107 - Bedside Upper Gastrointestinal (BUGI) NICU Studies: How bougie is BUGI?

Publication Number: 2102.107

Sarah Abdalian, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States; Kelly Roush, Case Western Reserve University School of Medicine, Cleveland, OH, United States; Sheila Berlin, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States; Eiichi Miyasaka, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States; Mark Ricciardi, Case Western Reserve University School of Medicine, Cleveland Hts, OH, United States; Rita M.. Ryan, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States; Pauravi Vasavada, Case Western Reserve University School of Medicine, Chagrin Falls, OH, United States

Background: The upper gastrointestinal (UGI) series is the current gold standard for diagnosing malrotation when evaluating infants with bilious emesis. However, for some neonatal intensive care unit (NICU) patients, a trip away is suboptimal. Therefore, a multidisciplinary team at our institution developed bedside upper gastrointestinal (BUGI) and bilious emesis protocols to minimize the risks of transporting critically ill NICU infants including hypothermia and dislodgement of endotracheal tubes.

Objective: To evaluate the feasibility of using BUGI to evaluate malrotation in critically ill infants in the NICU. A successful study was considered correctly identifying the duodenojejunal junction (DJJ).

Design/Methods: We retrospectively reviewed BUGI examinations performed in 20 infants admitted to the NICU from June 2023 to August 2025. BUGI utilized an average of 3.7 mL of contrast and radiographs were obtained at 1 and 2 minutes after administration. If the DJJ could not be identified after the 2 minute film, subsequent films were obtained per radiologist recommendation. A normal positioning of the DJJ was defined as being to the left of the left vertebral pedicles at the same level or inferior to the duodenal bulb. We report standard demographic and study data including gestational age, weight, indication for study, whether an abdominal ultrasound was also performed as initial imaging modality, and whether malrotation was identified, ruled out or was indeterminate.

Results: There were 20 NICU patients with bilious emesis (n=18) or bilious residuals (n=2) who underwent BUGI. They were approximately 26 weeks (w) gestational age with 1000 grams birthweight, and 27w postmenstrual age (Table 1). One baby was identified with malrotation, while 18 babies were easily identified as normal (Figure 1). One had an inconclusive study, although an abdominal ultrasound obtained following the BUGI did not show concern for malrotation or volvulus. In some infants additional radiographs were necessary (Figure 2). While the BUGI is not a gastric emptying study, we did have several patients in whom there was a significant delay in transit time, with the DJJ identified up to as long as 199 minutes after contrast administration.

Conclusion(s): BUGI is a feasible technique to evaluate malrotation in critically ill NICU infants with bilious emesis when it is undesirable to perform a study in the fluoroscopy suite in a distant location. We will provide our updated BUGI protocol, improved by our experience, as well as our new local protocol for evaluation of bilious emesis using a combination of BUGI/UGI and ultrasound.

Table 1: Bedside UGI Infant Characteristics


Figure 1: Representative Images from BUGI in 4 different patients
(a): Image of a 17 day old neonate, 26w0d gestational age. Image 7 minutes after administration of barium demonstrates normal positioning of the DJJ (arrow) with proximal loops of jejunum in normal position in the left side of the abdomen.

(b): Image of a 5 day old neonate, 27w4d gestational age. Image 9 minutes after administration of barium demonstrates mildly distend loops of bowel resulting in slight depression of the DJJ (arrow). However DJJ is in normal position at the lower margin of the duodenum to the left of the spine.

(c): Image of an 11 week old neonate, 29w2d gestational age. Initial BUGI images obtained at 1 minute and 10 minutes in this neonate with multiple dilated loops of small bowel were non-diagnostic however a 30 minute delayed image accurately determined the normal positioning of the DJJ (arrow). Small amount of residual contrast in the bladder and right collecting system is from prior CT imaging.

(d): An 8 day old neonate, 37w2d gestational age, with history of repaired gastroschisis on day 1 of life and known intestinal malrotation. This study was done for new onset bilious emesis and was to also include small bowel follow through images. A 5 minute image demonstrates a low lying DJJ (arrow) which is to the right of the of the spine and contrast within a proximal loop of small bowel within the right side of the abdomen confirming the known malrotation. A 45 minute delayed image (not shown) was also obtained which demonstrated progression of contrast through multiple dilated jejunal loops on the right side of the abdomen, consistent with malrotation.

Figure 2: Sequential Images in a 6 Day Old Neonate
Images from a bedside UGI examination in a 6 day old neonate, 26w0d gestational age. Images including a radiograph obtained 1 minute after contrast administration via enteric tube (a), at 2 minutes (b) and at 5 minutes. Initial 1 and 2 minute images demonstrate contrast within the stomach After right lateral decubitus positioning between images the normal position of the DJJ is seen on the 5 minutes (c) image to the left of the spine at the level of the pylorus (red line).