenal ulceration.
The initial 3cm of the superior duodenum is covered anteriorly and posteriorly by visceral peritoneum, with the remainder retroperitoneal (only covered anteriorly).
D2 – Descending (L1-L3)
The descending portion curves inferiorly around the head of the pancreas. It lies posteriorly to the transverse colon, and anterior to the right kidney.
Internally, the descending duodenum is marked by the major duodenal papilla – the opening at which bile and pancreatic secretions to enter from the ampulla of Vater (hepatopancreatic ampulla).
D3 – Inferior (L3)
The inferior duodenum travels laterally to the left, crossing over the inferior vena cava and aorta. It is located inferiorly to the pancreas, and posteriorly to the superior mesenteric artery and vein.
D4 – Ascending (L3-L2)
After the duodenum crosses the aorta, it ascends and curves anteriorly to join the jejunum at a sharp turn known as the duodenojejunal flexure.
Located at the duodenojejunal junction is a slip of muscle called the suspensory muscle of the duodenum. Contraction of this muscle widens the angle of the flexure, and aids movement of the intestinal contents into the jejunum.
Fig 2 – The different parts of the duodenum. The liver, gall bladder and transverse colon have been removed.
Clinical Relevance: Duodenal Ulcers
A duodenal ulcer is the erosion of the mucosa in the duodenum. It may also be described as a peptic ulcer (although this term can also be used to refer to ulcerations in the stomach). Duodenal ulcers are most likely to occur in the superior portion of the duodenum.
The most common causes of duodenal ulcers are Helicobacter pylori infection and chronic NSAID therapy.
An ulcer in itself can be painful, but is not particularly troublesome and can be treated medically. However, if the ulcer progresses to create a complete perforation through the bowel wall, this is a surgical emergency, and usually warrants immediate repair. A perforation may be complicated by:
Inflammation of the peritoneum(peritonitis) – causing damage to the surrounding viscera, such as the liver, pancreas and gall bladder.
Erosion of the gastroduodenal artery – causing haemorrhage and potential hypovolaemia shock.
Jejunum and Ileum
The jejunum and ileum are the distal two parts of the small intestine. In contrast to the duodenum, they are intraperitoneal.
They are attached to the posterior abdominal wall by mesentery (a double layer of peritoneum).
The jejunum begins at the duodenojejunal flexure. There is no clear external demarcation between the jejunum and ileum – although the two parts are macroscopically different. The ileum ends at the ileocaecal junction.
At this junction, the ileum invaginates into the cecum to form the ileocecal valve. Although it is not developed enough to control movement of material from the ileum to the cecum, it can prevent reflux of material back into the ileum (if patent, see below).
Fig 3 – The ileocecal junction
Clinical Relevance: Characteristic Features of the Jejunum and Ileum
During surgery, it is often necessary to be able to distinguish between the jejunum and ileum of the small intestine:
Jejunum | Ileum |
Located in upper left quadrant | Located in lower right quadrant |
Thick intestinal wall | Thin intestinal wall |
Longer vasa recta (straight arteries) | Shorter vasa recta |
Less arcades (arterial loops) | More arcades |
Red in colour | Pink in colour |
Vasculature and Lymphatics
Duodenum
The arterial supply of the duodenum is derived from two sources:
Proximal to the major duodenal papilla – supplied by the gastroduodenal artery (branch of the common hepatic artery from the coeliac trunk).
Distal to the major duodenal papilla – supplied by the inferior pancreaticoduodenal artery (branch of superior mesenteric artery).
This transition is important – it marks the change from the embryological foregut to midgut. The veins of the duodenum follow the major arteries and drain into the hepatic portal vein.
Lymphatic drainage is to the pancreatoduodenal and superior mesenteric nodes.
Jejunum and Ileum
The arterial supply to the jejunoileum is from the superior mesenteric artery.
The superior mesenteric artery arises from the aorta at the level of the L1 vertebrae, immediately inferior to the coeliac trunk. It moves in between layers of mesentery, splitting into approximately 20 branches. These branches anastomose to form loops, called arcades. From the arcades, long and straight arteries arise, called vasa recta.
The venous drainage is via the superior mesenteric vein. It unites with the splenic vein at the neck of the pancreas to form the hepatic portal vein.
Lymphatic drainage is into the superior mesenteric nodes.
Fig 4 – Arterial supply to the jejunum and ileum of the small intestine
Clinical Relevance: Ileocaecal valve
The ileocaecal valve represents the separation between the small and large intestine. Its main function is to prevent the reflux of enteric fluid from the colon into the small intestine. It is also used as an landmark during colonoscopy, indicating that the limit of the colon has been reached and that a complete colonoscopy has been performed.
The ileocaecal valve is also important in the setting of large bowel obstruction. Should the ileocaecal valve be competent, a closed loop obstruction can occur and cause bowel perforation. Should the ileocaecal valve be incompetent (i.e. allow backflow of enteric contents into the small bowel) then the situation is less emergent and the trajectory of the obstruction less rapid.
