Upper GI Series

The upper gastrointestinal series evaluates the stomach and duodenum, and often the distal oesophagus, using combined double- and single-contrast fluoroscopy. In adults it demonstrates ulcers, masses, outlet obstruction and post-surgical anatomy; in infants it is the reference standard for confirming the position of the duodeno-jejunal junction and excluding malrotation with midgut volvulus.

Indications

Epigastric pain, dyspepsia and suspected gastric or duodenal peptic ulceration
Suspected gastric outlet obstruction, gastric mass or linitis plastica
Assessment of post-surgical anatomy after gastrectomy, fundoplication or bariatric surgery
Suspected leak or gastric emptying disorder when endoscopy is contraindicated or non-diagnostic
Paediatric bilious vomiting to evaluate for malrotation and midgut volvulus

Contraindications & Cautions

Suspected perforation or post-operative anastomotic leak: use water-soluble iodinated contrast first, not barium
High aspiration risk in infants: use low-osmolar non-ionic contrast rather than hyperosmolar ionic agents
Complete distal obstruction where retained barium may inspissate
Recent surgery without surgical clearance for oral contrast

Patient Preparation

Adults nil by mouth from midnight or at least 6 hours to empty the stomach
Infants fasted for one feed cycle (approximately 3 hours) before the study
Withhold agents that alter motility where possible
Explain effervescent granules and the manoeuvres to coat the mucosa
Confirm no suspected perforation before selecting barium

Technique & Parameters

Scout image then effervescent granules with a small amount of water to distend the stomach with gas
High-density barium swallowed and the patient rotated to coat the gastric mucosa for double-contrast views
Single-contrast phase with low-density barium to assess distension, contour and gastric emptying
Compression and prone/oblique views of the antrum and duodenal bulb to profile ulcers
In infants a small volume of contrast is given through the nasogastric tube or bottle and the duodeno-jejunal junction is imaged in a true AP projection
Follow the contrast to confirm the duodeno-jejunal junction lies left of the spine at the level of the duodenal bulb

Systematic Review

Assess gastric distensibility, fold pattern and areae gastricae for infiltration
Profile the antrum and duodenal bulb for ulcer craters and deformity
Evaluate the position and configuration of the duodenal C-loop
In paediatrics confirm the duodeno-jejunal junction position and the course of the third part of the duodenum
Assess gastric emptying and look for extrinsic compression or mass effect
Inspect the distal oesophagus and gastro-oesophageal junction

Key Findings & Significance

Benign gastric ulcer: rounded crater projecting beyond the lumen with smooth radiating folds reaching the edge
Malignant ulcer: crater within a mass, nodular rolled edges and folds that stop short of the crater
Linitis plastica: rigid, non-distensible narrowed stomach from diffuse infiltration
Gastric outlet obstruction: dilated stomach with delayed emptying and antral or duodenal narrowing
Malrotation: duodeno-jejunal junction displaced to the right of the midline and low
Midgut volvulus: corkscrew spiralling of the duodenum and proximal jejunum

Differential Considerations

Gastric mass: adenocarcinoma, lymphoma, GIST, or benign polyp
Thickened gastric folds: hypertrophic gastritis, Menetrier disease, lymphoma or infiltrating carcinoma
Duodenal narrowing: peptic stricture, annular pancreas, superior mesenteric artery syndrome or tumour
Filling defect in the bulb: ulcer-related oedema, Brunner gland hyperplasia or polyp
Paediatric bilious vomiting: malrotation, duodenal web, atresia or annular pancreas

Pearls & Pitfalls

A right-sided duodeno-jejunal junction in an infant with bilious vomiting mandates urgent surgical referral
Folds radiating to a smooth ulcer crater favour benign disease; nodular converging folds favour malignancy
Use water-soluble contrast first whenever a leak or perforation is possible
Adequate gaseous distension is essential to demonstrate the areae gastricae and small mucosal lesions
A normal upper GI does not exclude intermittent malrotation; correlate with clinical suspicion

Structured Report

State the contrast agent and phases performed
Describe the stomach, duodenum and distal oesophagus with any ulcers, masses or narrowing
Characterise ulcers as benign or malignant by morphology
In paediatrics explicitly state the position of the duodeno-jejunal junction and whether malrotation is present or excluded
Give an impression and recommend endoscopy or CT where appropriate

References

ACR-SPR Practice Parameter for the Performance of Esophagography and Upper Gastrointestinal Examinations
Applegate KE et al. Malrotation and Midgut Volvulus: Radiographic Evaluation. RadioGraphics
Levine MS, Rubesin SE. Diseases of the Stomach and Duodenum. Textbook of Gastrointestinal Radiology
Royal College of Radiologists iRefer: Making the Best Use of Clinical Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.

Upper GI Series

📋 Indications

⛔ Contraindications & Cautions

🧑‍⚕️ Patient Preparation

⚙️ Technique & Parameters

🔎 Systematic Review

🩻 Key Findings & Significance

🧠 Differential Considerations

💡 Pearls & Pitfalls

📝 Structured Report

📚 References