Authors: John Petronovich MD, Matthew Koeberl MD, Steven Denson MD, Joseph Budovec MD
Objectives: Provide clinicians with a basic knowledge of the technical factors involved in common fluoroscopic studies performed on the geriatric patient
Context: Geriatric patient in fluoroscopic studies
Action: Performing a fluoroscopic radiologic study on geriatric patients with varying degrees of mobility
Incidence/Prevalence: Though the use of fluoroscopy has declined over the past 20 years, it remains a unique tool for dynamic evaluation of anatomical structures. Swallow studies are the most commonly performed studies, which evaluate swallowing dynamics, as aspiration may occur in about 40%-50% of stroke patients. Swallow studies are also common in patients with neurological diseases such as Parkinson’s disease and dementia. Esophagrams evaluate a variety of symptoms, most importantly “presbyesophagus” (alterations in esophageal muscle function) in the geriatric patient. While upper GI studies and small bowel series are less frequently performed in the elderly, understanding of such procedures is important as certain pathologies (i.e. gastric ulcers, partial small bowel obstruction, gastroparesis and motility disorders) can be seen in the elderly. Barium enemas are less frequently performed today due to colonoscopy and CT colonography, but there are instances in which the barium enema remains a tool for evaluation of the colon.
Background: Clinicians should understand the necessary positioning and mobility requirements for patients undergoing a fluoroscopic study, as geriatric patients are more likely to have mobility and musculoskeletal constraints that limit the ability to perform ordered studies. Knowledge of positioning may help clinicians anticipate the benefit of each study in a particular patient.
Underlying Science: The breadth of pathology these studies evaluate is beyond the scope of this review. Fluoroscopy permits evaluation of dynamic organs in real time, allowing an understanding both of anatomy and function that may not be otherwise captured on static images. Fluoroscopy consists of real-time visualization of anatomic structures in motion. A continuous x-ray beam passes through the patient before projecting to a fluorescent screen where the light pattern is amplified and digitally recorded for viewing1. It is therefore useful in evaluating the physiologic movement of structures such as GI peristalsis.
Fluoroscopy Procedures: The positioning involved in common fluoroscopic studies are as follows:
Swallow Study: The patient is examined while seated in an upright position in a chair. The patient is presented with measured volumes of liquids with barium. If patient is immobile, the study can be performed in a wheelchair or lying on a cart with a back support that is elevated to a vertical position2.
Esophagram: The patient is imaged while in an upright, supine, and prone right anterior oblique position (on their right side, tilted approximately 45 degrees with their left (upper) knee forward to support their weight). As the patient will be drinking barium in all positions. As such, the patient must have the ability to tolerate lying prone and supine with manipulation of their hip and knee. Considerations should be made for patients with musculoskeletal problems such as scoliosis, lordosis, and degenerative disk disease, arthritis of the shoulder, back, hip, and knee, and similar conditions.
Upper GI series: The initial positioning is similar to the esophagram, examining the esophagus, stomach, and duodenum. The goal is to get adequate contrast lining of the mucosal surfaces of the esophagus and stomach. The patient is asked to perform at least two 360 degree turns, from supine to prone to supine. While this can be modified for the patient, it is important for the patient to know that this may be asked of them.
Small bowel series: The patient drinks barium and lies supine on a table with x-rays taken periodically thereafter. Total duration is variable, as the contrast is followed until it is in the cecum. The test frequently takes over 2 hours to complete. The patient must be able to lie supine, but is frequently asked to lie on his/her side and in the prone position.
Barium enema: Patient placed in right/left lateral decubitus (on their side) position. Barium is instilled through the rectum. The patient is asked to turn and lie in right/left posterior oblique (on their side, tilted backward approximately 45 degrees, with a pillow or blanket to support this position), prone, lateral decubitus, and supine positions as necessary to fill and image the colon in its entirety. The patient needs to maintain fecal continence.
ACGME Competencies: Patient care, Practice-based learning and improvement, Medical Knowledge
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Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: John Petronovich MD, Matthew Koeberl MD, Steven Denson MD, Joseph Budovec MD, Fast Fact #30: Fluoroscopy, April 2013.
Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
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