Back to Upper GI Set 1

CB1515

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Case Notes

History

10-year-old female with past medical history of chromosomal deletion and Nissen fundoplication. Evaluation of recent hematemesis and possible reflux.

Exam

Prior Study

None

Dicom

 
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Section 1

Submit Findings

CB1515

Findings

Scout Image of the abdomen

There is an NG/OG/FT tube which is malpositioned

There is an unexpected radiopaque foreign body or incidental non-surgical foreign body in the abdomen or pelvis.

There are additional lines, tubes, catheters or drains in place (examples include chest tubes, mediastinal drains, rectal temperature probe, etc.).

There is dilatation with gas or fluid of multiple or diffuse loops of bowel.

​Both the small and large bowel are filled with air and/or fluid and may or may not be distended.

There is a paucity of gas in the abdomen.

There are centralized loops of small bowel with distention of the abdomen and pelvis.

There is organomegaly.

There are intra-abdominal calcifications.

There is free air present.

The visualized bones are abnormal.

Fluoroscopic examination of the chest shows pneumonia, atelectasis, or cardiomegaly.

The hemidiaphragmatic excursions are inequal and nonsynchronous.

Procedural

The patient was given thin barium/water soluble contrast to drink via bottle/syringe/sippy cup/straw/cup. A total of---mL of thin barium/water soluble was used for this examination.

The exam is limited by patient motion or non-cooperativity.

The exam is limited by small or inadequate boluses/contrast intake.

The swallowing act is abnormal.

There is tracheal aspiration. 

The course of the esophagus is abnormal.

The caliber of the esophagus is abnormal.

There is stenosis of the upper/mid/distal esophagus.

There is dilatation of the upper/mid/distal esophagus.

There is a tracheoesophageal fistula present. 

There is a filling defect. 

There is dysmotility of the esophagus.

There is extrinsic mass effect.

There is a vascular ring.

The stomach does not fill readily.

If the contrast is instilled via NG tube/gastrostomy tube/orogastric tube: There is abnormal contrast opacification of the stomach.

The stomach empties abnormally.

There is gastric outlet obstruction.

The duodenal C-loop is abnormal in size.

The location of the ligament of Treitz is abnormal.

The proximal jejunum is dilated. 

There is gastroesophageal reflux observed to the upper/mid/distal esophagus.

The reflux does not clear quickly.