BARIUM ENEMA

BARIUM ENEMA

1.  BARIUM ENEMA PROCEDURE AND PATTERNS DR . J K PATIL Prof . department of Radio-diagnosis, DY Patil medical college, hospital & research institute Kolhapur

2. It is the radiographic study of the large bowel by administration of barium through the rectum. The major advantage of barium enema is its ability to examine the entire colon. It is reasonably accurate, minimally invasive and requires no sedation on routine basis.

3. INDICATIONS: Screening for colon cancer Inflammatory bowel disease Diverticular disease Inconclusive colonoscopy Assessing integrity of rectal anastomosis is prior to take down of diverting colostomy or ileostomy  CONTRAINDICATIONS Toxic megacolon Recent biopsy Rigid endoscope within 5 days Flexible endoscope within 24 hrs Generalized peritonitis

4. METHODS DOUBLE CONTRAST SINGLE CONTRAST The method of choice to demonstrate mucosal pattern. The primary aim in a double contrast study is to achieve good mucosal coating. Preferred in high risk patients- rectal bleeding, anemia, weight loss, family history of carcinoma / polyp, suspected IBD. Contrast medium - high density barium suspension – 60-120% w/v and a kilo voltage of about 90 is used. simpler, shorter and does not require rigorous maneuvers. Preferred in very young, very old, sick and disabled patients. In suspected obstruction and in evaluation of distal colon after colostomy Contrast medium - low density barium suspension - 12-25% w/v, and a kilo voltage of 100 -110 is used.

5. Patient preparation: For 3 days prior to examination Low residue diet. On the day prior to examination Fluids only Drink plenty of water to prevent dehydration. Magnesium citrate solution or Dulcolax tablets for 2 days. A tap water cleansing enema of 1500 ml on the morning of the barium enema examination.

6. Procedure of double-contrast enema The quality of the images depends on - mucosal coating which in turn depends on the barium suspension. - distension ( should just efface the normal mucosal folds ) - projection ( ideally without any overlapping loops and with lesions in profile )

7. Procedure A scout film is taken of the AP- if retained stool is present consider rescheduling. The patient lies on their left side with right leg flexed in Sims position, and the catheter tip is lubricated and is inserted gently into the rectum. The insertion should not exceed 3 to 4 cm. It is taped firmly in position. Inflate the rectal balloon only if necessary.

8. Connections are made to the barium reservoir and the hand pump for injecting air. An intravenous injection of Buscopan (20 mg) or glucagon (1mg) may be given. The infusion of barium is commenced. Intermittent screening is required to check the progress of the barium. The infusion is terminated when the barium reaches the hepatic flexure.

9. The column of barium within the sigmoid colon is run back out by either lowering the infusion bag to the floor or tilting the table to the erect position. Air is gently pumped into the bowel, forcing the column of barium round towards the caecum, and producing the double contrast effect. CO2 can be used as an alternative to air.

10. Spot films of all areas of the large bowel are taken including oblique views. Rectum: PA and left lateral view Sigmoid : LPO and right lateral Splenic flexure: RPO view Hepatic flexure: LPO view Caecum: AP and LPO view

11. Single contrast barium enema The aim is to achieve a homogeneous barium particle suspension throughout the bowel lumen. Basic principle is that all segments of colon should be clearly seen without overlapping loops. Each segment should be seen on at least 2 films so that any suspected lesion can be verified . This is done by a combination of fluoroscopy and compression spot films of the entire colon.

12. Adverse reactions Constipation Hypersensitivity reactions – rare Perforation Intravasation into veins

13. PATTERNS IN BARIUM ENEMA   Surface patterns Fold patterns Protruding lesions Depressed lesions Contour abnormalities

14. Surface patterns in enema  Surface patterns The normal mucosal surface usually has a smooth, featureless appearance.

15. Reticular pattern Granularity Nodularity Cobblestoning Innominate grooves This refers to a net like appearance due to barium in intervening spaces of normal columnar mucosa. - It is seen in any condition causing edema or inflammation. punctate dot like appearance due to subtle elevation of the mucosal surface. - can be due to mucosal edema, inflammatory exudate relatively well circumscribed elevations are seen as round or ovoid radiolucencies fissuring of mucosal surface with extension in to sub mucosa and muscularis propria . - seen in chrons disease seen as collections of barium within the fissure of the normally collapsed colon. It should not be mistaken for superficial ulceration. Ulcers will persist with distension of colon and innominate grooves will disappear.

16. Folds patterns in enema Coil spring sign Serpentine Folds Pleating If barium is forced between one loop of bowel intussuscepting into another loop, the barium may coat the mucosal folds of the outer loop. -The resulting radiographic appearance of concentric rings of barium is said to resemble a coil spring. Serpentine folds are sinuous or wavy and are often aligned parallel to the longitudinal axis of the bowel. - Serpentine folds are seen in mucosal and submucosal inflammatory or vascular processes. If an extrinsic desmoplastic process extends into the bowel wall, the overlying mucosa may be thrown into thin folds, termed pleating . - In the colon, this finding suggests endometriosis or intraperitoneal metastases involving the serosal surface.

17. Protruding lesions in enema Protrusions into the lumen of a hollow viscus can be either normal structures such as mucosal folds or pathologic lesions such as tumors. A protrusion on the dependent surface displaces barium from the barium pool and is seen as a filling defect . A protrusion on the nondependent surface is coated with barium and the X ray beam catches the edges of the protrusions, which are then "etched in white."

18. Protruding lesions Filling Defect - A filling defect is a radiolucency in the barium pool caused by displacement of the barium by a protruding lesion in a single contrast study . Contour Defect - A contour defect is a disruption of the expected luminal contour by a sessile lesion protruding into the lumen.

19. Polyp - A polyp is a protrusion from a mucous membrane. - Polyps may be seen as radiolucent filling defects on the dependent surface or may be etched in white on the nondependent surface

20. Carpet Lesion - focal, flat, well- circumscribed surface elevations. -When barium fills the intervening spaces of the lesion, multiple small, polygonal radiolucent filling defects are seen surrounded by barium.

21. Saddle Lesion - A focal mass that is just beginning to encircle but is still predominantly on one wall may resemble a saddle and is described as a saddle or semi annular lesion

22. Annular Lesion - Lesions that extend circumferentially around the bowel lumen are termed annular. - Annular configurations are seen in benign strictures caused by ischemia, radiation therapy, or diverticulitis or in malignancies such as primary tumors or metastases.

23. Depressed lesions in enema Depressed lesions are lesions that extend beyond the normal contour of the bowel, such as ulcers or diverticula. When located on the dependent surface, they trap the barium and therefore are seen as a focal barium collections. When located on the nondependent surface, they empty of barium. If there is adequate coating of the sides of the depressed lesion, it is seen as a ring shadow.

24. Depressed lesions Aphthoid Ulcer - An aphthoid ulcer is a small ulcer occurring on a mucous membrane. -The most common causes of aphthoid ulcers are Crohn’s disease & viral infections.

25. Linear Ulcer - Linear ulcers are frequently seen and have a variety of causes, especially Crohn’s disease or the toxic effects of drugs such as aspirin and other nonsteroidal anti-inflammatory agents.

26. “Collar Button” Ulcer - Collar button ulcers are ulcers with a narrow neck and a broad base. -These ulcers are formed when the inflammatory process spreads in the soft fat of the lamina propria and submucosa, parallel to the mucosal surface.

27. Exoenteric Mass - Exoenteric masses are masses of gastrointestinal origin that extend predominantly outside the bowel rather than into the lumen of the bowel. -The most common neoplastic exoenteric masses include lymphoma, metastatic melanoma, and gastrointestinal stromal tumors.

28. Tracking - Linear collections of contrast medium within the bowel wall are termed intramural tracks. Linear collections of contrast medium outside the expected confines of the bowel are referred to as extramural tracks. -Tracks associated with radiation damage, trauma, Crohn’s disease, or iatrogenic perforation may spread in any direction.

29. Contour abnormalities in enema Tapering - A shallow, smooth- surfaced, gradual narrowing of the contour of the bowel reflects a desmoplastic disease in the mucosa and sub mucosa that tapers the lumen. -Tapering is usually due to benign scarring from chronic inflammatory disease.

30. String Sign -The term string sign is used when severe narrowing of a bowel loop causes the lumen to resemble a string. -This term is especially applied in Crohn’s disease when severe narrowing is caused by edema, spasm, inflammation, or fibrosis.

31. Thumb printing - Submucosal hemorrhage or severe edema occurs to a greater degree along the mesenteric border of the small bowel and is manifested radiographically by thumb printing.

32. Sacculation - Sacculation refers to broad-based out poaching of the bowel wall. Relatively normal bowel wall may appear sacculated between folds radiating toward a neoplastic or a desmoplastic process. -This form of sacculation occurs on the bowel wall opposite the mesenteric changes of Crohn’s disease, ischemia, or diverticulitis.

33. Spiculation - A desmoplastic process extrinsic to the bowel, resulting from either inflammatory or neoplastic disease, may extend into the serosa or muscularis propria and pull the luminal contour into spike like points, termed spiculation .

34. Thankyou.