Upper Gastrointestinal Contrast Research Articles

A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting.

BackgroundBilious vomiting in children requires an urgent evaluation with upper gastrointestinal (UGI) fluoroscopy as it may herald life-threatening midgut malrotation with volvulus (MMWV). There are no published data available on the duration of time-critical UGI workflow steps.ObjectivesA digital audit of workflow in emergency UGI contrast studies performed on children with bile-stained vomiting at a large South African teaching hospital.MethodA retrospective study was conducted from 01 May 2012 – 31 May 2019. A customised search of the institutional radiology information system (RIS) defined all children with bilious vomiting who underwent emergency UGI fluoroscopy. Extracted RIS timestamps were used to calculate the median duration of the ‘approval’, ‘waiting’, ‘study’ and ‘reporting’ times. One-way analysis of variance and Chi-squared tests assessed the association between key parameters and the duration of workflow steps, with 5% significance (p < 0.05).ResultsThirty-seven patients (n = 37) with median age 0.8 months were included, of whom 20 (54%) had an abnormal C-loop. The median ‘total time’ from physician request to report distribution was 107 min (interquartile range [IQR]: 67−173). The median ‘approval’ (6 min; IQR: 1–15) and ‘reporting’ (38 min; IQR: 17–91) times were the shortest and longest workflow steps, respectively. Abnormal C-loops (p = 0.04) and consultant referrals (p = 0.03) were associated with shorter ‘approval’ times. The neonatal ‘waiting’ time was significantly longer than that for older patients (p = 0.02).ConclusionThe modern RIS is an excellent tool for time-critical workflow analyses, which can inform interventions for improved service delivery.

The diagnostic accuracy of ultrasound and upper gastrointestinal contrast studies for locating atresia/stenosis and intestinal malrotation and detecting annular pancreas in pediatric patients with duodenal atresia/stenosis.

This study aimed to evaluate the diagnostic performance of ultrasound to locate atresia/stenosis and other abdominal anomalies in pediatric patients with duodenal atresia/stenosis, including intestinal malrotation and annular pancreas. We classified 36 retrospective cases of duodenal atresia/stenosis based on intestinal malrotation status, and evaluated the diagnostic performance of ultrasound/upper gastrointestinal contrast studies to locate atresia/stenosis and intestinal malrotation, as well as ultrasound for detecting additional anomalies such as annular pancreas. The incidence of annular pancreas was compared between groups using Fisher's exact test. Atresia/stenosis was correctly located by ultrasound in 33 (91.7%) cases and by upper gastrointestinal contrast study in 36 (100%) cases. Of the eight cases with intestinal malrotation, five and two were correctly diagnosed by ultrasound and upper gastrointestinal contrast study, respectively. Ultrasound correctly diagnosed annular pancreas in 6/14 cases. The incidence of annular pancreas was significantly different between the groups (present/absent in groups with vs. without intestinal malrotation: 6/2 vs. 8/20, P = 0.036). Ultrasound has a relatively high capability in locating atresia/stenosis. However, some cases are misdiagnosed. In clinical practice, upper gastrointestinal contrast studies should be used complementarily during diagnosis. Additional anomalies may not be detected by preoperative examinations; therefore, surgeons should carefully evaluate for additional anomalies during surgery, especially coexisting intestinal malrotation and annular pancreas.

Neonatal intestinal malrotation: A diagnostic pitfall

Intestinal malrotation is a rare abnormality, resulting in intestinal malrotation and impaired fixation. This clinical entity encompasses spectrum of anatomical conditions and associated clinical disorders. Main symptoms of intestinal obstruction related to malrotation are sudden bilious emesis in a previously healthy term neonate. Upper gastrointestinal (UGI) contrast study is the examination of choice and remains as gold standard for intestinal malrotation. With 90% positive predictive value, misdiagnosis in rotational abnormalities could still happen in UGI contrast study. We report a case of pitfall diagnosis in an 8-day-old male neonate, in which obstruction has been misinterpreted as duodenal web rather than malrotation that was furthered found during surgery.

Is There a Role for Elective Early Upper Gastrointestinal Contrast Study in Neurologically Impaired Children following Laparoscopic Nissen Fundoplication?

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11–18.41) years. Mean body weight was 16.22 (3.3–62.5) kg. Mean duration of follow up was 4.15 (0.01–16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

A Rare Entity: Case Report of Recurrent Hypertrophic Pyloric Stenosis

Introduction: Hypertrophic pyloric stenosis (HPS) is well known in pediatric surgery and has good outcomes after pyloromyotomy.1 Emesis in the immediate postoperative period occurs in 40% of patients with HPS and is attributed to gastroparesis from prolonged gastric distention.2 Emesis presenting weeks to months after pyloromyotomy prompts an evaluation that often yields pathology unrelated to HPS. Because recurrent HPS is rare, making this diagnosis highlighted the importance of practicing broad differential diagnoses, ruling out most common causes, and including obscure etiologies. Clinical Findings: A 3-week-old male born after full-term gestation with a history of HPS underwent an uncomplicated laparoscopic pyloromyotomy. He had an uneventful initial recovery but then presented with recurrent projectile nonbilious emesis 7 weeks postoperatively. Between presentations, the patient consistently tolerated feeds and gained weight. Informed consent was obtained. Clinical Course: The patient was evaluated with an abdominal ultrasound, which revealed a hypertrophic pyloric channel, and an upper gastrointestinal contrast (UGI) study, which showed a partial gastric outlet obstruction. He underwent laparoscopy, which revealed a thickened pyloric channel, prompting a repeat pyloromyotomy. Postoperatively, his diet was advanced, and he was discharged on postoperative day 1. Conclusions: Emesis after pyloromyotomy for HPS is common and usually self-limited. Recurrent emesis after normal feeding for weeks or months often yields a diagnosis unrelated to HPS. However, if other more common causes of emesis are excluded, then recurrent HPS can be evaluated with abdominal ultrasound and an UGI study. Once diagnosed, laparoscopic repeat pyloromyotomy is an appropriate treatment option.

Is there a role for upper gastrointestinal contrast study to predict the outcomes of sleeve gastrectomy? Lessons learnt from a prospective study.

Context:The importance of upper gastrointestinal (UGI) contrast study following sleeve gastrectomy (SG) is equivocal. It can, however, yield anatomical and functional details, the significance of which mostly remains unknown.Settings and Design:This prospective, single-center study included SG patients between January 2018 and January 2019.Materials and Methods:UGI contrast study was done on post-operative day 1. The findings of the study namely gastroesophageal junction (GEJ) holdup time, presence of fundus, gastroduodenal emptying (GDE) time, and sleeve shape were compared with weight loss, improvement of glycosylated hemoglobin (HbA1c) and gastroesophageal reflux disease (GERD) symptoms at 3, 6, and 12 months follow-up.Results:There were 138 patients with 100% follow-up. Radiological sleeve patterns observed were: tubular (62.3%), superior (16.0%), and inferior (21.7%) pouches. GEJ holdup time had no effect on percentage total weight loss (%TWL) (P = 0.09) or HbA1c improvement (P = 0.077). The absence of fundus led to greater %TWL at 6 months (P = 0.048). GDE time <15 s led to higher %TWL (P = 0.028) and lower HbA1c (P = 0.010) at 12 months. Antrum size <2 cm was associated with higher %TWL (P = 0.022) and lower HbA1c level (P = 0.047) at 12 months. Vomiting and regurgitation were common with tubular sleeves.Conclusion:UGI contrast study can predict weight loss, HbA1c improvement, and GERD symptoms. The absence of fundus, small antrum, and rapid GDE are associated with better weight loss. HbA1c improvement is better with small antrum and rapid GDE. Tubular sleeve predisposes to vomiting and regurgitation.

Duodenal displacement and acquired intrathoracic stomach in an extreme premature baby on jejunostomy feeds- a case report

Repeated and persistent displacement forces can lead to acquired abnormalities in the position of the foregut in premature neonates. Cow milk protein intolerance should be considered early as a cause of feed intolerance, recurrent vomiting and other gastrointestinal symptoms in premature neonates. Upper gastrointestinal contrast study cannot be used to diagnose gastro-oesophageal reflux disease.

Biliary Reflux in Annular Pancreas in Upper Gastrointestinal Contrast Study.

Biliary Reflux in Annular Pancreas in Upper Gastrointestinal Contrast Study.

Imaging pearls of the annular pancreas on antenatal scan and its diagnostic dilemma: A case report

Background: Annular pancreas is an uncommon cause of duodenal obstruction and rarely causes complete duodenal obstruction. Due to its rarity of identification in the antenatal period and overlapping imaging features with other causes of duodenal obstruction; it is often misdiagnosed.&#x0D; Case presentation: A 33-year-old primigravida came for routine antenatal ultrasonography at 28 weeks and 4 days of gestational age. On antenatal ultrasonography, dilated duodenum and stomach were seen giving a double bubble sign and a hyperechoic band surrounding the duodenum. Associated polyhydramnios was also present. Fetal MRI was also done. Postpartum ultrasonography demonstrated pancreatic tissue surrounding the duodenum. The upper gastrointestinal contrast study showed a non-passage of contrast beyond the second part of the duodenum. Due to symptoms of obstruction, the neonate was operated on, and the underlying cause was found to be the annular pancreas.&#x0D; Conclusion: Diagnosis of duodenal obstruction due to the annular pancreas is very important in the antenatal period to plan for appropriate therapeutic interventions after birth. A double bubble sign is seen due to various etiologies however the presence of a hyperechoic band in the antenatal ultrasound may point to the diagnosis of the annular pancreas.

Clinical Findings Versus Imaging Studies in the Diagnosis of Infantile Hypertrophic Pyloric Stenosis

Background : Infantile hypertrophic pyloric stenosis is the commonest surgical cause of vomiting in early infancy and can be diagnosed clinically or by imaging studies. OBJECTIVES : To assess the accuracy of clinical examination as compared with ultrasound and upper gastrointestinal contrast imaging in the diagnosis of infantile hypertrophic pyloric stenosis. PATIENTS AND METHODS : A prospective study of 30 patients referred to the pediatric surgical department in pediatric teaching hospital in Erbil with a possible diagnosis of IHPS in the period from June 2006 to January 2009. RESULTS : The male to female ratio was 3.28:1 .The mean age at onset was 29.5 days. The mean age at presentation was 48 days. Projectile vomiting was present in all infants (100%). Pyloric mass was palpable in 21 infants (70%). Visible peristaltic waves were noted in 12 infants (40%). 27 patients (90%) had gastric aspirate of more than 10cc. Ultrasound examination was confirmatory in 29 patients (96.6%). Barium study was positive in 27 cases (90%) and different signs were noted with various percentages. All patients underwent Ramstedt`s operation through right upper transverse incision. The average hospital stay was 3.5 days. The long term results in all the 30 cases were excellent. CONCLUSION : A palpable pyloric mass with suggestive history is a sufficient indication for proceeding to surgical treatment without confirming diagnostic imaging studies. However, when physical findings alone are inconclusive, an upper gastrointestinal series or an abdominal ultrasound examination should be done because of their high sensitivity in identifying the underlying problems. DOI: 10.7176/JHMN/76-04 Publication date: June 30th 2020

Pyloric Duplication in Ten Years Old Girl: A Case Report

Gastrointestinal duplication cysts are rare congenital anomalies. Pyloric duplication represents 2.2% of all gastrointestinal tract duplications. The presentations merely depend on the site of occurrence, size and type of the cyst, and presence of ectopic mucosal lining. A ten years old girl vomited for two months, accompanied with stomach ache and difficulty in defecation. The color of stool sometimes was black. The body weight decreased twelve kilograms in two months. On physical examination, no abdominal distention and no palpable mass was found, bowel sound was decreased and there was tenderness in epigastric area. Nutritional status of patient was severe malnutrition. Laboratory test revealed mild hypochromic microcytic anemia, severe hyponatremia, severe hypokalemia, and hypoalbuminemia. Abdominal ultrasound revealed thickening of the gastric wall and upper gastrointestinal contrast study revealed partial stenosis with thickening of pyloric wall. Esophagogastroduodenoscopy revealed multiple gastric ulcers and gastric outlet obstruction. Cyst duplication and stricture in the pylorus were found during surgical procedure. The pediatric surgeon performed an excision of duplication cyst and gastroduodenostomy side to side anastomosis. Histopathologic examination from cyst confirmed the enteric duplication cyst. The patient was discharged in good condition. We concluded that pyloric duplication is considered as one of the differential diagnosis in children with symptoms of gastric outlet obstruction. Appropriate surgical procedures should be undertaken to avoid complications.

Congenital intrathoracic stomach can be safely managed laparoscopically.

Congenital intrathoracic stomach (CIS) is an uncommon pediatric surgical diagnosis where > 2/3rd of the stomach lies within the chest through a hiatus defect. We reviewed our recent experience with this condition. A retrospective single-center review of children with a diagnosis of CIS (2007-2018) was performed. Patient demographics, presentation, imaging and management were assessed. Results are expressed as median (range). Eleven patients (6 girls) were identified with onset of symptoms at 2 (0-26) months of age. Presenting symptoms were vomiting (8/11), respiratory symptoms (4/11) and failure to thrive (2/11). Two patients had Marfan's syndrome. An upper gastrointestinal contrast study demonstrated gastric herniation in all. All were corrected laparoscopically with hiatus repair and fundoplication [age at surgery 10.5 (1.5-34.5) months]. A concurrent gastrostomy was done in children ≤ 6 months (n = 5). Enteral feeds were commenced on post-operative day one in 9 and second post-operative day in 2. At 7 (0-95) months follow-up, all were on full enteral feeds. One patient had a recurrence 6 months post-operatively, which was re-operated laparoscopically without any further recurrence. This is the largest reported series of children with CIS. All could be managed laparoscopically with no conversions and a low recurrence.

Esophageal tuberculosis mimicking malignancy on 18F-FDG PET/CT

Abstract A 42-year-old woman presented with a ten-day history of dysphagia, slight chest pain and occasional vomiting. With the performance of thoracic and abdominal enhanced computed tomography (CT) and upper gastrointestinal contrast, once esophageal cancer was suspected. Significant activity mass in esophagus and mediastinal lymph nodes could be found on the imaging of 18F-FDG PET/CT, which also supported malignancy. However, The biopsies of the mid-esophagus were negative for malignancy. Then a video-assisted thoracic surgery (VATS) for mediastinal lymph node biopsy was taken and esophageal tuberculosis was diagnosed by histopathologic examination. This rare case reminds us of esophageal tuberculosis as a possible differential diagnosis in esophageal mass with enlarged lymph nodes.

Role of esophageal manometry in children with refractory gastroesophageal reflux symptoms.

We investigated the prevalence of psychiatric referral, frequency of repeat upper gastrointestinal (UGI) contrast studies, and esophagogastroduodenoscopy (EGD) in children with ineffective esophageal motility (IEM) before the confirmation of esophageal dysmotility. A total of 19 children (nine boys, 10 girls; mean age, 13.80±5.10years) with symptoms of refractory gastroesophageal reflux (GER) who underwent high-resolution esophageal impedance manometry (HRIM) were enrolled in this retrospective analysis. Refractory GER symptoms were defined as persistent symptoms even under acid-suppression therapy for 8weeks in this study. Clinical data including age, gender, time from symptom onset to diagnosis, and number of UGI contrast studies and EGD before diagnosis were obtained. HRM parameters and the prevalence of psychiatric referral were also analyzed. There are 14 children (73.68%) diagnosed with IEM by HRIM, and another 5 children (26.32%) diagnosed as GER disease (GERD) by EGD. A significant proportion of IEM children were misdiagnosed with psychological problems compared with the GERD children (78.57% vs 20.00%, P=0.04). Three IEM children (21.43%) received antipsychotic and antidepressant agents before diagnosis of IEM, and all of them discontinued these medications after diagnosis. IEM children underwent a greater number of UGI contrast studies (1.07±0.92 vs 0.20±0.45; P=0.02) and EGD (2.36±2.50 vs 0.60±0.55; P=0.03) before HRM than GERD children. Esophageal manometry for the diagnosis of IEM should be considered in children with GER symptoms refractory to acid-suppression therapy for 8weeks to avoid repeat UGI contrast studies, EGD, and psychological therapy.

A thoracoscopically resected case of the diverticulum in the middle esophagus

BackgroundApproximately 65% of esophageal diverticulum cases are asymptomatic and are found by endoscopic examination. Symptomatic middle esophageal diverticulum requiring surgery is rare. In recent years, endoscopic surgery for middle esophageal diverticulum has been reported, but cases remain few in number, and the surgical indication, surgical procedure, and postoperative results are unknown.Case presentationA 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. The diameter of his middle esophageal diverticulum was 47 mm. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row. The pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient in a prone position via 4 ports, and intraoperative endoscopy was performed during the surgery. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled, and the diverticulum was resected using an automatic suturing device.A postoperative upper gastrointestinal contrast examination revealed no abnormalities. He was discharged on postoperative day 12.ConclusionsDuring thoracoscopic surgery for middle esophageal diverticulum, we think that pulling and separating the diverticulum and confirming the lumen using endoscopy are useful for reducing the risk of postoperative recurrence and stenosis. Few reports of long-term performance after surgery have been made for this procedure. Therefore, we believe that long-term follow-up is necessary.

Reliability and usefulness of upper gastro intestinal contrast studies to assess pouch size in patients with weight loss failure after Roux-en-Y gastric bypass

Background: Weight loss failure or weight regain occurs in up to 25% of patients with a Roux-en-Y gastric bypass (RYGB). Post-operative anatomical changes, like pouch or stoma dilatation, might contribute. Aim of this study is to assess reliability and usefulness of upper gastro intestinal (UGI) contrast studies to detect pouch dilatation.Methods: Retrospective case–control study of patients with weight loss failure between 2010 and 2015 (failure group, n = 101) and a control group (n = 101) with adequate weight loss. Pouch dilatation was systematically reassessed. Clinical parameters were extracted from the electronic patient records.Results: Systematic reassessment showed 23/101 (23%) pouch dilatation in the failure group, compared to 11/101 (11%) in the control group (p = .024). Revision surgery was performed in 43/101 patients in the failure group. After this surgery, only 8% of patients with pouch dilatation achieved adequate weight loss, whereas 39% of patients without pouch dilatation achieved adequate weight loss (p = .07). There was no difference in return to adequate weight loss between patients treated surgically and conservatively (30% vs 28%).Conclusion: Systematic reassessment of UGI contrast studies showed 23% pouch dilatation in patients with weight loss failure after RYGB. However, low interobserver agreement and discrepancy in success rate of revision surgery greatly questions the reliability and usefulness of this diagnostic modality.

Myasthenic crisis following iodinated contrast material (iohexol) aspiration: a case report

BackgroundThe number of contrast media-related procedures is ever increasing due to the widespread availability of theoretically safe, low osmolar iodinated contrast material. Although intravenously administered contrast is known to precipitate myasthenic crisis, oral contrast aspiration as a causative factor is not yet documented as such.Case summaryA 48-year-old Sinhalese man diagnosed as having myasthenia gravis, was evaluated for progressive dysphagia with an upper gastrointestinal contrast study. Iodinated contrast material (iohexol) was used as the contrast medium and there was direct evidence of contrast aspiration during the study. Several minutes after the procedure, severe respiratory distress with evidence of myasthenic crisis requiring intubation and intensive care admission was noted. Treatment with intravenous immunoglobulin, high-dose steroids, and broad-spectrum intravenously administered antibiotics led to an uneventful recovery, although the latter part of the clinical course was complicated with total left lung collapse.SummaryMyasthenic crisis can be precipitated by various factors and a successful recovery requires mechanical respiratory support with immunomodulatory and steroid therapy. This is the first reported case that describes the development of myasthenic crisis following iohexol-associated aspiration pneumonitis.

Childhood Intestine Rotation Anomalies in Aba, Nigeria

Background: The anomalies of rotation, migration and fixation of the intestines are of intense interest to the pediatric surgeon, as they are frequently associated with midgut volvulus which has catastrophic consequences when diagnosis is delayed or even not considered. This study evaluates the outcomes of surgical management of intestinal malrotation in children. Materials and Methods: The medical records of all patients with symptomatic malrotation, who underwent surgery between January 2010 and September 2018, were reviewed. Patients' demographic characteristics, clinical features management, complications, and outcome were evaluated. Results: Ten patients (nine boys and a girl) underwent surgery for malrotation at a median age of 3months. Eight presented with acute symptoms and two with chronic symptoms. All the patients had symptoms of intermittent or complete upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study in six of them. Volvulus was found at the time of surgery in 5 patients, three of whom were neonates. Eight patients were treated by Ladd's operation. Median length of stay was 10 days. One patient with massive bowel gangrene due to volvulus had right hemicolectomy. There was two perioperative death from anastomostic leak and septicaemia with an overall mortality of 20%. Conclusion: Bowel gangrene from volvulus contributes to mortality and small bowel adhesive intestinal obstruction is a cause of morbidity and mortality following surgery for intestinal malrotation. Neonates with bilious vomiting should raise the suspicion of malrotation until proven otherwise and given prompt intervention.

Utility of Immediate Postoperative Upper Gastrointestinal Contrast Study in Bariatric Surgery.

Routine use of postoperative upper gastrointestinal (UGI) contrast studies after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) is controversial. We sought to determine the usefulness of routine UGI contrast studies during postoperative day (POD) 1 in patients who underwent bariatric surgery. We performed a retrospective study of patients who underwent SG or RYGB between January 1, 2016, and October 31, 2017. Demographics, surgical data, and immediate surgical adverse effects were collected. We compared patients who underwent routine UGI contrast studies on POD 1 versus patients who did not. A total of 284 patients were analyzed; 197 (69.4%) patients underwent RYGB, while 87 (30.6%) underwent SG. Routine UGI contrast study was performed in 96 (48.7%) patients in the RYGB group versus 31 (35.6%) in the SG group. The overall adverse effect rate was 2 (0.7%); postoperative UGI contrast study was negative in both cases. Mean (SD) length of stay (LOS) for patients who underwent UGI contrast study versus those who did not was similar in the RYGB group (1.8 [1.6] days vs 1.8 [0.9] days, respectively) and the SG group (2 [1.18] days vs 1.9 [0.9] days). The average cost of a postoperative UGI contrast study was $600, resulting in an additional overall cost of $76,800. Use of routine UGI contrast studies after bariatric procedures does not appear to add clinical value for the detection of leaks. Furthermore, systematic use of postoperative UGI contrast studies neither seem to reduce LOS, nor appear to increase procedure costs.

Dextrogastria and Malrotation of Midgut in a Neonate

A neonate presented with bilious vomiting and hematochezia. The infantogram and upper gastrointestinal contrast study were suggestive of dextrogastria with malrotation of midgut. Laparotomy confirmed isolated dextrogastria, malrotation of the midgut and volvulus. Reverse Ladd’s procedure was done.