Barium meal follow through (BMFT), Enteroclysis and Barium enema (BE)

detailed procedure of BMFT, Eneroclysis & BE

1. Barium meal follow through (BMFT), Enteroclysis & Barium enema KHURSHEED AHMAD GANIE MRIT 3 rd SEM. MODERATER:- NITISH SIR

2. Contents Anatomy Clinical indication Contraindication Patient preparation Contrast media & dosage Equipment used Technique Filming After care

3. Anatomy of small & large intestine. Small intestine - Extends from pyloric sphincter to the ileocaecal junction avg. l ength 4.5- 5.5m. Diameter varies from 3.8cm at proximal aspect & 2.5cm at distal aspect. Wall consist of 4 layers-serosa, muscularis, sub-mucosa & mucosa. Divided into 3 parts i.e; duodenum, jejunum & ileum as in fig. 13-4.

4. DUODENUM (RUQ & LUQ) - Begins at pylorus curves around head of pancreas as “C” & join with jejunum to form duodeno-jejunal flexure. - 25cm long and widest part. - Consists of four portions:- a. Superior- duodenal blub. b. Second descending portion. c. Horizontal portion. d. Ascending portion.

5. Jejunum (LUQ & LLQ) - 2/5 th of the remaining aspect of small intestine. - Numerous mucosal folds which produces feathery appearance to the jejunum. Ileum (RLQ & LLQ) - Distal 3/5 th of the remaining aspect of small intestine . - Terminal ileum joins to the caecum to form ileocaecal junction in the RLQ.

6. Large intestine - Begins in RLQ about 1.5m long & 6cm in diameter. - Divided into four parts:- a. Cecum. b. Colon. c. Rectum. d. Anal canal.

7. a. Caecum - Proximal end of large intestine 6cm long and 7.5cm broad. - Large blind pouch located 2.5cm below the ileocaecal valve called appendix. b. Colon - The open end of the cecum merges with a long tube called the colon - Divided into 5 parts i.e; . ascending colon 20cm length. . Transverse colon 45cm.

8. . Descending colon 30cm long. . Sigmoidal colon 40cm . c. Rectum - Begins at the level of S3 & is about 12cm long. - Rectal ampulla is the dilated portion of rectum anterior to the coccyx. d. Anal canal - The final 2.5-4cm of large intestine constrict to form anal canal which leads in to anus.

9. Barium M eal Follow Through (BMFT) BMFT is the radiographic examination of GIT ( up to ileocecal junction) after administration of oral contrast media. - May be done separately or in continuation with Barium meal. Methods - single contrast BMFT - with the addition of effervescent agent. - Addition of Pneumocolon technique.

10. clinical indication - Pain - Diarrhea - Anemia/gastrointestinal bleeding - Partial obstruction - Malabsorption - Abdominal mass - Failed small bowel enema.

11. Contraindications - Colonic obstruction. - Suspected perforation. - Paralytic ileus. Patient preparation - Low residue diet for 48 before contrast study is conducted. - NPO 12 hours before the study is performed. - Take laxative agent on the evening prior to contrast study. - Remove jewelry or any other thing that may cause artifact. - Metoclopramide 20mg orally 20 min before or during examination. - Ask patient to void before the start of procedure.

12. Contrast media & dosage BaSo4 solution 100% W/V 300ml (150ml if performed immediate after Barium meal). Addition of 10ml gastrografin reduces transit time BaSo4 sol. Through small bowel. 3-4ml/kg is suitable in childrens. Non ionic water soluble contrast media is used in case barium is contraindicated. Equipment used - Fluoroscopic equipment with II TV system. - Over-couch X-ray tube. - Tilting x- ray table. - Spot filming device.

13. Preliminary film - AP full abdomen. Technique & Filming > Single contrast study - Aim to obtain continuous column of barium from duodenum to ileocecal junction. - Give dry food if transit time is slow. - ask the patient to drink Barium suspension as rapidly as possible. - Place the patient at right side dependent position. - after 15-20 min PA prone image is taken to determine jejunum & proximal ileum. - subsequent images are taken after every 15-30 min till ileocaecal junction is opacified.

14. - Spot films are taken in supine right side up for ileocaecal junction. - Compression pad is used to displaces overlying loops of intestine. * Always empty bladder before spot film. ** If BMFT is combined with Barium meal glucagon is used instead of Buscopan for duodenal cap view ( short time action + not interfere transit time). Additional films 1. To separate loops of small bowel : a. oblique films. b. 30 ̊̊ caudal angled view of pelvis c. with the patient tilted head down.

15. 2. To demonstrate diverticula: erect - this position will reveal any fluid levels caused by contrast medium retained within the diverticula. Double contrast BMFT examination - Same as single contrast study. - Gas producing agent is given when head of Barium column reaches the caecum. This should generate about 750-1000 ml of gas. - Pt is placed on the left side slightly head down to allow the gas to leave the stomach & enter the small bowel.

16. - Compression radiographs with patient in supine or oblique positions are taken . A . BMFT B. Spot film of terminal ileum

17. Per oral Pneumocolon - It is the double contrast radiographic examination of terminal ileus and right colon in which air is insufflated through rectum in conjunction with BMFT. - It is performed when terminal ileus is suspicious. - Colonic preparation similar to Barium enema. Technique - Baso4 suspension is administered orally. - Air is insufflated rectally when Barium reaches at right colon & proximal transverse colon.

18. - spot films of different areas of small bowel are taken especially suspicious terminal ileus. - Compression may be used. A . Conventional spot film ( poor demonstrated terminal ileum) B . peroral Pneumocolon ( well demonstrated)

19. After care - patients should warned about the white bowel motion for few days. - advice intake of large water to avoid barium impaction. - patient should not leave the department till the blurred vision produced may not resolved. Advantages of BMFT - Easily performed. - No discomfort/intubation to the patient unlike in Enteroclysis. - It is a physiological process hence transmit time can be assessed.

20. Disadvantages - Overlapping of barium filled bowel loops in the pelvis . - Poor distension of bowel loops. - Inappropriate timing for visualization of partial (or) intermittent small bowel obstruction. - Operator dependence. - Time consuming . Complications - leakage of Barium from unsuspected perforation.

21. - Conversion of partial obstruction large bowel into complete obstruction by barium impaction. - Aspiration of Barium. - Barium appendicitis if barium impacted in the appendix. - Side effects of pharmacological agents used.

22. ENTEROCLYSIS/ SMALL BOWEL ENEMA The radiographic examination of small bowel from jejunum to the ileocaecal junction in which contrast media is directly installed in to the proximal jejunum through nasogastric tube. Indications - Partial small bowel obstruction. - Crohn’s disease- to know its extent. - Malabsorption. - Tumors of small intestine. - Occult GIT bleeding. - Equivocal BMFT but strong clinical suspicious.

23. Contraindications - Complete colonic obstruction . - Suspected perforation. - Massive dilatation of the small bowel. - Duodenal obstruction and gastrojejunostomy. - Paralytic ileus. Patient preparation - Low residue- diet for 2 days before the examination. - NPO 6 hours prior to study. - laxative should be taken at the bed time before examination.

24. - If the patient is taking any antispasmodic drugs , they must be stopped 1 day prior to examination . - Immediately before the examination, the pharynx is anaesthetised with lignocaine jelly. Contrast media & dosage - Single contrast Enteroclysis:- barium suspension 70%w/v is diluted to prepare 1500ml barium suspension 20% w/v . - Double contrast Enteroclysis:- Barium suspension 200-250% w/v is ideal. We can use 95% Microbar by diluting it to 70% to decrease viscosity. 600ml of 0.5% Carboxyl- methyl cellulose (CMC) after 500ml of Barium suspension 70% w/v.

25. Contrast Dose in infants 3-5 Months age 200 ml, 5-8 Months 300 ml, 8-11 Months 400 ml, 1-3 Years 500 ml Equipment used - Same as that in BMFT. - Two types of tubes are used for administration of CM viz.. * Bilbao-Dotter tube with guide wire. ** Silk tube (10F, 140cm long) with a tungsten-filled guide-tip. It is made of polyurethane and the stylet and the internal lumen of the tube are coated with a water-activated lubricant to facilitate the smooth removal of the stylet after insertion.

26. Preliminary film Supine AP full abdomen plain radiograph. Technique > single contrast study - Single lumen tube is introduced into the proximal jejunum after anaesthetization of pharynx. - RAO position aids in passage of tube by gastric peristalsis from stomach to duodenum. - barium suspension 20%w/v is infused through the tube @ 75ml/min.

27. - Spot films are taken of the Barium column & follow under fluoroscopy until colon reaches. - Fluoroscopy is performed during infusion & images are recorded using 100/105 mm films or full radiograph as required. Enteroclysis

28. Double contrast study - 150-500ml High density BaSo4 suspension is injected @ 100ml/min through the tube. - Air or CMC is injected @ 75-120ml/min. - Spot-films should be taken when Barium reaches ileocaecal junction than again for double contrast. - ileocaecal junction is well seen in double contrast immediate after defecation & spot films may be taken.

29. After care - Nil orally for 5 h after the procedure. - patient should be warned that diarrhoea may occur as a result of the large volume of fluid. Disadvantages - Intubation may be unpleasant for the patient. - It is more time-consuming for the radiologist. - H igher radiation dose to the patient (screening the tube position).

30. Barium enema It is the radiographic examination of large bowel after administration of BaSo4 suspension through the rectum to determine form & function of large bowel and to detect any abnormal conditions. Indications - benign tumors (such as polyps ). - Ulcerative colitis (inflammatory bowel disease). - Chronic diarrhea. - Blood in stools. - Constipation . - Irritable bowel syndrome.

31. - Unexplained weight loss. - Change in bowel habits. - Suspected blood loss. - Abdominal pain. Contraindications Absolute - Toxic megacolon - Pseudomembranous colitis - Rectal biopsy via: a. rigid endoscope within previous 5 days. b . flexible endoscope within previous 24 h.

32. Relative - Incomplete bowel preparation - Recent barium meal - it is advised to wait for 7-10 days - Patient frailty. Patient preparation Many regimes of bowel preparation exists a suggested regime is as follows: - low residue diet for 3 days prior to study. - Take plenty of water on the day proceeding the examination. - Stop the iron containing medicine 2 days prior to the examination as they make the stool adhere to mucosa.

33. - Advice laxative for two days prior to examination (Biscodyl 15-20mg, Castor oil-30ml or Magnesium citrate – 5-10mg). - Wash the bowel on previous night & 2 hours prior to examination. Preparation of the Patient should not be done in - Diarrhea. - Total obstruction . - Paralytic ileus. - Children less than 8 yrs. of age. Contrast media - for Single contrast 15%-25% W/V barium suspension. - For double contrast a. Polibar 115% w/v 500 ml (or more, as required ) b. Air.

34. Equipment used - Same as used in BMFT examination. - Rectal tube (e.g. Miller tube) for administration of contrast * Miller tube has three components; a. a (wide bore) tube for administration of Barium b. a (usually blue) tube for administration of gas c. A small tube for inflating the balloon at the tip - Adhesive tape to fix the tube to the patient so prevent from back out - Enema bag & IV pole.

35. Enema tip insertion procedure - Explain the tip insertion procedure to the patient. - Place the patient in sims position. Shake the enema bag to mix Baso4 suspension well. Remove the air in tube. Wearing glove & coat the enema tip with lubricant. Direct the tip approx. 2.5-4cm towards umbilicus. Advance 3-4cm superiorly & slightly anterior. Tape the tube in place to prevent spillage . Ensure enema bag is no more than 60cm above the table.

36. Double contrast barium enema - Patient lie in sim’s position & catheter is introduced. - Connect it with barium reservoir & hand pump for injecting air. - IV injection Buscopan (20mg) or glucagon (1mg) is given. - Patient lie in prone or left side down oblique position & high density barium is allowed to flow up to splenic flexure. - Roll the patient from prone to left lateral than RAO to coat bowel with Barium. - Install air/Co2 in the bowel in prone position. - Air must push barium forward not passed through it.

37. - install air till it outlines ileocaecal junction. - Take spot films of junction & flexures. Single contrast barium enema - Infuse low density barium 15-25% w/v in left lateral position. - Clamp the catheter after rectum is full & take spot film. - Place pt. prone with Continue infusion take frontal view of rectum. - Prone right side down oblique position & take spot films of recto- sigmoidal curve. - Prone oblique left side down to open splenic flexure & take spot film.

38. Turn pt. right side down oblique position to follow barium towards hepatic flexure & take spot film. - As refluxes seen in ileocaecal junction clamp the tube & take spot films. - Take film of entire colon. - Remove the catheter & take Post evacuation film. Normal single contrast BE

39. Filming - Spot film for rectum & sigmoid colon (lying); a. RAO b. Prone. c. LPO. d. Left lateral of rectum. - Spot films for flexures & rectum (erect); a. LAO to open out splenic flexure.

40. b. RAO to open out hepatic flexure. c. Right lateral of rectum. - Spot films of caecum (lying) supine, lying slightly on the right side & with a slight head down position. - Over couch films to demonstration all large bowel (lying). a. Supine b. Prone c. Left lateral decubitus.

41. d. Right lateral decubitus. e. Prone with tube angled 45 ̊ caudal angulation to separate the overlying loops of sigmoidal colon. - Extra spot film of any abnormal area if required.

42. After care - Patient should be warned about the white bowel motion for few days. - Advice laxative to prevent barium impaction. - Patient must not leave the department until any blurred vision produced by Buscopan will not resolve. Complications - Bowel perforation. - Transient Bacteraemia. - Side effects of pharmacological agents.

43. - Cardiac arrhythmia due to rectal distension. - Venous intravasation. Advantages of Double Contrast Over Single Contrast • Better surface details . • 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.

44. References A guide to radiological procedures by Stephen chapman and Richard Nakielyn (4 th edition). Dr. Bhushan N Lakhkar Radiological procedures (3 rd edition). Text book of Radiographic positioning and Related Anatomy by Kenneth L. Bontrager & John P. Lampignano (8 th edition). D ifferent internet sources .

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