2.Barium Study of Lower GI TRACT PPT BY RAVINDRA KUMAR.pptx

Detailed knowledge about procedure including anatomy and pathology.
Should know about c/m, its preparation & its contraindications.
Should be capable of tackling any emergency arose due to c/m.
Knowledge of handling the equipment.
Care & maintenance of the equipment .
Knowledge of Quality assurance program.
Knowledge of radiation protection.
Barium Study of Lower GI Tract knowledge :-
BMFT
Peroral Pneumocolon
Small Bowel Enema (Enteroclysis)
Barium Enema
Air Enema
Reduction of an Intussusception
Distal Cologram
Loopogram
Pouchogram.
Barium Studies are safe & useful initial diagnostic procedure for evaluating GIT abnormalities.
It uses radiolucent & radiopaque c/m in combination to a fluoroscopy unit to visualize the anatomy as well as the physiology.
However these have limitations in the assessment of extra mucosal extent of the pathology.
Although newer modalities are present but Barium is still considered as a basic and essential study.

1. BARIUM STUDIES LOWER GI TRACT 1 Department of radiodiagnosis and imaging , pgimer , Chandigarh PRESENTER RAVINDRA KUMAR TECHNOLOGIST Ravindra kumar M.SC. Medical Technology (Radiodiagnosis and imaging) PGIMER Chandigarh, India.

2. Barium Study of Lower GI Tract BMFT Peroral Pneumocolon Small Bowel Enema (Enteroclysis) Barium Enema Air Enema Reduction of an Intussusception Distal Cologram Loopogram Pouchogram 2

3. Barium Meal Follow Through It is the radiographic examination of GIT- oesophagus, stomach, duodenum, small bowel and ileocecal junction by oral administration of contrast media. It is so called because it is performed following a barium meal. 3

4. Indications Patients who have low suspicion of small bowel disease, abdominal pain and diarrhea. Patient with suspected complete or partial small bowel obstruction. Elderly patients with suspected jejunal diverticulosis who present with malabsorption. In patients who are unwilling or in whom it is not possible to perform intubation. 4

5. Contraindications Colonic obstruction Suspected perforation Paralytic ileus 5

6. Contrast medium Medium density barium suspension ( 50-60% w/v ) is used in dedicated Barium meal follow through study. High density barium may produce an appearance of fold thickening and clumping in the small bowel. A water soluble iodine contrast agent as Gastograffin is of limited value as it will be diluted and loose density in the small bowel . 6

7. Preparation The colon should be cleaned by the administration of a suitable purgative. A low roughage diet and a high fluid intake is also maintained for 48 hours prior to the investigation. No food or fluid should be taken for 12 hours before the investigation. If the patient is taking tranquilizers, antispasmodics and codeine, they should be stopped for 24-48 hrs before the examination. 7

8. Methods 1) Single Contrast BMFT 2) Double Contrast BMFT 3) With the addition of a Pneumocolon technique. 8

9. Single contrast technique Barium suspension (600-900 ml) 50-60% w/v is allowed to drink orally. Patient is asked to drink this as rapidly as possible. Patient is then put in the right side dependent position to aid rapid gastric emptying. 9 Fundus Body Duodenum Duodenal Bulb Pylorus Rt.Lateral

10. After 15 to 20 min, a film is taken with patient prone to separate the bowel loops. Subsequent films are taken at 15-20 min interval till ileocecal junction is opacified. 10 Stomach Duodenum Jejunum Ileum Prone

11. To demonstrate I-C junction, supine right side up is the best position since ileum enters into cecum in the posteromedial part. 11 LPO I-C Valve Cecum Appendix Ileum

12. Precautions If investigation takes time, then patient is sent for dry meal so that Barium is propelled towards the IC junction. 12

13. Additional Films For Diverticulum : views in upright position are taken to show any fluid level . Overlap of Contrast filled bowel loops in the pelvis is often a problem. For separating loops, patient can be tilted or table can be tilted to see appropriate view. 13

14. 14 Summary of position for dedicated Barium Meal Follow Through

15. Double Contrast Technique Same as single contrast study. Gas producing agent is given when Barium reaches the cecum. Patient is placed on the left side slightly head down to allow the gas to leave the stomach and enter the small bowel. 15

16. Advantage Better Distension Separation of loops Improved mucosal detail Disadvantage Difficulty in interpretation by gas bubbles .(mimic polyp) 16

17. Advantages of BMFT 1) Easily performed. 2) No discomfort / intubation to the patient unlike in Enteroclysis . 3) It is a physiological process. 4) Transit time can be assessed. 17

18. Disadvantages Of BMFT 1) Overlapping of Barium filled bowel loops in the pelvis. 2) Poor distension of bowel loops. 3) Inappropriate timing for visualization of partial/ intermittent small bowel obstruction. 4) Operator dependence. 5) Time consuming. 18

19. Complications 1) Leakage of Barium from an unsuspected perforation. 2) Aspiration. 3) Partial large bowel obstruction into a complete obstruction by the impaction of Barium. 4) Barium appendicitis, if Barium impacts in the appendix. 5) Side effects of pharmacological agents used. 19

20. Peroral Pneumocolon The per oral Pneumocolon examination is the method for obtaining a double contrast image of the terminal ilium. Indication: A poorly seen terminal ilium. Clinically suspected inflammatory bowel disease with an apparently normal terminal ilium. An abnormal terminal ilium with suspicious fistula. 20

21. Peroral Pneumocolon Preparation :- Colonic preparation is similar to barium enema. Technique :- Barium is administered orally. When Barium has reached the right & proximal transverse colon, air is insufflated into the rectum & refluxed into distal ileum. Glucagon can be used to relax the IC valve. It is usually employed at the end of BMFT, when the appearance of terminal ileum is suspicious & needs clarification. 21

22. Enteroclysis This is the radiological study of small bowel from jejunum to the ileocaecal junction by intubation & instillation of contrast through the tube. Indications Partial small bowel obstruction Crohn’s disease Suspected diverticulum Malabsorption syndrome Tumors of small intestine Equivocal BMFT. 22

23. Contraindications Complete colonic obstruction Suspected perforation Massive dilatation of the small bowel Duodenal obstruction & gastrojejunostomy Paralytic ileus 23

24. Equipment Bilbao Dotter Tube :- This is a 22 F polyethylene tube which is 150 cm long. The tube is 5cm longer than the guide wire in order to eliminate the risk of perforation by the wire protruding beyond the tip. The guide wire is Teflon coated to reduce friction. 24

25. Bilbao Dotter Tube 25

26. Contrast Medium For single contrast Enteroclysis : 20%w/v suspension of Barium sulphate is used. For double contrast Enteroclysis : high density low viscosity Barium sulphate suspension is ideal which is 50-70%w/v . For double contrast we can use carboxymethylcellulose (CMC) or air. 26

27. Preparation The Patient is subjected to liquid diet (2-3 litres ) for a full day before the examination & is called after overnight fasting for the procedure. 2-4 Dulcolax tablets in the evening preceding the Enteroclysis are given. The above said preparation is very important because a full cecum or a food filled ileum seriously retards intestinal flow & more fluid is needed to reach the cecum quickly. 27

28. Conti.. No rectal enema should be given because the enema fluid may reflux into the small bowel & create confusing small bowel patterns when it mixes with the Barium suspension. Drugs such as tranquilizers, sedatives & antispasmodics should be discontinued the day before the examination. Immediately before the examination, the pharynx is Anaesthetised with lignocaine jelly. 28

29. Technique Preliminary plain Radiographs of the abdomen. They are useful to determine whether the Patient is adequately prepared & to exclude the presence of Barium from previous examinations. An upright film is useful to determine whether a large amount of fluid is present in the stomach/small bowel loops, which needs to be aspirated before the study can be performed. 29

30. Procedure The Patient sits on the edge of the table. The pharynx is thoroughly anaesthetized with lidocaine spray. 2-3 cc of 2% Xylocaine jelly is introduced into the nostril through which the tube is to be placed after ensuring that there is no nasal blockage or mass. Pt’s neck is hyperextended in lying down position and the Bilbao Dotter Tube without the guide wire is inserted through one of the nostrils and advanced with the swallowing action of patient. 30

31. Conti.. The guide wire may be used to stiffen the tube to assist advancement through the oesophagus into the stomach Make sure that tube is in the oesophagus & not in the trachea. At the end, the tube will be approx. 4-5 cm distal to Treitz ligament . Such a placement prevents reflux of Barium & Carboxymethyl cellulose into proximal parts of duodenum & stomach. 31

32. 32 Placement of Bilbao dotter tube

33. Single Contrast Enteroclysis This is performed in Patient with high grade partial small bowel obstruction, especially if significant dilated bowel loops are present. Barium suspension 20%w/v is injected at the rate of 75 to 120ml/min . Care should be taken to ensure that no air goes in during the injection. An average of one to one & half liters of Barium sulphate is injected without any interruption. The average time taken to reach the ileocecal junction is about 15 mins . 33

34. 34

35. Double Contrast Enteroclysis 150 – 500ml of high density Barium suspension ( 50-70% w/v ) is injected @ 80-100ml/min, till the proximal ileum is reached. The Barium is followed under fluoroscopy guidance & films are exposed wherever necessary. After this, 0.5% suspension of CMC is injected @ around 75-120ml/min. Very rapid injection may result in atonia. (Loss the muscle tone) Ileocaecal spot films should be taken initially when the Barium column reaches the ileocaecal junction & then again when the Ileocaecal junction(IC junction) is in double contrast. 35

36. Double Contrast Enteroclysis Preparation: Laxatives are given the night before the examination. Nothing is to be taken by mouth after 7pm the night before the examination. Procedure: 50% to 70%w/v Barium sulphate. At a rate of approx. 60ml/min, using 100ml syringe, 150-200ml of Barium is injected slowly. The progress of the Barium column is observed under fluoroscopy guidance. When the head of the Barium column reaches the distal ileum, air should be injected. 36

37. Conti.. Initially, 200ml of air is injected slowly @ approx. 100ml/min. After observing the progression of Barium distally, inject 100-200ml of air. About 600-1000ml of air is necessary for double contrast views of the whole small bowel. When the air reaches the distal ileum, an antispasmodic agent is injected intravenously or intramuscularly . 37

38. Air Double Contrast Enteroclysis Barium in colon Barium/Air in small intestine Bilbao-Dotter Tube 38

39. Advantages:- The mucosal detail seen on the air double contrast study of the small bowel is superior to any other examination. Ulcer & minute scar can be picked up easily. Disadvantage:- Uncomfortable to the Patients. 39

40. Advantages Of Enteroclysis Contrast material is administered at a desired rate & not influenced by the action of pyloric sphincter. Direct infusion at a rate that produces Hypotonia, completely dilates the entire small intestine & therefore the fold patterns & mucosal abnormality can be easily assessed. Sinuses & fistulous tracts can be demonstrated by Enteroclysis . The time taken for the examination is not more than 20-30 mins . Enteroclysis permits better detail of the small bowel than that achieved by BMFT. Segmentation of the Barium column & flocculation is avoided . 40

41. Disadvantages Of Enteroclysis Placement of nasogastric tube for the procedure causes discomfort. Nausea & vomiting due to inadequate tube placement. Operator dependent. Failure to depict extra-intestinal changes. 41

42. After Care The Patient should be warned that diarrhoea may occur as a result of the large volume of fluid given. Patient can take full diet following the procedure. Complications: 1) Aspiration 2) Perforation of the bowel 42

43. Barium Enema It is the radiographic study of the large bowel by administration of the contrast medium through the rectum. Technique Single-contrast Double-contrast 43

44. Preparation Diet: Pt. Should be given a low residue(low fiber) diet for 2 days prior to the examination. Patient should not have any fatty fried foods. Patient should drink plenty of clear fluids on the day preceding the examination. Iron containing medication should be stopped 2 days before the examination because they make stools adhere to mucosa. All patients must be changed into a hospital gown. 44

45. Laxatives For removal of most solid material. Castor Oil(30ml) Dulcolax BOWEL WASH :- Previous night In the morning, 2 hours prior to the procedure. 45

46. Barium Enema Kit 46

47. Single Contrast Barium Enema Indications : - Uncooperative, very immobile patient Evaluation of acute obstruction Reduction of intussusception. Show configuration of colon Where only gross pathology is to be excluded 47

48. Contraindication Allergy to Barium suspension Risk of perforation Peritonitis Acute ulcerative colitis Following a recent deep Biopsy. 48

49. Absolute Contraindication for both DCBE & SCBE Toxic Megacolon Pseudomembranous colitis If rectal biopsy has been done in the previous 5 days Paralytic Ileus Difficulty to pass the tube in rectum. For e.g , inflammed piles growth etc. Relative Contraindication :- Incomplete bowel preparation 49

50. Single Contrast Barium Enema Barium suspension of Low density 15% to 20% w/v . is used for see through effect of colon. Tube is placed in the rectum with the Patient in left lateral position . The height of the enema should not be more then 1 meter above the table top. As soon as the entire rectum is full tube is clamped and a lateral view is taken. 50

51. Procedure 51

52. Conti.. 52 Rectal Ampulla Sigmoid Colon Rectum Enema tube in anal canal Lateral View

53. Then the patient is put prone and with the infusion running ,the frontal view film of rectum is exposed. The Patient is kept prone with right side down oblique (RAO) to open up the curve of recto sigmoid junction. Spot view of recto sigmoid junction with barium flowing are taken. 53

54. Patient is kept prone oblique with left side down (LAO). Splenic flexure opens out and spot view of splenic flexure is taken. 54 LAO Position Splenic Flexure Descending Colon Hepatic flexure Ascending Colon Transverse Colon

55. As barium flows towards hepatic flexure , patient is turn right side down oblique (RAO) and spot films of hepatic flexure taken. 55 RAO Position Splenic Flexure Descending colon Sigmoid colon Hepatic Flexure Ascending Colon

56. Conti.. With continuous flow of barium cecum fills up. As soon as the reflux across ileocecal junction takes place, the tube is clamped and ileocecal spot films are exposed. A full film is now exposed to show entire colon. After evacuation mucosal relief film is exposed to rule out polyposis and diverticulosis. 56

57. Splenic Flexure Hepatic Flexure Transverse Colon Descending Colon Ascending Colon Caecum Sigmoid Colon Rectum Full Length Film 57 I.C Junction

58. Post Evacuating film showing Mucosal Pattern 58

59. Double Contrast Barium Enema DCBE can be done following a SCBE. Indications Of DCBE High Risk Patient- rectal bleeding, previous H/O carcinoma or polyp, family H/O colorectal cancer or polyposis. Demonstration of sinuses or fistulas. Patient with severe Diverticulosis, polyposis or Diarrhea. 5) Reduction of an Intussusception. 59

60. Contraindication Allergy to Barium suspension 2) Peritonitis 3) Acute or fulminating inflammatory colon disease 4) H/O recent colonic biopsy 60

61. Procedure Barium suspension: High density(slower flowing, better coating) 75% to 95% w/v. The Patient is in prone position with left side down oblique & high density low viscosity Barium suspension is allowed to flow up to splenic flexure . Now air is introduced with Patient prone. Air should push the Barium column & never pass beyond the column. 61

62. Conti. The Patient is taken back in prone position with right side dependent & air is pumped into left sided colon. Once Barium comes into transverse colon turn the Pt. left side up- Barium enters right sided colon & reaches the ileocaecal junction. Now with the right side up, more air is pumped till air outlines the ileocaecal junction. Take spot films for flexures & ileocaecal junction. 62

63. Prone 63 Spot compression view for recto-sigmoid junction

64. Splenic Flexure Hepatic Flexure Descending Colon Ascending Colon Sigmoid Colon Rectum LPO View 64

65. Decubitus view 65

66. Advantage of DC Over SC Better surface details Surface lesion can be demonstrated to the best effect. Easy unraveling of the colon as it is possible to look through loops Disadvantage of DC Over SC Difficult in uncooperative Pt. Fistulae/sinuses can be missed 66

67. Points If colon repeatedly gives contraction, Buscopan 1ml I.V, can be given If Pt. does not retain Barium , then for better retention: a) make Pt. prone b) distend the colon slowly c) reassure the Pt. d) if there is sphincter incompetence, then strap the buttocks with sticking plaster. e) Use foley’s catheter with big balloon. The balloon is inflated in mid rectum & then gently pulled back till there is resistance- do not use balloon in acute inflammation. 67

68. Safety Concerns During Barium Enema Review Patient's Chart: Determine whether the patient has any known allergies to the contrast media or the natural latex products. Diabetic patients shall not be given glucagon prior to or during procedure unless ordered by physician. Never Force Enema Tip Into Rectum: This action may lead to a perforated rectum. Escort Patient to the Restroom After Completion of the Study: A barium enema can be stressful for some patients. Patients have been known to faint during or after evacuation. 68

69. Views Rectum Ap , Lat Recto sigmoid LPO Splenic Flexure RPO, Lat Transverse Colon Prone, Prone with 15 degree table head down Hepatic Flexure LPO, RAO Entire Colon Supine IC junction Prone with 15 degree table head elevation 69

70. Toxic Mega colon 70

71. 71 Typical 'apple core' carcinoma in the sigmoid colon. Hirschsprung disease is a blockage of the large intestine. It occurs due to poor muscle movement in the bowel. It is a congenital condition. Hirsch sprung disease carcinoma in the sigmoid colon Swan Neck Appearance

72. Crohn’s disease 72

73. Distal Cologram It is a radiological study of large bowel by administering contrast media through colostomy opening. It is indicated mainly after surgery for evaluation of operation and follow-up of the patient. It is also helpful in determining the efficacy of treatment in diverticulitis or ulcerative colitis. In patient with colostomy the usual preparation is irrigation of stoma the night before study and again on the morning of examination. 73

74. Patient should lie down on the x-ray table in supine position if abdominal colostomy is done and in prone position if perineal colostomy is done. Clean the skin around stoma appropriately. Cannulate the ileostomy with an appropriate Foley catheter. Carefully inflate the balloon. Dilute barium is used for Distal cologram study. Water soluble contrast medium can also be used. 74

75. Single Contrast Double Contrast Distal Cologram 75

76. AIR ENEMA Indication : To demonstrate the extent of ulcerative colitis. Technique: Insert 14-16 F, Foley's catheter into the rectum & inflate balloon. Take an over couch AP film of the abdomen. View the film without patient moving & then inflate air into the catheter lumen with gentle puffs. Take AP view of abdomen. 76

77. REDUCTION OF AN INTUSSUSCEPTION This procedure should only be attempted in full consultation with the surgeon in-charge of the case & a trained anesthetist, when proper pediatric anesthetic equipment is available. Intussusceptions :- it is the enfolding of one segment of the intestine within the another. Methods: Using air and fluoroscopy- barium is no longer used in the majority of centers as air reduction has the following advantages: More rapid reduction, because the low viscosity of air permits rapid filling of the colon. Reduced radiation dose because of the above. More effective reduction. There is more accurate control of intraluminal pressure Less expensive. 77

78. Contraindications: Peritonitis or perforation. The pneumatic method should probably not be used in children over 4 years of age as there is a higher incidence of significant lead points which may be missed. Patient preparation: Sedation is decided by surgeon while analgesics like morphine are usually given. Correction of fluid & electrolytic balance . Contrast media: Air. Barium Sulphate 100% w/v. Water soluble c/m (LOCM)*. 78

79. TECHNIQUE Preliminary examinations: Plain abdomen film: to assess bowel distension & to exclude perforation. US: to confirm the diagnosis. Technique A 16-22 F catheter is inserted into the rectum and the buttocks taped tightly together to provide a seal. It may be necessary to inflate the balloon but if this is done it should be performed under fluoroscopic control so that rectum is not over distended. The intussusception can be carried out by: Pneumatic reduction. Barium reduction (Rare). 79

80. Equipment for reduction of intussusception. (a) Individual components. (b) Assembled. (c) Assembled with an inflated balloon 80

81. PNEUMATIC REDUCTION The child is placed in the prone position so that it is easier to maintain the catheter in the rectum. Air is instilled by a hand or mechanical pump and the intussusception is pushed back by a sustained pressure of up to 80 mmHg . if this fails the pressure may be increased to 120 mmHg . Pressure should be monitored all the times & there should be a pressure release valve in the system. An intussusception if unsuccessful once is repeated after 3 min interval & three tries are done . A still immovable intussusception is considered irreducible & arrangement of surgery are made. Reduction is successful when there is free flow of air into the distal ileum. 81

82. Plain radiograph showing the intussusception projecting into the air column during reduction Plain radiograph showing gas in both small and large bowel after successful reduction 82

83. Barium Reduction Patient positioning is as for the pneumatic method. The bag containing barium is raised 100 cm above the table top and barium run in under hydrostatic pressure. Progress of the column of barium is monitored by intermittent fluoroscopy. If the intussusception doesn’t move for 3 min after consistent pressure, child is given a 3 min rest & then repeat the procedure. The points regarding failed procedure also apply here. 83

84. COMPLICATIONS Perforation For the pneumatic method, if a pump is used without a pressure- monitoring valve, perforation may result in a tension pneumoperitoneum, resulting in respiratory embarrassment. After care: Observation in hospital for 24 hours. 84

85. Manual reduction of intussusception with usg guided 85

86. Loopography ( conduitography ) This technique is used to image the ileal loop obstruction . A medium-sized Foley catheter is passed retrogradely through the stoma and the balloon is inflated. Gentle traction on the catheter occludes the stoma. Urografine / iohexol 150ml is slowly infused until the whole loop is filled and bilateral ureteric reflux is observed. Spot radiographs are obtained, including drainage views to demonstrate that emptying of the kidneys, ureters and loop is adequate. If reflux from an ileal conduit into both ureters does not occur, then ureteric obstruction is a serious consideration. Poor drainage from the stoma at the end of the procedure may indicate stomal stenosis. 86

87. 87

88. Pouchography Pouchography imaging in the late postoperative period is performed to document the capacity of the pouch, to assess the degree of urinary stasis, to detect pouch-ureteric reflux and to exclude distal obstruction. 88

89. ROLE OF TECHNOLOGIST Detailed knowledge about procedure including anatomy and pathology. Should know about c/m, its preparation & its contraindications. Should be capable of tackling any emergency arose due to c/m. Knowledge of handling the equipment. Care & maintenance of the equipment . Knowledge of Quality assurance program. Knowledge of radiation protection. 89

90. Conclusion Barium Studies are safe & useful initial diagnostic procedure for evaluating GIT abnormalities. It uses radiolucent & radiopaque c/m in combination to a fluoroscopy unit to visualize the anatomy as well as the physiology. However these have limitations in the assessment of extra mucosal extent of the pathology. Although newer modalities are present but Barium is still considered as a basic and essential study. 90

91. References Radiological Procedures A Guideline by Dr. Bhusan N.Lakhkar . Techniques in Diagnostic Imaging ~. EDITED BY GRAHAM H. WHITE MB, BS (London FRCP, FRCR• Professor of Diagnostic Radiology . University of Liverpool AND BRIAN S. WORTHINGTON BSe , Ms, BS(London), FRCR, DMRI), LIMA Professor of Diagnostic Radiology University of Nottingham THIRD EDITION Merill’s atlas of radiographic positioning and procedure. www.Google.com /images Wikiradiography.com 91

92. THANK YOU THANK YOU 92