BARIUM ENEMA - NISCHAL SILAKAR_NMC02.ppt

Techniques for barium enema & other test.

2. BARIUM ENEMA
•NISCHAL SILAKAR
•BSc. MIT 2 year
•NMCTH

3. Large bowel enema
•It is the radiographic study of the large
bowel by administration of the contrast
medium through the rectum.
•Major advantage of barium enema is its
ability to examine the entire colon.
•Reasonably accurate, minimally invasive
and requires no sedation on routine basis.

4. The large intestine
extends from the
ileocecal valve to the
anus and has an average
length of 1.5 meters.
It is wider in diameter
than the small intestine,
with a maximum
diameter of the caecum
at 9 cm and the
transverse colon at 5.5
cm
ANATOMY

6. •Colon-marked by taeniaecoli-three separate
flattened bands of longitudinal smooth muscle,
contract lengthwise to produce thehaustra, the
bulges in the colon.

7. Types of Barium enema
•Double contrast barium enema
•Single contrast barium enema
•Water-soluble contrast enema.

8. DOUBLE CONTRAST BARIUM ENEMA
•The 'double contrast' refers
to the use of positive and
negative contrast agents to
increase the sensitivity of
the examination.
•positive contrast:barium or
barium-like agent, e.g.
Gastrograffin
•negative contrast:air or
CO2

9. Indications
•Double contrast enema is the best method for
evaluating the mucosal surface and for detecting
small lesions of colon. Small polyps, fine
ulcerations, granularity of the mucosa, lymphoid
nodules and small sessile lesions are best
detected.
•Common indications
1.Rectal bleeding -gross or occult
2.Polyps or carcinoma -suspected or known
3.Inflammatory bowel disease -suspected or
known

10. Contraindications
•Suspected acute perforation
•Acute, fulminating colitis/
pseudomembranous colitis.
•Immediately after rectal biopsy( rigid
endoscope within previous 5 days and
flexible one within previous 24 hrs.)

11. Patient preparation
•Many regimes exist
•Suggested regime is as follow:
–3 days prior to examination:
•low residue diet.
•Tab bisacodyl 2 tab HS
–On the day prior to examination:
•Plenty of fluids only.
•Magnesium sulphate 50% sol 90 ml-30 ml 6 am;
30 ml 2 pm; 30 ml 10 pm.
•Tab bisacodyl 2 tab HS

12. –On the day of examination:
•Nil per oral
•Bisacodyl suppository 2 such P/R at 6 am. To
evacuate after a while.
•Admission and priority
–Admit elderly and pts with social problems.
–Diabetics and serious first.

13. •Prophylactic antibiotics
–In the patients with prosthetic heart valves, a
previous h/o endocarditis or a surgically
constructed systemic pulm shunt or conduit.
–Amoxycillin plus gentamicin iv 15 min prior to
the procedure and oral amoxycillin 6 hour later.
–In penicillin allergic patients, vancomycin plus
gentamycin.

14. EQUIPMENTS

16. •Polibar 115% w/v 500 ml or as required
•Air
CONTRAST MEDIA

17. Use of glucagon in Ba enema
•Glucagon -1 mg iv in adult and 0.8 to 1.25
microgram in children given slowly over 1 minute.
•Used if there is spasm in the large bowel or if the
patient becomes extremely uncomfortable.
•Some radiologists prefer to give glucagon I.V.
prophylactically to prevent pain and spasm
associated with colon distension in pateints with
known irritable bowel syndorme (spactic colon) or
severe diverticulos.

18. Preliminary Film
Evaluate preliminary plain film of the abdomen
for
•Relative contraindications (stool or contrast
material in colon)
•Absolute contraindications to performing a
barium enema (i.e., free air in peritoneum, rigid
abdomen, toxic megacolon).

20. Procedure
•Question the patient about:
1.relevant symptoms and previous abdominal
surgery.
2.the "three P's" (pregnancy, recent procto, and
bowel prep).
•Explain the procedure to the patient. Ask if
he/she has any questions. Talk to the patient
throughout the examination to decrease anxiety
and divert attention.

21. •Pour 350 ml. of the suspension into an enema
bag, run barium from the enema bag into the
plastic tubing to expel the air.
•Clamp the tubing.
•Place the patient on his left side, lubricate the
enema tip, and insert it into the patient's
rectum.

22. Conduct Of The Examination
Modified Miller and Dean Maglinte’s method
1) The patient in the left lateral position.
•Unclamp the tubing and allow barium to flow by
gravity or by gently squeezing the enema bag.
•When you estimate that the rectum is filled with
barium, check the position of the enema tip with
fluoroscopy and inflate the retention balloon in the
rectal ampulla with only one puff of air during
fluoroscopic monitoring.

23. Contd..
•Rectal discomfort and urgency throughout the
examination can be avoided by only half filling the
balloon.
•The purpose of the balloon is to keep the enema tip
from coming out -not to block egress of barium.
•Do not inflate the retention balloon in the presence of a
large rectal tumor, acute inflammation, stricture, or
recent biopsy because of the potential for rectal
perforation.
•2) As the barium continues to flow, tilt head of x-ray
table down about 15°. When the bag is empty of
barium, clamp the tubing, and return the table to a
horizontal position.

24. 3) Begin insufflating air at a rate of not more than one puff
per second. Add 5 puffs of air in each of the following
9 patient positions: left lateral, LAO, prone, RAO,
right lateral, RPO, supine, left lateral, and, finally,
prone.
4) After the final turn and air insufflation, look to see that
barium has entered the ascending colon. If barium is in
the ascending colon, proceed to Step #5. If not,
perform Modification #1, to be followed by
Modification #2, if necessary (see Modifications,
below).

25. 5) With the patient in the prone position, raise the head of
the table 45°. Place the barium bag between the
patient's legs, unclamp the tubing, and allow barium to
drain from the rectosigmoid.

26. 6) Return the table to a horizontal position. Turn the
patient over into the supine position.
•During fluoroscopic monitoring, instill enough air to
distend the rectosigmoid.
•Take RPO and LPO spot images of the sigmoid
colon.

27. 7) Roll the patient onto the left side.
•Raise the head of the table to 75°. (NOTE: With
colon distended, some patients have a vaso-vagal
reaction when standing. Before placing the patient
upright, advise him to warn you if he feels faint,
so that you can lower the table to a horizontal
position before he passes out and falls.)
•With the patient upright, unclamp the tubing and
allow barium to drain into the enema bag during
the entire time that you are taking spot films of the
hepatic and splenic flexures.

30. 10)Clamp the enema bag tubing.
•Lower the table to a horizontal position.
•Roll the patient into the left lateral position.
•Lower the head of table down to -10°.

31. 12) Turn the patient
over to the prone
position.
•Raise the head of the
x-ray table to +45°.

32. 13)Return the table to a horizontal position.
•Add air slowly until the entire colon is well
filled. (Let the distension of the transverse colon
be your guide.)

33. Exposures

34. Modifications of double contrast enema
•Modification = if barium has not reached the
ascending colon. Turn the patient 360°in each
direction. When the patient is again prone, take
another look.
•(NOTE: Do not insufflate additional air at this point,
as it will likely produce an air-lock in the cecum.)

35. •Modification #2.
Pour one liter of thin (dilute) barium into the
enema bag. Use this thin barium as a plunger to
push the thicker, double-contrast barium into the
ascending colon. After the head of the barium
column reaches the ascending colon, return to

36. Overhead Radiographs (to be obtained
by the technologist)
1.PA view of colon to
include rectum -
perpendicular
central ray -14" x
17" film

37. 2) 15°RAO view of rectosigmoid with 35°caudad
central ray -14" x 17" film

38. 3) 20°RPO view of colon to include splenic flexure and
descending colon -14" x 17"

39. 4) 45°LPO view of colon to include hepatic
flexure and ascending colon -14" x 17"

40. 5) 15°LPO view of rectosigmoid with 35°
cephalad central ray on 14" x 17" film

41. 6) Right lateral decubitus view of colon to include rectum
on 14" x 17" film (After #6, turn patient through the
prone position to obtain #7.)

42. 7) Left lateral decubitus view ofcolon to include rectum on 14" x
17" film (Before taking this film, deflate rectal balloon, add two
pumps of air to rectum, and remove enema tip.)

43. AFTERCARE
•Warn about the white bowel for a few days
•Plenty of water to clear the bowel of Ba
•Laxatives if required to clear the bowel of Ba.
•Patient must not leave the department till
blurring of vision due to buscopan ( if used ) has
resolved.

44. COMPLICATIONS
•Perforation –more chance in infants and elderly;
obstruction of bowel; ulceration; patients on steroid
therapy; hypothyroidism
•Vasovagal attack and cardiac arrhythmias due to rectal
distension
•Transient bacteremia
•Side effects of pharmacological agents
•Venous intravasation which may cause pulmonary
embolus –carries 80 % mortality.

45. Advantages of Double Contrast Over Single
Contrast
• Better surface details and surface lesions can be
demonstrated to the best effect.
• Easy unraveling of the colon as it is possible to
look through loops.
Disadvantages of Double Contrast Over Single
Contrast
• Difficult in uncooperative patients.
• Fistulae/sinuses can be missed.
• Effacement of submucosaldetail of the colon and
overlooking of annular /polypoidlesion is
possible.

47. SINGLE CONTRAST BARIUM
ENEMA
•"Single contrast" refers
to imaging with barium
or water-soluble contrast
only, without addition of
gas or CO2.

48. Indications for single contrast barium enema
•Children-since it is not usually necessary to
demonstrate mucosa
•Patient under 40 years of age with abdominal signs or
symptoms not suggestive for polyps, colitis, or
bleeding (i.e., pain only, bloating only)
•Suspected diverticulitis
•Bowel not prepared but limited exam requested to
verify or exclude obstruction, volvulus, appendicitis,
fistula, etc.
•Uncooperative, disabled, very old, or very ill patient
unable to tolerate or perform the maneuvers required
for a double contrast study
•To reduce the intussusception.

49. •CONTRAINDICATIONS
•Same as DC enema.
•Patient preparation
•Bowel prep needed as in DC study for better
analysis.

50. Contrast media
•Barium sulphate 13% w/v

51. TECHNIQUE
•Insertion of tube, flow of barium and inflation
of tube in rectum ( same as DC)
•Then Barium is run slowly in a controlled way
by clamping and unclamping the tube.while
taking the film of particular part tube is
clamped.

52. •Spot films are taken as follow:
–RPO then LPO for sigmoid
–RPO for cecum( with graded compression) and for
splenic flexure
–LPO for hepatic flexure
–Survey whole abdomen fluoroscopically. If any
lesion, take compression view.

53. Overhead Radiographs

54. •Prone angle view of rectosigmoid -patient
prone, 35°cephalad central ray, 14" x 17"
film
•45°LPO view to include hepatic and
splenic flexures
•45°RPO view to include splenic and
hepatic flexures

55. Left lateral rectum

56. Post-evacuation film -patient prone, PA
view, vertical central ray, 14" x 17" film

57. SINGLE CONTRAST FOLLOWING
DOUBLE CONTRAST
•INDICATIONS
–Very large lesions sometimes escape detection. This
is particularly true in pts in whom ileocecal valve is
widely patent due to which hautral folds do not
distend and often mask an annular lesion.
–In pts in whom residual fecal matter is present, DC
study may not be satisfactory as the fecal matter
adheres to the wall and do not float. In such
condition, ask the pt to evacuate the air and Ba and
do SC study.

58. Water-Soluble Contrast Enema
Indications
•To check the patency of recent surgical anstomosis
•Suspected acute (uncontained) intestinal
perforation
•Colon examination in which the potential for
perforation is high (i.e., cecal distention, gas in
bowel wall, thumb printing of bowel on plain
film)
•Therapeutic enema for relief of fecal impaction
(but only after failure of routine cleansing enemas)
or intussusception.
•Fistulas (vesicocolonic, vaginocolonic)

59. Contraindication
•Allergy to iodinated radiographic contrast
media

60. Materials
•Contrast agent: Oral Hypaque or
gastrograffin -15% solution
•Enema bag and rectal tip
•Lead glove

61. Technique
•The technique of performing a water
soluble contrast enema is virtually identical
to that for a single contrast barium enema.

62. INSTANT ENEMA
•Unprepared enema
•Indications
–To identify the level of suspected large bowel
obstruction. In this case single contrast study will
be sufficient.
–To show the extent and severity of ulcerative
colitis and crohn’s disease. Double contrast study
is needed for this purpose.

63. •Contraindications
–Suspected acute perforation
–Acute, fulminating colitis/ pseudomembranous
colitis.
–Immediately after rectal biopsy( rigid endoscope
within previous 5 days and flexible one within
previous 24 hrs.)

64. •Contrast medium
–Water soluble contrast
•Preliminary film
–To r/o contraindicated conditions
•Technique
–Contrast medium is run slowly upto the obstructed
area thro the bag and tubing. Films are taken as
required.
–To see the inflammatory conditions, do the DC
study of the colon. Films are taken as required.
Instant DC examination is done based on the fact
that the feces won’t adhere to the inflamed bowel
mucosa.

65. COLOSTOMY ENEMA
•A double contrast study is ideal method of
investigation. Single contrast can also be done.
•Bowel prep as in routine DC study.
•This is a difficult examination, so all patients should be
given a hypotonic agent (1.0 mg Glucagon or 20 mg
Buscopan).
•Polibar (105% w/v) barium diluted to about 45% w/v is
used. If leakage is suspected use water-soluble first-if
no leakage then polibar can be used.
•A large 18F Foley catheter, with the balloon inflated to
secure a seal, is used.
•Air is insufflated after barium has reached cecum.

66. WATER ENEMA
•To diagnose the gastrointestinal lipoma
•CT has replaced its role in modern radiology.
•Can still be useful where CT is not available.

67. Contrast enema
•Conditions causing low intestinal obstruction
in neonates
–Hirschprung’s disease
–Functional immaturity of the colon( small left
colon syndrome, meconium plug syndrome)
–Colonic atresia
–Meconium ileus
–Ileal atresia

68. •All infants with low intestinal obstruction
require a contrast enema
•Contraindication
–Perforation
•Patient preparation
–Iv access
–Well hydration

69. •Contrastmedium
–Urograffin150
•Technique
–Contrast is introcudedinto the rectum thro the
small catheter. No inflation of balloon
–Advance the coantrastinto the colon slowly .
–Observe periodically in the fluoroscopy.
–Take the films to show the appropriate
lesions/conditions.

70. •For the treatment of meconium ileus,
–aim is to run the water-soluble contrast into the
small bowel to surround the meconium..
–Attempt is made to get the contrast back into
dilated small bowel.
–If successful, meconium should pass in next hour.
If no success and child deteriorates-surgical
intervention.
–If child is stable and meconium is passed
incompletely, multiple enemas in succeeding days
is necessary to complete the meconium passage.
–Overall success rate ~ 50 –60 %
–Perforation rate-2%

71. Hirschsprung disease

73. Ulcerative colitis

74. Crohn’s disease

75. Diverticulosis

76. Polyp

77. Intussusception

78. Colorectal carcinoma

79. Sigmoid volvulus

82. Question ?
•Describe the indications, contraindications
,patient preparations and procedure of
double contrast Barium enema.

83. REFRENCES
1.A guide to radiological procedures (5
th
edition)-Frances Aitchison and Stephen
Chapman
2.Radiological procedures a guideline
-Dr Bhushan N. Lakhkar
3.Clarks radiological procedures
4.RADIOPAEDIA
5.www.CIMS.org

84. •Next presentation:
MRI PULSE SEQUENCE
•Presenter: PRATIVA KHANAL

85. [email protected]