Gastroesophageal Reflux Scan

Gastroesophageal Reflux Scan

Synonym/acronym: Aspiration scan, GER scan, GERD scan.

Common use

To assess for gastric reflux in relation to heartburn, difficulty swallowing, vomiting, and aspiration.

Area of application

Esophagus and stomach.

Contrast

Oral radioactive technetium-99m sulfur colloid.

Description

The gastroesophageal reflux (GER) scan assesses gastric reflux across the esophageal sphincter. Symptoms of GER can include heartburn, regurgitation, vomiting, dysphagia, and a bitter taste in the mouth. This procedure may be used to evaluate the medical or surgical treatment of patients with GER and to detect aspiration of gastric contents into the lungs. A radionuclide such as technetium-99m sulfur colloid is ingested orally in orange juice and scanning studies are done immediately to assess the amount of liquid that has reached the stomach. An abdominal binder is applied and then tightened gradually to obtain images at increasing degrees of abdominal pressure: 0, 20, 40, 60, 80, and 100 mm Hg. A computer calculation determines the amount of reflux into the esophagus at each of these abdominal pressures as recorded on the images. For aspiration scans, images are taken over the lungs to detect possible tracheoesophageal aspiration of the radionuclide.

In infants, the study distinguishes between vomiting and reflux. Reflux occurs predominantly in infants younger than age 2 who are mainly on a milk diet. This procedure is indicated when an infant has symptoms such as failure to thrive, feeding problems, and episodes of wheezing with chest infection. The radionuclide is added to the infant’s milk, images are obtained of the gastric and esophageal area, and the images are evaluated visually and by computer.

This procedure is contraindicated for

  • Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • Patients with hiatal hernia, esophageal motor disorders, or swallowing difficulties.

Indications

  • Aid in the diagnosis of GER in patients with unexplained nausea and vomiting
  • Distinguish between vomiting and reflux in infants with failure to thrive, feeding problems, and wheezing combined with chest infection

Potential diagnosis

Normal findings

  • Reflux less than or equal to 4% across the esophageal sphincter

Abnormal findings related to

  • Reflux of greater than 4% at any pressure level
  • Pulmonary aspiration

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
    • Metallic objects (e.g., jewelry, body rings, dentures) within the examination field, which may inhibit organ visualization and cause unclear images.
    • Retained barium from a previous radiological procedure.
    • Other nuclear scans done within the previous 24 to 48 hr.

  • Other considerations

    • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray or radionuclide procedures. Personnel working in the examination area should wear badges to record their level of radiation.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in evaluating stomach reflux.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, sedatives, or radionuclides.
  • Obtain a history of the patient’s gastrointestinal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results, including examinations using barium- or iodine-based contrast medium.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, or there may be moments of discomfort. Reassure the patient that the radionuclide poses no radioactive hazard and rarely produces side effects. Inform the patient that the procedure is performed in a nuclear medicine department by an HCP specializing in this procedure, with support staff, and takes approximately 30 to 60 min. Pediatric Considerations Preparing children for a gastroesophageal reflux scan depends on the age of the child. Encourage parents to be truthful about what the child may experience during the procedure (e.g., the child may feel an upset stomach), stressing the importance of drinking as much of the “juice” as possible so the test is successful, and to use words that they know their child will understand. Toddlers and preschool-age children have a very short attention span, so the best time to talk about the test is right before the procedure. The child should be assured that he or she will be allowed to bring a favorite comfort item into the examination room, and if appropriate, that a parent will be with the child during the procedure. Explain the importance of remaining still while the images are taken.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined.
  • Note that there are no food or fluid restrictions unless by medical direction.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Although it is rare, there is the possibility of allergic reaction to the radionuclide. Have emergency equipment and medications readily available. If the patient has a history of allergic reactions to any substance or drug, administer ordered prophylactic steroids or antihistamines before the procedure.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Record baseline vital signs and assess neurological status. Protocols may vary among facilities.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Administer a sedative to a child or to an uncooperative adult, as ordered.
  • Place the patient in an upright position and instruct him or her to ingest the radionuclide combined with orange juice. Pediatric Considerations If the patient is an infant, a small amount of radionuclide will be added to the patient’s feeding.
  • Place the patient in a supine position on a flat table 15 min after ingestion
  • An abdominal binder with an attached sphygmomanometer is applied, and scans are taken as the binder is tightened at various pressures.
  • If reflux occurs at lower pressures, an additional 30 mL of water may be given to clear the esophagus.
  • Instruct the patient to take slow, deep breaths if nausea occurs during the procedure. Monitor and administer an antiemetic agent if ordered. Ready an emesis basin for use.
  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Advise the patient to drink increased amounts of fluids for 24 to 48 hr to eliminate the radionuclide from the body unless contraindicated. Tell the patient that radionuclide is eliminated from the body within 6 to 24 hr.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor intake and output at least every 8 hr. Compare with baseline values. Protocols may vary among facilities.
  • Instruct the patient to resume usual diet, fluids, medication, and activity, as directed by the HCP.
  • No other radionuclide tests should be scheduled for 24 to 48 hr after this procedure.
  • If a woman who is breastfeeding must have a nuclear scan, she should not breastfeed the infant until the radionuclide has been eliminated. This could take as long as 3 days. She should be instructed to express the milk and discard it during the 3-day period to prevent cessation of milk production.
  • Instruct the patient to immediately flush the toilet and to meticulously wash hands with soap and water after each voiding for 24 hr after the procedure.
  • Instruct all caregivers to wear gloves when discarding urine for 24 hr after the procedure. Wash gloved hands with soap and water before removing gloves. Then wash hands after the gloves are removed.
  • Nutritional Considerations: A low-fat, low-cholesterol, and low-sodium diet should be consumed to reduce current disease processes. High fat consumption increases the amount of bile acids in the colon and should be avoided.
  • Recognize anxiety related to test results, and be supportive of expected changes in lifestyle. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include CT abdomen, esophageal manometry, gastric emptying scan, and upper GI series.
  • Refer to the Gastrointestinal System table at the end of the book for related tests by body system.