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4 Esophagram
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Acknowledgements None.
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Conicts of Interest There are no conicts of interest to disclose
and no funding for this study.
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The Upper GI Series
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EmilyAdams andAnnaIbele
An upper gastrointestinal study (UGIS) is a uoroscopic study,
which evaluates the contrast-lled esophagus, stomach, gastric
outlet, and proximal duodenum. It is useful in establishing or further dening pathology at the gastroesophageal junction, pathology related to the gastric outlet and duodenum, and post-surgical
anatomy and related pathology. The upper GI series (UGIS) classically involves the patient ingesting contrast, while under uoroscopic and spot radiographic imaging so that the movement of
contrast through the esophagus, gastroesophageal junction, stomach, and rst portion of the duodenum may be visualized and
recorded in real time. Classically, the study is performed with
barium sulfate as an oral contrast medium. Some radiologists prefer to initiate the study with water-soluble contrast if there is clinical concern for a leak (historically gastrogran although, this has
fallen out of favor due to concerns for the risk of aspiration pneumonitis) The American College of Radiology states that the upper
GI examination can be helpful in the diagnosis of peptic ulcer
5
E. Adams · A. Ibele (*)
Department of Surgery, The University of Utah,
Salt Lake City, UT, USA
e-mail: emily.adams@hsc.utah.edu; anna.ibele@hsc.utah.edu
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_5
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disease, hiatal hernia (HH), varices, neoplasm, gastric outlet
obstruction, gastric or duodenal mass, and varices [1]. In
practicality, many of these entities such as ulcers, masses, and
varices are best and most safely diagnosed endoscopically.
E. Adams and A. Ibele
UGIS in Conventional Anti-Reux Surgery
Although not a sensitive or specic test for pathologic reux,
UGIS can be helpful in the assessment for hiatal hernia as a potential anatomic contributing factor to reux symptoms or dysphagia
and is also sometimes useful for the evaluation of postoperative
dysphagia, regurgitation, or vomiting after an anti-reux operation. Barium esophagram and/or upper GI X-rays were historically recommended as a screening test for GERD, but are no
longer part of the diagnostic algorithm to conrm or refute pathologic reux. In a study of 125 patients, Johnson etal. compared
esophageal pH monitoring and barium esophagram/upper GI to
assess the accuracy of barium screening as a predictor of pathologic reux. The sensitivity and specicity of barium study to
identify pathologic reux were insufcient [2], and objective testing with upper endoscopy and esophageal pH monitoring is now
the gold standard for diagnosis of pathologic GERD.
The upper GI X-ray is useful in the initial evaluation of dysphagia and reux symptoms when there is clinical suspicion of
distal esophageal pathology or abnormal postoperative anatomy
[3]. In the patient presenting for consideration of anti-reux surgery who has undergone minimal objective evaluation, an UGIS
can also help to further dene the presence, type, and size of a
hiatal hernia, which can guide further diagnostic maneuvers and
operative planning [4]. For example, an upper GI X-ray, which
demonstrates anatomy conducive to obstructive symptoms such
as a type III paraesophageal hernia with delay in the ow of contrast on cine images, may indicate to the ordering physician that
anatomic obstruction is the likely etiology for symptoms of regurgitation and dysphagia. Based on such imaging, the aforementioned patient may not require physiologic pH testing prior to
anti-reux surgery, while a patient experiencing heartburn with a
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63
small type I hiatal hernia will likely require this additional testing
to clarify whether the symptoms are truly from pathologic GERD
(Fig.5.1). In patients with dysphagia, an upper GI is a quick and
relatively well-tolerated examination that may give the clinician
an early suspicion of achalasia of the esophagus; the classic nding for achalasia on a UGIS is a markedly dilated and tortuous
esophagus with characteristic “bird’s beak” tapering at the lower
esophageal sphincter. There is often an air-uid level visualized
within the esophagus, which can correspond with the degree of
resistance imposed by the non-relaxing sphincter. (This diagnosis
is then conrmed and further classied via high-resolution
manometry.) An upper GI X-ray may also demonstrate evidence
of esophageal stricture or foreshortened esophagus and may allow
the surgeon to anticipate the need for an esophageal dilation or
esophageal lengthening procedure during an anti-reux operation.
D E
Fig. 5.1 Upper GI series in two patients presenting with reux and dysphagia. The patient in (a) has a small hiatal hernia and underwent esophageal
manometry, which was consistent with type 2 achalasia. The patient in (b) has
a large type 3 paraesophageal hernia with esophageal compression of the
esophagus by the herniated stomach, which is an anatomic explanation for
her dysphagia
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It should be noted that while UGIS provides a useful initial
evaluation of anatomy in a patient presenting with reux, regurgitation, or dysphagia, endoscopy has been shown to be more specic for preoperative assessment of hernia type when used solely
as a tool for assessment of the nature of a hiatal hernia. Linke
etal. prospectively evaluated 40 consecutive patients who were
tested with preoperative barium upper GI and endoscopy before
laparoscopic surgery for gastroesophageal reux disease and/or
symptomatic hiatal hernia. The presence and the type of hiatal
hernia found by UGI and endoscopy were correlated with the
intraoperative nding as the reference standard. A barium study
and endoscopy allowed the diagnosis of hiatal hernia in 75% and
97.5%, respectively (p=0.003). The correct classication of hiatal hernia was conrmed in 50% by barium swallow and 80% by
endoscopy (p=0.005) [2].
E. Adams and A. Ibele
UGIS inConventional Bariatric Surgery
In many bariatric practices, UGIS is done prior to surgery to
assess for hiatal hernia (HH) with the anticipation that this might
require concurrent repair as part of a bariatric operation. In a 2009
study, Fornari et al. compared the efcacy of endoscopy and
UGIS in the diagnosis of type I hiatal hernia prior to bariatric
surgery. Endoscopy was found to have low sensitivity (40%) and
high specicity (94%) in the diagnosis of type I hiatal hernia compared to UGIS [5]. However, additional groups have found that
preoperative UGIS is unlikely to change the operative course for
the patient. A study by Ghassemian etal. showed similar ndings
after they retrospectively reviewed 817 charts of obese patients
who underwent gastric bypass surgery. Of these patients, 80.7%
of them had undergone UGIS screening prior to surgery. Of this
group, 40.2% had abnormal ndings (most commonly hiatal hernia, 62%), none of which resulted in cancelation or delay of surgery; however, the authors did not comment on whether the
nding of hiatal hernia led to a modication in type of surgery or
operative approach [6]. In 2004, Sharaf etal. conducted a retrospective study in which the records of 171 patients with obesity
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65
who underwent UGIS prior to bariatric surgery were reviewed.
Although 48% of patients had an abnormal nding on UGIS, only
5.1% of patients had a clinically relevant nding, which delayed
surgery or changed the surgical approach, most commonly being
a crural repair for a hiatal hernia (18.7%) [7]. It should be noted
that both of these studies, however, were published before the
advent of laparoscopic sleeve gastrectomy (LSG). In 2019,
Mizrahi etal. reviewed the cases of 1810 patients who underwent
routine UGIS prior to LSG for the radiographic and intraoperative
presence of hiatal hernia, Considering the intraoperative identication of HH the gold standard for diagnosis, the sensitivity and
specicity of preoperative UGI uoroscopy for HH detection
were 32% (66/201) and 94% (1512/1609), respectively. The
median operative time was signicantly longer when concomitant
LSG and HH repair was performed compared to LSG alone
(76min vs. 55min, p<0.001, respectively). The foreknowledge
of HH had no inuence on the median operative times (77min vs.
75min, predicted vs. incidental, respectively, p=1.34) [8].
In the early days of laparoscopic bariatric surgery, many groups
routinely obtained postoperative upper GI X-rays to evaluate for
leak prior to patient discharge. Subsequent research has shown
that routine postoperative UGIS is not useful in detecting or predicting leaks after bariatric surgery and therefore not indicated
unless the patient shows clinical signs of leak [9–11]. Brockmeyer
etal. and Csendes etal. both published studies demonstrating that
UGIS on post-op days 1–3 after RYGB might show a mechanical
defect in the staple or suture line, but was unlikely to demonstrate
leaks from other, more common, causes of leaks such as ischemia,
or tension/traction on the staple line, all of which classically manifest later in the postoperative course [11, 12]. In 2014, Quartararo
et al. performed a systematic review including 22 studies and
19,389 patients who underwent Roux-en-Y gastric bypass. Based
on their review of the extant data, the group argued that selective
UGIS based on clinical presentation is preferable to routine
screening [13] However, the effectiveness of UGIS in conrming
a clinically suspected leak may be inferior to that of a CT scan
with IV and oral contrast. Bingham etal. showed that CT scan had
a 95% sensitivity (95% CI 81.8–99.1%) and a 100% specicity
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E. Adams and A. Ibele
(95% CI 93.1–100%) compared to a 79.4% sensitivity (95% CI
61.6–90%) and 95% specicity (95% CI 85.2–98.7%) of UGIS in
detecting anastomotic leaks in patients who underwent RYGB
[14]. Arteaga-González etal. found data to support this conclusion in a study that included patients who underwent RYGB and
sleeve gastrectomy. In their study, 15% of abdominal CT scans
had false negativity for leak versus 28.6% for intraoperative oral
methylene blue and 33.3% for UGIS [15]. Based on the above
literature, the practice at our institution is to obtain a CT abdomen
with IV and oral contrast in patients that show clinical signs of
anastomotic leak [9–11, 14].
The UGIS plays a more important role in establishing the
diagnosis in a patient who presents with a late or chronic complication of bariatric surgery. For example, in patients presenting with weight regain and epigastric pain after non-divided
gastric bypass or vertical banded gastroplasty, gastro-gastric stula is often a concern. Carrodeguas etal. found that the UGIS
was the most sensitive test for gastro-gastric stula following
gastric bypass when compared with CT scan and upper GI
endoscopy [16]. Brethauer etal. showed that UGIS was complementary to an EGD in diagnosing gastro-gastric stulae and that
when these tests were combined, all gastro-gastric stulae were
successfully diagnosed in their patient population [17]. In a
small series by Gumbs etal., the use of UGIS to detect a gastrogastric stula combined with a conrmatory EDG was their
diagnostic method of choice [18].
UGIS can also be helpful in the diagnostic evaluation of reux
following sleeve gastrectomy. The study can demonstrate de novo
or recurrent hiatal hernia, dilation of the fundus, and incisural narrowing, all of which may contribute to acute or chronic reux and
regurgitation following sleeve (Fig. 5.2). However, if incisural
narrowing is suspected, some have advocated for proceeding
directly with endoscopy as opposed to obtaining imaging studies.
In a recent study of 30 consecutive patients with nausea, vomiting, and obstructive symptoms following the sleeve, Bhalla etal.
reviewed the positive and negative predictive value of upper GI
X-ray in assessing stenosis of the gastric sleeve. Twenty-two
(73.3%) patients underwent UGIS prior to EGD.On diagnostic
5 The Upper GI Series
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Fig. 5.2 Upper GI
series demonstrating
incisural narrowing and
subsequent dilation of
retained gastric fundus
in a patient with
refractory reux and
regurgitation following
laparoscopic sleeve
gastrectomy
67
EGD, 27 (87.1%) patients were diagnosed with gastric sleeve stenosis (GSS). The sensitivity and negative predictive value of
UGIS to detect GSS were 30.0% and 12.5%, respectively. All six
patients with GSS on UGIS also had incisural stenosis on endoscopic evaluation (specicity=100% and PPV=100%), leading
the authors to suggest proceeding directly with endoscopy if incisural stenosis is suspected in the early postoperative period [19].
In summary, the UGIS is a useful adjunct in the evaluation and
diagnosis of many upper gastrointestinal disorders including
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