G-I FLUOROSCOPY ROTATION AT THE VA

OBJECTIVES

For R-2 residents, this rotation will introduce you to GI fluoro procedures, and the equipment used in them.  By the end of your 4-week rotation, you will be capable of performing esophagrams, upper GIs, and small bowel follow-throughs, and will be cognizant of other less common procedures.  You will know the basics of operating the fluoroscope, and what maneuvers to use for optimal visualization of each specific area of the gastrointestinal tract, including which way to turn (or not turn) the patient in order to display the anatomy well.

Afternoons will be spent performing GU fluoro procedures (such as retrograde urethrograms, loopograms, and cystograms), and reviewing GI teaching files.  We’ll review 215 examples of common GI diseases in our teaching file, so that you can recognize these entities, and distinguish between them on barium and CT studies.

You can find the official competency based goals and objectives for this rotation at:
http://www.rad.washington.edu/academics/residency/currentres/rotationobjectives/gi-gu/goals-and-objectives-gi-gu

MY EXPECTATIONS

Arrive by 7:45 a.m. on Monday and Wednesday (the days we do fluoroscopy), and review the requests for the day; determine whether there have been prior exams in the past, and if so, what they revealed.  Also check for other related imaging that might alter our approach.  The goal here is to individualize the study for each patient.

Familiarize yourself with the portions of the University of Washington Manual of GI and GU Radiology Procedures relating to Esophagrams, UGIs, and ACBEs.  Barium enemas are infrequent here, and we’ll focus primarily on the upper gastrointestinal tract exams during this rotation.  Page 23 of the manual is a very nice one-page summary of the components of a complete study.
My method of doing a biphasic UGI varies slightly from the manual, and we’ll compare and contrast these techniques during this rotation, and the reasons for these variations.

Read the recommended reading selections for this rotation, listed at the end of this handout.  Also review the PowerPoint presentations on how to perform UGIs and Swallowing evaluations (located on the G Drive of the VA Network; see below).

Dictate each day’s exams, under the supervision of the attending that day.

Sign your reports promptly.  Check for reports to sign before you leave each day, and upon arrival the next day.

WHAT YOU CAN EXPECT ON THIS ROTATION

One’s first fluoroscopy rotation is almost always daunting, because you’re learning and using several new skills at once: how to operate the fluoroscope; how to recognize what you SEE with the fluoroscope; how to perform fairly complex studies, in terms of positioning the patient to best visualize each area; and how to communicate to the patient what you want them to do, so that you have the best chance of their doing it efficiently.

The first week or two, we’ll work side by side as a team.  Initially I’ll do most of the talking, so that you can concentrate on operating the fluoroscope.  Once the study is underway, I’ll help guide the fluoroscope for you, until you’re doing it on your own.

As you progress, I’ll do less and less, as you become comfortable with and capable of doing it by yourself.  My goal is to be able to watch from outside the fluoro room by your last week of the first rotation, and sooner, if you’ve had a GI Fluoro rotation before.

For complex or difficult cases, I’ll step in sooner or do them as the primary radiologist, until you are comfortable doing them yourself.

I hope that you’ll feel free to ask questions, and to communicate with me if something I am doing (or not doing) seems counter-productive to your progress on this rotation.  While I’ve always enjoyed GI fluoro procedures, and have served as the main fluoro instructor in the residency at Virginia Mason, this hasn’t been my focus since coming to the VA in 2001.  So like you, I am in a new position, learning new skills.
I will welcome feedback and dialogue, so that this rotation is beneficial to you, as well as to me.

RECOMMENDED READING

There are two small pamphlet-like books to read while on this service.  You are welcome to take them home while on this service, but MUST return them on the last day of the rotation, so that they are available for the next resident.

Fundamentals of Gastrointestinal Radiology, by Davis and Houston, WB Saunders & Co., 2002.

Fundamentals of Fluoroscopy, by Houston and Davis, WB Saunders, 2001.

A third book to review is: Atlas of Gastrointestinal Imaging. Radiologic-Endoscopic Correlation, by Pickhardt and Arluk, WB Saunders, 2007
This is a great book to page through, looking at all the illustrations and reading the captions, to familiarize yourself with the terminology used for various radiographic manifestations of pathology, AND with the gross or microscopic features that relate to those manifestations.

Dr. Rohrmann’s PowerPoint presentation:

 How to perform a high-quality upper GI, can be found at the following URL:
https://www.rad.washington.edu/academics/residency/currentres/lecturesconfs/pptlectures/

Review this before you start the rotation, and as often as you find useful thereafter.

There are also folders with articles on various topics in the GI Reading area, for your use.

Reiley Kidd, MD
VA Radiology