ICRI GUIDELINES ON PAEDIATRIC FLUOROSCOPIC PROCEDURES

ICRI SUB-SPECIALTY GROUP FOR PEDIATRIC IMAGING

SEPTEMBER 2020

DR . AKSHAY KUMAR SAXENA (SUB-SPECIALITY HEAD)

AKSHAY KUMAR SAXENA

DEVASENATHIPATHY KANDASAMY

ANMOL BHATIA

KUSHALJIT SINGH SODHI

NATASHA GUPTA

ANIT PARIHAR

DR. KUSHALJIT SINGH SODHI

(SUB-SPECIALTY CO-ORDINATOR)
 ICRI- GUIDELINES FOR PAEDIATRIC FLUOROSCOPIC PROCEDURES

General instructions & Precautions for any Paediatric Fluoroscopic

examination

Pre-Procedure:

1. At the time of giving appointment, scrutinize the clinical details and ensure that a

fluoroscopic examination is indicated. Attempts should be made to obtain the

answer to the clinical question from modalities using non ionizing radiation such

as ultrasound (USG) and Magnetic Resonance Imaging (MRI) (discussed below).

2. Child / parents/ guardians should be informed about the procedure and radiation

exposure especially if the procedure entails significant exposure [1].

3. Last menstrual period should be asked for all female patients/attendants who are

in the childbearing age group and inside the fluoroscopy room to avoid accidental

radiation exposure to the fetus.

4. Whenever combined Ultrasound (USG) and Fluoroscopy is to be used for image

guided procedures (e.g. placement of catheter, cannula etc.), it is important to

use USG for guidance most of the time and use fluoroscopy sparingly [2, 3].

5. All the operators should know and fully understand the modes and functioning of

the fluoroscopy machine and their implication on the radiation dose.

6. All personnel in the room including the patient attendants should wear

appropriate radiation protection such as lead apron (0.5 mm lead equivalent,

front and 0.25 mm on sides and back) and thyroid shields [1].

7. All the operators should wear radiation dosimeters on the collar outside the lead

apron and front of the torso underneath the lead apron [1].
8. One should always make an attempt to use a hanging lead shield and lead table

skirt. In centers with high throughput, lead glasses for lens protection are also

recommended. Lead gloves should be used if there is significant risk of exposing

of operators’ hand [1, 4].

9. The protective apparels and equipment should be periodically tested for its

quality.

10. One should choose the appropriate vendor provided preset or program for the

body part to be exposed. This will minimise the radiation exposure by adjusting

the exposure parameters, filtration, fluoroscopy frame rates and the positioning of

automatic exposure control (AEC) sensors. The AEC, also known as automatic

brightness control (ABC), in fluoroscopy uses a feedback loop and adjusts

various parameters in a chosen preset and delivers the best image quality with

optimal radiation exposure. This feedback happens in real time. The AEC

threshold is dependent on the preset chosen which highlights the importance of

choosing the right preset (anatomical programming) for any examination.

11. Should use the lowest possible frame rate to reduce radiation exposure.

12. If a procedure is performed by a trainee, it is important that the procedure should

be supervised by an experienced (paediatric) radiologist to avoid unnecessary

prolongation of procedure time.

During the Procedure:

1. The monitors and image intensifier should be in the optimal position before

starting the fluoroscopy. Adjusting them after or during fluoroscopy will deliver

unwanted radiation.
2. The operators should keep track of the fluoroscopy time.

3. Fluoroscopy should be used judiciously, only when real time view is needed.

4. X-ray beam should be collimated appropriately depending on the area and type

of examination. Special care to be observed for radiosensitive areas such as

breast, gonads, thyroid and eyes. Collimation not only avoids radiation to

unnecessary areas, but it also improves image quality by reducing scatter

radiation.

5. By reducing the scatter radiation, collimation reduces the exposure to operators

as well. Tighter collimation leads to large dose savings.

6. Fluoroscopy should be used in brief pulses and even a single frame is enough in

some cases such as ascertaining the position of catheters/cannula.

7. Last Image Hold (LIH) or Fluoroscopy Store functions should be used to avoid

repeat exposure or run. LIH displays the last frame of the fluoroscopy loop, and it

is very helpful because it reduces the need for another exposure. If LIH or fluoro

store images are good enough to answer a diagnostic question, then there is no

need for acquiring spot image exposure. Even if spot exposures are necessary,

use the lowest magnification and frame (pulse) rate possible.

8. Do not use continuous fluoroscopy. It increases radiation dose and decreases

the sharpness of image especially if the child is moving. Pulsed fluoroscopy with

low frame rate to be used. The pulse width used for children is usually less than

6 msec. Use “pause and pulse” technique and abide by “as low as reasonably

achievable” (ALARA) principle. One should be cautious and assume that even

small radiation doses can be harmful [5].

9. Continuous fluoroscopy produces a frame rate of 30 per second. Hence, a

pulsed fluoroscopy with 30 frames per second will deliver the same amount of

radiation as that of continuous fluoroscopy. Frame rate of 15 per second will

deliver about 50% of radiation compared to frame rate of 30 per second.

Generally, a frame rate of 1-4 per second is optimal in fluoroscopic examinations

of gastrointestinal tract (GIT) and urinary bladder [6].

10. Higher kV reduces patient dose but reduces contrast resolution, lower kV

increases patient dose but improves contrast resolution. Hence, a balanced

approach is needed. Fluoroscopy examination with iodinated contrast should not

use kV more than 80, whereas it can go up to 100 kV if barium is used as

contrast material [7].

11. Increase in mA or pulse width will have a similar effect on radiation dose. Their

increase will increase patient dose but decreases image noise. Before increasing

the pulse width, it is important to increase the mA to maximum. This will reduce

the exposure time and consequently improve the sharpness of the image which

is critical in moving/uncooperative kids [8].

12. Beam filtration reduces the radiation dose to patients by blocking the low energy

radiation which is non-contributory to image formation. This improves the quality

of the beam. Thinner the patient body thicker should be the filtration. Copper is

used as a filtration material in modern machines [9].

13. Magnification (smaller FOV) almost always increases the radiation dose. One

should always start with large FOV/no magnification and the areas outside the

body contour can be collimated. Smaller FOV/ magnification should be used only
 if there is a need to do so. In the machines with image intensifier-based systems

this electronic magnification leads to exponential increase in dose while the dose

increase is linear in machines having flat panel detectors. Digital magnification

which is a post processing method does not add on to the dose. Geometric

magnification which is performed by moving the image receptor away from the

patient leads to degradation of image quality. It should be discouraged in all

pediatric procedures [8].

14. Modern machines allow the operator to choose radiation dose rate (low, medium,

high) which is a measure of radiation reaching the receptor. For low contrast

structures (abdomen and non-contrast studies), the setting should be high and

vice versa in high contrast structures (lungs, bones, contrast studies) [6, 10].

15. Frame averaging is a method used to improve image quality by combining more

than one image. It adversely affects the temporal resolution which is not

acceptable in pediatric imaging and this setting should be kept minimal or turned

off [11].

16. Do not try to achieve a high-quality image (high signal to noise ratio [SNR],

visually appealing). It is enough to have a diagnostic quality image for the

problem at hand. This will drastically bring down the radiation dose [6].

17. In under-couch tube systems, the source-to-skin distance (SSD) should be as

large as feasible. It reduces the patient dose significantly according to inverse

square law. At the same time, the image intensifier/ flat panel detector should be

as close to the patient to prevent scatter radiation (Source to image receptor

 distance - SID, should be kept less). This will also improve the image quality by

increasing the number of photons reaching the receptor [8].

18. In the lateral position of the tube, the operator should be on the same side of the

image receptor (opposite to tube) to prevent scatter radiation [6].

19. It is important to know that an increase in body thickness increases the dose

dramatically. This is the reason why lateral and oblique projections deliver more

radiation compared to frontal projection and obese individuals get more radiation

compared to lean individuals. Hence, wherever feasible keep the thickness of the

body tissue minimal (e.g. keeping arms overhead in lateral exposures).

20. Removing the grid wherever possible (especially for children less than 20 kgs)

will bring down the radiation dose drastically without causing much effect on the

image quality [12].

21. As far as possible, all injections should be performed away from the radiation

source by using a long tubing. Alternatively, power injectors can be used.

22. Before injection or any critical phase which needs to be captured, make sure the

FOV, magnification and other parameters are as desired.

23. As far as possible all personnel should maintain distance from the radiation

source to minimise the radiation exposure.

24. Newer machines provide radiation exposure parameters such as air kerma, dose

area product, fluoroscopy time, kV, mAs etc. After the procedure these radiation

metrics should be checked and if it is exceeding the safe threshold, appropriate

actions are to be taken.

ALTERNATIVE MODALITIES TO FLUOROSCOPY

Ultrasonography (USG):

1. Guiding needles, catheters, guidewires in interventional procedures.

2. Infants with non-bilious vomiting should undergo USG first to rule out congenital

hypertrophic pyloric stenosis.

3. USG can be used ahead or instead of MCU in children with urinary tract infection

(UTI).

4. Evaluation of the diaphragmatic movements can be performed under USG rather

than fluoroscopy.

Magnetic Resonance Imaging (MRI):

1. MR urography can be used to evaluate the anomalies of kidneys and urinary

tract instead of intravenous urography (IVU) or sometimes even micturating

cystourethrogram (MCUG).

2. MR defecogram is another procedure which can provide much more information

than conventional defecogram in a cooperative child if the center has the facility

to perform the procedure.

COMMON PAEDIATRIC FLUOROSCOPIC PROCEDURES

Micturating Cystourethrogram (MCUG)

MCUG is a commonly performed procedure in children and it helps to evaluate

the lower urinary tract (Urinary bladder, urethra and possibly ureters). Radiography

and fluoroscopy is used in this procedure to record images. It is one of the best

modality to evaluate vesicoureteral reflux (VUR) and other bladder and urethral

abnormalities.

INDICATIONS [13-17]:

1. Hydronephrosis / hydroureteronephrosis.

2. First episode of urinary tract infection (UTI) with abnormal USG of kidney, ureter

or bladder in children of either sex.

3. Recurrent UTI, Congenital urinary tract abnormalities.

4. Neurogenic bladder, urinary incontinence, voiding difficulty.

5. Bladder outlet obstruction.

6. Trauma and post procedural evaluation.

In situations like trauma to the urinary tract with blood in the meatus, it is

important to perform retrograde urethrography (RGU) to evaluate urethra before

catheterising the child for MCUG. This will avoid more damage to the urethra during

catheterisation. Decisions to perform MCUG should be taken carefully in situations

like recent surgery, trauma and acute urinary tract infection. If all the precautions are

taken, complications due to MCUG are unusual. Routine prophylactic antibiotics are

not necessary, except in patients with increased risk of infection such as children

with high grade VUR and other abnormalities which would increase the risk of
infection. Other modalities which can be used as an alternative to diagnose VUR are

contrast enhanced voiding urosonography (no radiation) and nuclear cystography

(radiation dose comparable to state-of-the-art fluoroscopy). However, these

modalities are not good enough to provide a detailed anatomical demonstration like

MCUG.

PROCEDURE:

● Sedation is not needed for the procedure since it needs some level of

cooperation and preservation of voiding reflex.

● Fasting is not needed.

● Check LMP for all female attendants in the reproductive age group who are

present in the examination room.

● Plain image (radiographic exposure / fluoroscopic store) is important to record

before injecting contrast.

● Anesthetic gel (lignocaine gel) can be used to reduce the pain and distress due

to catheterisation. It can be injected into the urethra in boys and can be applied

externally as well in both boys and girls

● Catheterisation should be performed after appropriate cleaning of the meatal

area under strict aseptic conditions by an experienced medical personnel. In

neonates and infants, a 5 F catheter is appropriate and for older children 8 F is

appropriate. Larger size catheters can be used in adolescents. Avoid inserting

too much catheter into the bladder to avoid looping and knotting. Balloon

catheters should also be avoided because it can mask the bladder base

abnormalities in the early filling phase. In males immediately after catheterisation,

 the foreskin should be positioned back. The catheters can be kept in place by

using tapes.

● After catheterisation, the bladder should be drained completely. This will reduce

the dilation effect and be useful in calculating the bladder volume.

● Use ionic contrast for the procedure, preferably warmed. Contrast can be diluted

(1:4) and instilled via gravity (around 3 feet) into the bladder or using a hand

injection. The volume of infusion is calculated based on the age of the child. For

infants the bladder volume can be calculated by: volume in ml = 38 + (2.5 × age

in months) [18]. In older children the bladder volume is calculated by: volume in

ml = (age in years + 2) × 30 [19]. In a post op situation, low-pressure infusion is

recommended.

● Infusion / injection should be stopped when the child complains of pain or the

contrast extravasation happens in children with a history of surgery or trauma.

● Images of the early filling phase needs to be recorded and the filling phase can

be monitored by intermittent fluoroscopy. Continuous monitoring is not

necessary. It is important to record the volume of the full bladder (volume of

infusion/injection).

● Full bladder image along with bilateral oblique need to be recorded. If there is

reflux the image should also include the renal area for grading. Sometimes, reflux

can occur during the voiding phase only which needs to be recorded.

● Lateral film is indicated only if there is suspicion of urachal abnormality and in

children with urogenital sinus abnormalities (genitogram).

● Cyclical filling of bladder (repeated filling up to 3 times after emptying of bladder)

can be helpful in infants who usually micturate before adequate filling and in

children with grossly dilated ureters.

● Keep the head end of the fluoroscopy table a little elevated to ensure that

contrast flows down the table and does not smear the buttocks and the back.

● Micturition phase should be recorded in the proper position. Although frontal view

is adequate for girls for the urethral evaluation, bilateral oblique views are also

suggested to avoid missing out on low grades of VUR. For boys, bilateral oblique

views are optimal in showing the entire urethra in profile [17]. While waiting for

the child to micturate, it is important not to keep the fluoroscopy on and the

operator needs to visually watch the perineum to look for the signs of voiding.

Only the brief period of voiding needs to be recorded.

● Immediately after voiding the renal fossae and ureters need to be screened for

reflux and then post void image of pelvis should be recorded.

● Whenever VUR is visualized (whether in resting or voiding phase), an AP film of

KUB region should be recorded to document laterality and grading of VUR.

● After the procedure, send the patient back with proper instructions. Patients have

to be instructed to report to concerned unit or department in case a child

develops urinary retention, hematuria or fever.

 TYPICAL MCUG REPORT:

MCUG study was performed by retrograde catheterization of urinary bladder and

injecting dilute ionic contrast solution under strict aseptic precautions. No procedure

related complications were encountered.

Findings:

● Plain film of the KUB region shows no radio opaque calculus.

● Urinary bladder is normal in shape, distension and outline.

● Urethra is normal in course, caliber and outline.

● No vesicoureteric reflux seen during static or micturating phase.

● Post void residual urine is insignificant.

Impression: Normal Study.

VUR can be graded as follows [20]:

Grade 1: reflux limited to the ureter.

Grade 2: reflux up to the renal pelvis.

Grade 3: mild dilatation of ureter and pelvicalyceal system.

Grade 4: tortuous ureter with moderate dilatation, blunting of fornices but preserved

papillary impressions.

Grade 5: tortuous ureter with severe dilatation of ureter and pelvicalyceal system,

loss of fornices and papillary impressions.

 CONTRAST ENEMA

Contrast enema is also a commonly used procedure in pediatric imaging which

can provide lots of information on the large as well as small bowel [21]. The

technique of performing contrast enema is very variable and it depends on the

clinical question. Hence, one should understand the needs of the clinician and tailor

the study accordingly.

INDICATIONS [22]:

1. Lower intestinal obstruction in neonates such as Hirschsprung’s disease,

meconium ileus, meconium plug syndrome, ileal or colonic atresia.

2. Constipation, unexplained abdominal pain.

3. Intussusception.

4. Pre and post operative evaluation.

5. Inflammatory or infective diseases.

Any sign of bowel perforation, peritonitis, ischemia and toxic megacolon are

contraindications for doing a contrast enema

PROCEDURE:

● There is no need for sedation or keeping the child fasting for the procedure.

● Procedure should be properly explained to the child or parents (depending on the

age).

● Check LMP for all female attendants in the reproductive age group present in the

examination room.

● Plain image (radiographic exposure / fluoroscopic store) is important to record

before injecting contrast.

● Infants and small children need to be immobilised with care so that the procedure

is done smoothly in a short time.

● The type of contrast will depend on the clinical scenario. Usual recommendation

is that for neonates and infants, water-soluble urographic contrast is used and for

children above 1 year of age dilute barium is used. Water Soluble contrast

(preferably iso to mildly hyperosmolar) is also used when there is a possibility of

perforation. High osmolar contrast agents are used in treating conditions like

meconium ileus and not for diagnosis. Diluted barium is appropriate when there

is suspicion of childhood Hirschsprung’s disease. Water-soluble contrast (iso-

osmolar to prevent electrolyte imbalance) is preferred in neonates or infants with

Hirschsprung’s disease [22, 23].

● Rectal catheterisation should be performed by a medical personnel only with

experience in doing it. Minimum length of tube should be inserted into the

rectum. For the routine contrast enema, tube with balloon is not recommended. It

can potentially mask the features in conditions like Hirschsprung’s disease. If

there is a need for inflating the balloon to achieve proper seal it should be done

after evaluating the rectum and rule out Hirschsprung’s disease. Tube with

inflatable balloon is generally used for reduction of intussusception [22, 24].

● The examination is started in the lateral projection and the initial filling phase

should be recorded especially when the suspicion is Hirschsprung’s disease.

Once the contrast enters the sigmoid colon, the position of the child can be

changed to supine or oblique depending on the course of the loop. When the

cecum is visualised, its position should also be recorded. It is a good practice to

 record non-critical views using fluoroscopy store rather than radiographic

exposure (around 10 times increased radiation) [8].

● In children with Hirschsprung’s disease, it is not important to document the entire

colon because it will be hugely dilated and loaded which might cause electrolyte

disturbances because of absorption. Hence, the study can be stopped once the

transition zone is demonstrated. Also, during the study if there is any evidence of

perforation, the study should be stopped and the clinician should be informed for

further management. Post evacuation images are recorded and some

radiologists also recommend 24-hour image to look for the contrast retention in

the colon [25]. If there is significant barium retention after 24 hours, the child

should be referred to the clinician for bowel wash.

● In children with suspected pouch colon, it is important to evaluate the entire colon

which is critical for the management of these patients [25].

● In children with suspected meconium ileus, contrast enema should be performed

only if it is uncomplicated. Any clinical or imaging sign of complication in

meconium ileus is a contraindication for contrast enema. When a therapeutic

contrast enema using a high osmolar agent is performed for meconium ileus,

there is a risk of electrolyte imbalance and dehydration because of fluid shift.

Hence, during this procedure it is important to watch for these complications [22].
 TYPICAL CONTRAST ENEMA REPORT:

Study done by per rectal administration of dilute urographic/ barium solution. No

procedure related complications were encountered.

Findings:

● Rectum, sigmoid colon, descending colon, transverse colon, ascending colon

and cecum are normal in course, caliber, outline and position.

● No dilated segment or transition zone seen.

● 24-hour film shows no/ insignificant residual contrast in colo-rectum.

Impression: Normal contrast enema study.

DISTAL COLOGRAM:

Distal cologram is another commonly performed study in the pre and post operative

scenario to demonstrate the colon distal to the stoma.

INDICATIONS:

1. Anorectal malformations.

2. Preoperative evaluation in conditions such as Hirschsprung’s disease.

3. Post operative evaluation in trauma, perforation etc.

PROCEDURE:

● Check LMP for all female attendants in the reproductive age group present in the

examination room.

● Surgically created distal stoma is catheterised using the largest possible Foley’s

catheter which is inflated to create a proper seal. Distal stoma is the stoma other

than the one from which the baby passes stool.

● Insert only the minimum length of Foley’s catheter i.e. just sufficient to ensure

inflation of balloon.

● Mild pull on the catheter should be applied to avoid spillage or reflux.

● Use ionic contrast in 1:1 (contrast:saline) dilution.

● Keep the head end the fluoroscopy table a little elevated to ensure that contrast

flows down the table and does not smear the buttocks and the back.

● In patients with ARM dead lateral and optional AP views are critical to evaluate

the fistulous communications.

● AP views are enough in patients where the indication is to looks for narrowing,

continuity or perforation.
 ● Attempts should be made to evaluate and record the course, caliber and, outline

of distal colon, the level of its ending and the presence or absence of fistulous

communication with urogenital tract.

TYPICAL DISTAL COLOGRAM REPORT IN ARM PATIENTS:

Distal colostomy site was occluded with Foley’s catheter and study done by injecting 1:1

diluted non-ionic contrast solution. No procedure related complications were

encountered.

Findings:

● There is free flow of the contrast across the distal colon.

● The distal colon is seen to end as a high/low type blind pouch.

● A fistulous tract is seen to arise from the inferior blind end of distal colon and

communicate with posterior urethra.

● No leak/stricture seen.

Impression: High/low ARM with rectourethral fistula.

TYPICAL DISTAL COLOGRAM REPORT (OTHER THAN ARM CASES):

Distal colostomy site was occluded with Foley’s catheter and study done by injecting 1:1

diluted non-ionic contrast solution. No procedure related complications were

encountered.

Findings:

● There is free flow of the contrast across the distal colon.

 ● Caecum, ascending colon, transverse colon, descending colon, sigmoid colon

and rectum are normal in course caliber and outline.

● No stricture/leak/fistula seen.

Impression Normal study for distal colon.

CONTRAST ESOPHAGOGRAM / UPPER GASTROINTESTINAL (UGI)
SERIES / BARIUM MEAL FOLLOW THROUGH (BMFT)

Contrast esophagogram and upper GI series can provide information about the

esophagus and upper GI. Unlike in adults, where these techniques are largely

replaced by endoscopy, in neonates and children they still play an important role.

These techniques can be either in single contrast mode or in double contrast mode.

In pediatric imaging most of the studies are done in single contrast mode to

delineate the anatomy of the area. Double contrast studies are rarely performed in

children.

INDICATIONS FOR ESOPHAGOGRAM [26]:

● Recurrent pneumonia or chest infection.

● Tracheo-esophageal fistula.

● Dysphagia, odynophagia.

● Pre and post operative evaluation.

● Sricture, perforation, leak.

INDICATIONS FOR UPPER GI SERIES [26]:

● Abdominal pain, vomiting.

● Failure to thrive.

● Suspicion of intestinal malrotation.

● Recurrent respiratory infection.

● UGI bleeding.

● Diaphragmatic hernia.
● Hypertrophic pyloric stenosis if USG is not available or USG findings are

equivocal.

● Gastric outlet or upper GI obstruction.

● Caustic ingestion.

INDICATIONS FOR BARIUM MEAL FOLLOW THROUGH [27]:

● Stricture / obstruction of small bowel.

● Infective and inflammatory bowel diseases (when CT or MR enterography is not

feasible).

● Abnormal motility.

● Mass lesions.

● Small intestinal bleed.

PROCEDURE:

● Child should be fasting before the procedure and the time-period of fasting

depends on the age of the child. For neonates 2-3 hours of fasting is enough,

whereas for infants and older children 4 hours of fasting is optimal. However,

emergency procedures can be performed in less time-period of fasting as well.

● There is no need for sedation during the procedure.

● The radiologist should tailor the study to the clinical question.

● Check LMP for all female attendants in the reproductive age group present in the

examination room.

● A plain image of the area to be imaged is recorded prior to taking contrast

images.
● The mode of contrast administration depends on the age of the patient. Small

children can be administered contrast through a feeding bottle or through an

infant feeding tube. If small children are not tolerating oral feed, injection of

contrast directly into the stomach through a nasogastric tube can be done.

Flavoured contrasts are more acceptable to older children. In children suspected

with H-type tracheoesophageal fistula, it is important to inject contrast using an

infant feeding tube starting from the lower esophagus and slowly pulling the tube

cranially while injecting contrast. This will better demonstrate the fistula. In

patients with indwelling tubes such as gastrostomy or jejunostomy tubes,

contrast can be injected through them.

● Diluted barium can be used in most of the situations. However, in neonates and

infants and where perforation or leak is suspected it is important to use water

soluble urographic contrast. Whenever water soluble urographic contrast is used

it should be either iso-osmolar or near iso-osmolar. Hyperosmolar contrast

should be discouraged because of the risk of aspiration (leading to pulmonary

edema) and electrolyte imbalance. In children with suspected intestinal

malrotation or proximal small bowel obstruction, the gastric contents need to be

aspirated before administering contrast.

● Esophagogram is typically started with the level of soft palate in lateral view

documenting any abnormality of deglutition or reflux into nasopharynx. Rest of

the esophagus is examined in AP and lateral positions. For suspected H type

trachea-esophageal fistula, the study should be started in lateral position. It is

important to distend the esophagus to demonstrate subtle H-type fistula which

 can be achieved by controlled injection and pulling of tube as described above.

This process has to be continuously monitored under fluoroscopy to differentiate

airway opacification contrast due to aspiration versus fistula.

● Upper GI examination should be tailored in such a way to evaluate the entire

esophagus, stomach and duodenum till duodenojejunal (DJ) flexure. In children

with suspected intestinal malrotation it is important to document the position of

DJ flexure in AP and lateral views to rule out malrotation. All these images can

be recorded by fluoroscopy store and not radiographic exposure except if there is

a reason to do otherwise. Presence or absence of gastroesophageal reflux and

gastric emptying should also be documented. The examination can be completed

after evaluating the passage of contrast into the jejunum.

● Barium meal follow through study is performed in a similar way like upper GI

study. Here the contrast passage has to be documented from stomach till it

reaches the colon. When the contrast reaches the jejunum, the child can be

made to sit outside the fluoroscopy room. Thereafter, the child needs to be

examined intermittently under fluoroscopy to look for the progression of contrast

passage. The child can be allowed food/milk after the stomach is emptied of the

contrast.
 TYPICAL ESOPHAGOGRAM REPORT:

A 5F infant feeding tube tip was placed in the pharynx and study done by

injecting non ionic contrast solution. No procedure related complications were

encountered.

Findings:

● There is free flow of contrast across the esophagus into the stomach.

● No reflux of contrast in to the nasopharynx seen.

● Esophagus is normal in course, caliber and outline. No leak, fistula or stricture

seen.

● Gastroesophageal junction is normal.

● No gastro esophageal reflux seen on fluoroscopy.

Impression: Normal study.

TYPICAL UPPER GI STUDY REPORT:

A 5F infant feeding tube tip was placed in the pharynx and study done by

injecting a non-ionic contrast solution. No procedure related complications were

encountered.

Findings:

● There is free flow of contrast across the esophagus into the stomach.

● No reflux of contrast in to the nasopharynx seen.

● Esophagus is normal in course caliber and outline. No leak /fistula or stricture

seen.

● Gastroesophageal junction is normal.

● No gastro esophageal reflux seen on fluoroscopy.

● Stomach is normal in site, shape, distension, and outline. Normal gastric

emptying seen.

● Duodenal cap is normal in shape, position and outline.

● Duodenal loop is normal in course, calibre and outline.

● Duodenojejunal flexure is normal in position.

● Proximal jejunal loops are normal.

Impression: Normal study.

TYPICAL BARIUM MEAL FOLLOW THROUGH REPORT:

● Stomach is normal in site, shape, distension, and outline.

● Duodenum is normal in course, caliber, and outline.

● Duodeno-jejunal flexure is normal.

● Jejunal and ileal loops are normal in course, caliber and mucosal pattern.

● Ileocaecal junction and caecum are normal.

● Transit time is ~ ----- hours (normal).

Impression: Normal Study.

References:

1. Checklists [Internet]. [cited 2020 Jul 28]. Available from:

https://www.imagewisely.org/Imaging-Modalities/Fluoroscopy/Checklists

2. Use of Ultrasound as an Alternative to Fluoroscopy [Internet]. [cited 2020 Aug 11].

Available from: https://www.imagewisely.org/Imaging-

Modalities/Fluoroscopy/Ultrasound-as-an-Alternative

3. Use of MRI as an Alternative to Fluoroscopy [Internet]. [cited 2020 Aug 11].

Available from: https://www.imagewisely.org/Imaging-Modalities/Fluoroscopy/MRI-

As-An-Alternative

4. Safety Awareness High Dose Operator [Internet]. [cited 2020 Aug 11]. Available

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