Synonym/Acronym
Gastric radiography, stomach series, small bowel study, upper GI series, UGI.
Rationale
To assess the esophagus, stomach, and small bowel for disorders related to obstruction, perforation, weight loss, swallowing, pain, cancer, reflux disease, ulcers, and structural anomalies.
Patient Preparation
There are no activity restrictions unless by medical direction. The patient should refrain from chewing gum or smoking prior to the procedure. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Pediatric Considerations: The fasting period prior to the time of the examination depends on the child’s age. General guidelines are that the patient should not eat for the period of time between normal meals: newborn, 2 to 3 hr; infants to 4 yr, 3 to 4 hr; 5 yr through adolescence, 6 to 8 hr.
Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Normal Findings
- Normal size, shape, position, and functioning of the esophagus, stomach, and small bowel.
Study type: X-ray, special/contrast; related body system: Digestive system.
The upper gastrointestinal (GI) series is a radiological examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate, which is a milkshake-like, radiopaque substance. A combination of x-ray and fluoroscopy techniques are used to record the study. Air or gas may be instilled to provide double contrast and better visualization of the lumen of the esophagus, stomach, and duodenum. If perforation or obstruction is suspected, a water-soluble iodinated contrast medium is used. This test is especially useful in the evaluation of patients experiencing dysphagia, regurgitation, gastroesophageal reflux (GER), epigastric pain, hematemesis, melena, and unexplained weight loss. This test is also used to evaluate the results of gastric surgery, especially when an anastomotic leak is suspected.
When a small bowel series is included, the test detects disorders of the jejunum and ileum. The patient’s position is changed during the examination to allow visualization of the various structures and their function. Images of the swallowed contrast medium as it moves through the digestive system are visualized on a fluoroscopic screen, recorded, and stored electronically for review. Drugs such as glucagon may be given during an upper GI series to relax the GI tract; drugs such as metoclopramide (Reglan) may be given to accelerate the passage of the barium through the stomach and small intestine.
When the small bowel series is performed separately, the patient may be asked to drink several glasses of barium, or enteroclysis may be used to instill the barium. With enteroclysis, a catheter is passed through the nose or mouth and advanced past the pylorus and into the duodenum. Barium, followed by methylcellulose solution, is instilled via the catheter directly into the small bowel.
Pediatrics: : An upper GI series is usually done in the pediatric population to diagnose the cause of recurrent GI signs (bleeding) and symptoms. The etiology is often related to age. In infants, recurrent symptoms such as vomiting after feeding, poor feeding, poor weight gain, and abdominal pain (evidenced by frequent crying during or after a feeding) may trigger an investigation. The most common causes of upper or lower GI bleeding in infants up to 1 mo include allergies to milk proteins, anorectal fissures, bacterial enteritis, coagulopathy, esophagitis, Hirschsprung disease, intussusception, peptic ulcer, stenosis, varices, or Meckel diverticulum. Children between 2 and 23 mo are most commonly diagnosed with allergies to milk proteins, anorectal fissures, esophagitis caused by GER, gastritis, intussusception, Meckel diverticulum, NSAID-induced ulcer, and ingested foreign body. Pediatric patients 24 mo and older are most commonly diagnosed with esophageal varices, Mallory-Weiss tears, peptic ulcer, related to Helicobacter pylori infection or peptic ulcer secondary to some other type of systemic disease (e.g., Crohn disease or inflammatory bowel disease [IBD]). Other abnormal findings in this age group include IBD, polyps, malignancy, sepsis, and Meckel diverticulum.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients suspected of having upper GI perforation, unless water-soluble iodinated contrast medium, such as Gastrografin, is used.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with an intestinal obstruction, because the barium or water from the enema may make the condition worse.
Factors That May Alter the Results of the Study
- Patients with swallowing problems may aspirate the barium, which could interfere with the procedure and cause patient complications.
- Possible constipation or partial bowel obstruction caused by retained barium in the small bowel or colon may affect test results.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
- Cancer (e.g., duodenal, esophageal, gastric, small bowel)
- Congenital abnormalities
- Diverticula (e.g., duodenal, esophageal, gastric, small bowel)
- Esophageal diverticula, inflammation, motility disorders, and varices
- Foreign body
- Gastritis
- Hiatal hernias
- Scarring
- Perforation of the esophagus, stomach, or small bowel
- Polyps
- Strictures
- Ulcers
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
|---|
| Fluid volume (deficit—related to NPO status, nausea, vomiting, fluid shift to peritoneal area secondary to obstruction) | Altered electrolytes; increased heart rate; decreased blood pressure; dry skin and mucous membranes; poor skin turgor; dark-colored urine; hemoconcentration; cool, clammy skin; poor urine output (less than 30 mL/hr); confusion; restlessness; agitation; capillary refill delay | | Gastrointestinal (altered—related to obstruction, tumor, stricture, congenital abnormality) | Variances in bowel sounds between high-pitched and absent sounds, crampy abdominal pain, nausea, vomiting, odorous emesis (fecal smell and appearance), constipation or diarrhea | | Pain (related to obstruction, tumor, stricture, congenital abnormality) | Self-report of abdominal pain; crying, moaning, groaning; increased heart rate and blood pressure; facial grimace |
|
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the esophagus, stomach, and small intestine.
- Explain that the procedure takes about 30 to 60 min and is performed in a radiology department.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Explain that for the study it will be necessary to drink a milkshake-like solution that has an unpleasant chalky taste.
Procedural Information
- Baseline vital signs are recorded and monitored throughout the procedure.
Pediatric Considerations
- Encourage parents/caregivers to be truthful about what the child may experience during the procedure (e.g., there may be a pinch or minor discomfort when the IV needle is inserted) and to use words that they know the child will understand.
- Talk about the test right before the procedure; toddlers and preschool-age children have a short attention span.
- Provide assurance that a favorite comfort item will be allowed into the examination room and, if appropriate, that a parent/caregiver will be with the child during the procedure.
- Provide older children with information about the test, and allow them to participate in as many decisions as possible (e.g., choice of clothes to wear to the appointment) in order to reduce anxiety and encourage cooperation.
- Encourage the child to practice the required position if the child will be asked to maintain a certain position for the test, provide a video or digital file that demonstrates the procedure.
- Teach strategies to remain calm, such as deep breathing, humming, or counting to oneself.
Upper GI Series
- Positioning for this procedure is on the x-ray table in a supine position, or standing in front of a fluoroscopy screen.
- Images are taken of pharyngeal motion while taking swallows of the barium mixture through a straw.
- If a double contrast study is requested, an effervescent contrast medium (e.g., gas-producing crystals) may also be given to the patient to swallow. The effervescent contrast material combines with barium to produce gas, which then introduces air into the stomach.
- Pediatric Considerations: For infants, barium contrast may be mixed with a small amount of the infant’s feeding to take in a bottle. If the patient is unable to drink the barium, a thin, flexible tube may be placed through the patient’s nose to get the barium into the esophagus.
- The upper GI series can take 40 min to 2 hr; follow-up images may be taken at 24 hr.
Small Bowel Series
- If the small bowel is to be examined after the upper GI series, the patient is instructed to drink an additional glass of barium while the small intestine is observed for passage of barium.
- Images are taken at 30- to 60-min intervals until the barium reaches the ileocecal valve.
- This process can last up to 5 hr; follow-up images may be taken at 24 hr.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Monitor for partial bowel obstruction caused by thickened or congealed barium.
- Explain the importance of immediately reporting symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Resume usual diet, fluids, medications, or activity, as directed by the HCP.
- Instruct the patient to take a mild laxative and increase fluid intake (four glasses) to aid in the elimination of barium unless contraindicated. Pediatric Considerations: Instruct the parents of pediatric patients to hydrate the child with electrolyte fluid post–barium enema. Older Adult Considerations: Chronic dehydration can also result in frequent bouts of constipation. Therefore, after the procedure, older adult patients should be encouraged to hydrate with fluids containing electrolytes (e.g., Gatorade, Gatorade low calorie for patients with diabetes, or Pedialyte) and to use a mild laxative daily until the stool is back to normal color.
- Explain that the stool will be white or light in color for 2 to 3 days. If the patient is unable to eliminate the barium, or if the stool does not return to normal color, the patient should notify the HCP.
Fluid Volume
- Monitor and trend laboratory studies: BUN, Cr, Hgb, Hct, and electrolytes.
- Monitor and trend blood pressure, heart rate, temperature, capillary refill, and skin turgor.
- Administer ordered parenteral fluids and replacement electrolytes.
- Perform a strict intake and output and monitor for fluid overload.
- Administer ordered antiemetics, analgesics, and antibiotics.
Gastrointestinal
- Enforce a nothing by mouth order (NPO).
- Facilitate gastric decompression as appropriate (nasogastric tube with intermittent suction).
- Administer ordered antiemetics, analgesics, and antibiotics.
- Assess the color and odor of any emesis (fecal odor or appearance).
- Assess the abdomen for bowel sounds, pain, tenderness, and distention.
- Administer ordered parenteral fluids.
- Prepare for ordered surgery; monitor and trend appropriate laboratory values and diagnostic studies (CBC, ABGs, electrolytes, GI studies), and intake and output.
Pain
- Assess pain character, location, duration, and intensity, and use an easily understood cultural- and age-appropriate pain rating scale.
- Consider alternative measures for pain management (imagery, relaxation, music, etc.).
- Assess and trend vital signs.
- Facilitate a calm, quiet environment and place in a position of comfort.
- Administer ordered antiemetics, analgesics, and antibiotics.
Clinical Judgement
- Consider how to best obtain buy-in toward implementation of therapeutic orders and improve GI status.
Follow-Up and Desired Outcomes
- Understands the medical and surgical options associated with the disease process.
- Agrees to follow therapeutic regime specific to disease process.