Barium procedures

DR Heera Ram JR2 MD radiodiagnosis

1. Barium Procedures BY DR. heera Ram

2. Definition:- Barium provides a roadmap of GI tract pathologies in the form x-ray examination of the esophagus , stomach, duodenum, small intestine & large intestine.

3. Contrast examination:- Barium sulphate is the best CM for demonstrating the GI-tract . - Single CM is used to outline the structure. - Double CM is used for detail viewing of the mucosal pattern . Water soluble CM is used in some cases such as : P erforation , S mall bowel obstruction, P ediatric patient.

4. Characteristic of barium:- The reason for using Barium sulphate for GI studies are : Ba has a high atomic number 56. Therefore, it is highly radioopaque and produces excellent bowel opacification. Non absorbable ( Therefore does not degrade throughout the bowel ), non-toxic. Insoluble in water/lipid. Inert to tissues. Suitable for double contrast studies as it coats the mucosa in a thin layer, thus allowing the introduction of 2nd or negative contrast agent without significant degradation . Route : Orally & Rectally

5. Adverse Effects of barium 1. Chemical peritonitis due to extravasation of additives of Barium Sulphate. 2. Extravasation into bronchial tree, urinary tract and other body cavities will produce inflammation. 3. Barium inspissation in cases of colonic obstruction to form hard stones. 4. Intravascular entry of Barium can cause embolism. 5. Barium Encephalopathy. * Small amount of Barium can be absorbed from the peritoneum in case of perforation Circulation --> concentrated in CSF with detectable levels --> Encephalopathy 6. Previous contrast media extravasated may mimic cancer due to inflammation. Longstanding barium deposits are carcinogenic.

6. Barium Studies Primer/General Principles Four main types of lesions – FUDS Filling defect Ulceration Diverticulum Strictures

7. Filling defect

8. Strictures Circumferential or annular narrowing

9. Diverticulum Saccular out pouching connected to the bowel lumen ,usually fills with barium

10. Ulceration Injury of the mucosal surface which becomes visible when the crater is filled with Barium

11. Common Barium Procedures Barium swallow - Pharynx to Fundus of the Stomach Barium meal - Oesophagus to proximal jejunum Barium meal follow through Small bowel enema/ Enteroclysis - Barium Enema – Colon

12. Barium Swallow R adiological study of pharynx and esophagus upto the level of fundus of stomach with the help of contrast.

13. Indications Dysphagia Heart burn, retrosternal pain, regurgitation & odynophagia Hiatus hernia Reflux oesophagitis Stricture formation Esophageal carcinoma Motility disorder like – Achalasia , diffuse esophageal spasms Pressure or invasion from extrinsic lesions Assessment of abnormality of P haryngo esophageal junction including zenkers diverticulum C ricoid webs C ricopharyngeal Achalasia.

14. Contraindications Barium should NOT be used initially if perforation is suspected. If perforation is not identifed with a water-soluble contrast agent then a barium examination should be considered. Tracheo -esophageal fistula

15. Patient preparation NPO for 6 hours prior to the examination. Smoking should be avoided on the day of examination. Muscle relaxants before the procedure

16. Contrast 2 Types of contrast study Single contrast study Double contrast study

17. Single vs double contrast:- Single contrast medium Double contrast medium Only barium is given. 60-100% w/v Barium with gas producing agent is given. 200-250% w/v To outline the structures, lumen and large abnormalities. For detail viewing of the mucosal pattern, making it easier to see narrowed areas (strictures), diverticula or inflammation.

18. Supplies and technical factors 4-6 oz (100-200 mL) regular barium (60% weight/volume) Barium cup Flexible large-caliber straw ± 2 oz (± 59 mL) regular barium (60% w/v) diluted with 2 oz (59 mL) water Scout film: Not routinely obtained . Image receptor (IR) or cassette: 14 x 14 inches (35 x 35 cm); for a 3-on-1 or spot-film image kVp : 80-120 MAs 30-40 Table-top position: the table is declined to -20° to allow for a full esophageal distension

19. Patient positioning for a single-contrast esophagram Place the patient in the right anterior oblique (RAO) position to offset the esophagus from the spine. The patient’s right arm is placed alongside the body, with the left knee flexed. PA oblique esophagus, RAO position (the midsagittal position forms an angle of 35°-45° from the grid device).

20. The technologist should place the cup of barium in the patient’s left hand, with the straw between the patient’s teeth. Patients who are unable to tolerate this position may be imaged in the left posterior oblique (LPO) position. Position the fluoroscope so that the apex of the left lung appears at the top of the monitor. The technologist will ask the patient to continuously drink the barium. This fills and distends the esophagus while the technologist obtains images of the proximal esophagus, midesophagus , and the distal esophagus, including an open lower esophageal sphincter (magnified if possible). Single-contrast study of esophagus in RAO position with table top in head-down -20° position

21. Double-contrast esophagram

22. Supplies and technical factors 2 medicine cups (for effervescent granules and water) 3/4 ampule effervescent granules 10 cc water 4-6 oz (100-200 mL) dense barium (200% to 250% w/v) Barium cup Scout film: Not obtained routinely IR or cassette: 14 x 14 inches (35 x 35 cm) for a 3-on-1 or spot-film image kVp : 90 Table-top position: vertical

23. The performance of the double-contrast esophageal examination is similar to that of a single-contrast examination. For a double-contrast examination, free-flowing, high-density barium must be used. A gas-producing substance, usually carbon dioxide crystals, can be added to the barium mixture or taken by mouth immediately before the barium suspension is ingested. Spot radiographs are taken during the examination, and delayed images may be obtained on request.

24. Patient positioning for a double-contrast esophagram Have the patient stand on a footboard in the LPO position to offset the esophagus from the spine. Place the cup of dense barium in the patient’s left hand. Have the patient take a small sip of the dense barium to become acclimated to its consistency. If the patient appears unable to tolerate the dense barium, obtain a single-contrast esophagram . Instruct the patient on the swallowing sequence. This is essential for obtaining a satisfactory exam

25. Swallowing sequence and technique The patient's head is tilted back to extend the neck . Center the fluoroscope over the upper third of the esophagus to localize the esophagus, then lower the tower and administer the effervescent granules and water. The technologist pours the granules into the back of the patient’s mouth, then adds the water and tells the patient to immediately swallow. ( Overdistension is prevented by using only 3/4 ampule of the effervescent granules.) patient drinks the barium with moderate rapidity and with constant encouragement by the technologist. Caution the patient not to burp. Image the entire esophagus as the patient is drinking, observe the esophagus for a "silver-satin" appearance -- indicating the best possible coating -- and obtain images of the proximal esophagus, midesophagus , and the distal esophagus

26. Postfluoroscopy projections The three basic postfluoroscopy projections for the esophagram are the anteroposterior (AP) or posteroanterior (PA) projection; AP or PA oblique in the RPO or LPO position; and the lateral projection from the right or left position

27. Patient positioning for postfluoroscopy projections Position the patient as for chest radiographs (AP, PA, oblique, and lateral). The right anterior oblique (RAO) position is usually used in preference to the left anterior oblique (LAO) position. An RAO position of 35°-40° gives a wider space for an image of the esophagus between the vertebrae and the heart. The LPO position may also be recommended. The patient is placed in the recumbent position for esophageal studies unless specified otherwise. This helps to obtain a more complete contrast filling of the esophagus (especially filling of the proximal part) by having the barium column flow against gravity. Moreover, the recumbent position is also used to demonstrate variceal distensions of the esophageal veins

28. Xray views Lateral projection:- Place pt in lateral position. Center midcoronal plane to cassette. Bottom of cassette below xiphoid process. Pt must drink continuously before and during exposure. Use shielding!

29. Xray views AP or PA Projection:- Pt. supine or prone Center midsagittal plane to cassette Bottom of cassette should be placed just below tip of xiphoid Pt. drinks contrast before exposure and continues drinking during exposure. Shield!

30. Xray views RAO or LAO Positions:- To throw the esophagus clear of the spine. Pt should be rotated 35 - 40 degrees Center about 2 inches lateral to MSP Bottom of cassette below xiphoid.

31. Pharynx One mouthful contrast bolus with high density(250% w/v). To get optimum mucosal coating patient is asked to swallow once and stop swallowing there after. Frontal and lateral view x-ray taken.

32. Complications - Aspiration - Leakage of barium from unsuspected perforation.

33. Barium meal Identifies lower half of oesophagus, the stomach and all of duodenum. Method A)double contrast – the method of choice to demonstrate mucosal pattern B)single contrast-used in children (not necessary to demonstrate mucosal pattern) And very ill adults (only gross pathology)

34. I n d i c a ti o ns 1)Dyspepsia 2)Weight loss 3)Upper abdominal mass 4)Gastro intestinal haemorrhage 5)suspected upper GI obstruction 6)assessment of the site of perforation(water soluble contrast is used)

35. Contra indications 1.Complete large bowel obstruction 2.Suspected perforation (unless water soluble contrast medium used ) Patient preparation 1. NPO after midnight(6 hrs) 2.abstain from-smoking, chewing gum or antacids- CONTRAST MEDIUM : 1 2 ml o f hig h den s i t y bar i u m 2 5 % W/V (Doub l e contrast) Sufficient 100 % W/V ( Single Contrast )

36. Technique-single contrast The examination is began with patient in the erect position.The fluoroscopist may first examine heart and lungs fluoroscopically and observe the abdomen to determine whether food or fluid is in the stomach. The patient then given a glass of barium and instruct to drink it as directed by fluoroscopist. If patient is in recumbent position,the mixture is administered through a drinking straw. The fluoroscopist instructs the patient to swallow two or three mouthfuls of the barium,during this time the fluoroscopist examine esophagus.Then stomach and duodenum. Fluoroscopy is performed with the patient in the erect and the recumbent positions,while the body is rotated and the table is angled so that all aspects of the esophagus,stomach and duodenum are demonstrated. Spot films taken as indicated.

37. Technique -double contrast 1.Hypotonic agent Buscopan(hyoscine butyl bromide,20 mg i.v) or 0.1-0.2 mg i.v glucagon is injected intravenously -relax stomach and suspend peristalsis. A packet of effervescent granules swallowed with small amount of water- releases CO2 and gastric distension.(approx 400ml CO2) High density barium is swallowed(120 ml- 250% w/v) and double contrast views of oesophagus is obtained standing RAO.

38. Patient faces Xray table,lowered to horizontal Then turned onto left side and finally supine . Patient rolled from side to side so as barium coats mucosal surfaces properly-washes over the mucus . Ask to roll onto the right side & then quickly over in a complete circle, to finish in an RAO position . Sequences of films of stomach obtained— When barium enters duodenum, patient is turned RAO – fills duodenum with gas, DC films are taken. Biphasic examination–Prone swallow of thin (125%w/v low density) barium given after contrast view obtained to optimize compression views of stomach and duodenum

39. Under fluoroscopic guidance, on the compression views-filling defects or abnormal collections are detected. Note:young children- main indication identify cause of vomiting eg:-pyloric Flow technique identifies-subtle mucosal abnormalities. obstruction,malrotation,and GOR.single contrast technique preferred(30% w/v Barium sulfate with no paralytic agent ). Note : kV range double contrast - 70-120 kV single contrast-120-150kV Note:If partial gastrectomy or drainage procedues ( eg ; pyloroplasty or gastrenterostomy ), begin with prone swallow using high density barium.Reaching duodenum or Genterostomy -turned supine for DC films.DC of stomach and oesophagus follows.

40. Positions employed Stomach and duodenum examined in the PA,AP,oblique and lateral directions,with the patient is the erect and recumbent postions .

41. S e q u e n c e s of f ilms f or ba r ium me a l examination

42. Right anterior oblique position  RAO –film -10x12 in. This projection with a rotation of 40 to 70 degrees gives the best image of the pyloric canal and duodenal bulb

43. Left posterior oblique position for stomach and duodenum LPO-film 10x12 in. best demonstrates the fundus portion of the stomach.

44. Right lateral position for stomach and duodenum Lateral projection-film 10x12 in. shows anterior and posterior aspects of the stomach,pyloric canal and duodenal bulb.

45. AP projection-film 11x14 in.-shows well filled fundic portion and usually DC delineation of the body ,the antral portion and the duodenum

46. Spot films for duodenal loop

47. Spot film of the abdomen with the patient in prone position

48. Modification technique for young children Indication Vomiting Technique Single contrast 30 % barium sulphate No paralytic agent

49. Afte r ca r e Patient should be told that the bowel will be white for few days Patient should be advised to drink adequate water Patient should not leave the department until blurring of vision has resolved

50. Barium follow- through examination

51. Anatomy of small intestine length = 6-7 m (approx) Extent - From Pylorus to ileo-caecal valve Proximal 2/5 th constitute the j e junu m and di s t al 3/ 5 t h c on s titu t e the ileum The Valvulae conniventes - 2 mm thi c k in j e j un um and 1 mm thick in ileum.

52. JEJUNUM & ILEUM 33 Jejunum begins at duodenojejunal flexure (L2) & ileum ends at ileocecalJunction . Jejunum & ileum = 6 to 7 m long (jejunum 2/5, ileum 3/5) Coils of jejunum & ileum are suspended by mesentery from posterior abdominal wall & freely movable.Most jejunum lies in left upper quadrant & most ileum lies in right lower quadrant

53. Introduction – Barium Follow Through Barium Follow Through is designed to demonstrate the small bowel from the duodenum to the ileoceacal region encompassing the duodenum , jejunum and ileum including the junctions superiorly with the stomach and inferiorly with the ascending colon. Also known as barium meal follow through (BMFT) & small bowel follow through (SBFT) 35

54. Barium meal follow-through Methods:- -single contrast. -with the addition of an effervescent agent. -with the addition of a pneumocolon technique. Indication:- - Diarrhoea - Anaemia -Partial obstruction -Malabsorption -Abdominal mass Contraindication:- -Complete obstruction -Suspected perforation -Paralytic ileus

55. Barium meal follow-through Contrast medium:- Barium sulphate solution 100% w/v 300 ml (150 ml if performed immediately after barium meal) Usually given in 10-15 min increments or full at once Transit time through small bowel has been shown to be reduced by the addition of 10 ml of gastrograffin to barium. In children , 3-4 ml/kg is suitable volume of contrast. Patient preparation:- Low residue diet for 2 days prior when possible NPO after midnight before exam. Metoclopramide ( maxolon ) 20 mg orally may be given before or during the examination to enhance gastric emptying. Pt’s bladder must be empty before & during procedure to avoid displacing or compressing ileum.

56. Preliminary Film Plain radiograph of the abdomen. To see bowel preparation. To rule out contraindication. Helps in assessing any abnormalities of gas filled bowel loops. If residual fecal matter presence-examination should be cancelled.

57. Technique Prone PA film of the abdomen are taken every 15-20min during the first hour. And subsequently every 20-30 min until the colon is reached. Spot film of the terminal ileum are taken in supine . Single Contrast Technique Patient is asked to drink Barium Suspension as rapidly as possible and then put the patient on right side to aid rapid gastric emptying. After 15 to 20 minutes , a film is taken with the patient prone to separate bowel loops , using high kV to demonstrate jejunum and proximal ileum. Subsequent films are taken with the right side up at 15-30 minute intervals till ileocecal junction is opacified .

58. Compression is mandatory To separate the bowel loops Assess mobility Define mucosal pattern Done by prone inflatable paddle

59. Additional films To separate loops of small bowel Oblique view With X-ray tube angled into the pelvis With patient tilted head down To demonstrate diverticula Erect-will reveal any fluid level

60. Single Contrast Technique Advantages of Prone Position Better separation & less overlap of bowel loops. In this position the centre of the abdomen is compressed making entire abdomen more uniform and thus more uniform x-ray penetration can be achieved. In this position loops of ileum tends to migrate cephalad and becomes less compacted in the pelvis which is often a common problem during procedure . Compression should be applied on the bowel loops to avoid overlap and to efface the mucosa so that the small lesions may not be missed and mobility of the loops can be well assessed

61. Single Contrast Technique Overlap of contrast filled bowel loops in the pelvis can be overcome by : Table head down . 30° caudal angled view of pelvis. Emptying of urinary bladder prior to filming the ileal loops . Drugs – Metaclopramide , Neostigmine, Glucagon, Cholecystokinin 20-40 ml of sodium / meglumine diatrizoate to the barium also reduces transit time. Cold barium speeds the gastric emptying and passes more rapidly through the intestine than does the room-temperature barium. Preliminary cleansing of the colon and placing the patient in right lateral recumbent position If desired, gastric and bowel peristalsis may be increased by various methods

62. Single Contrast Technique Note : 1. Polyposis : Films taken with collapsed loops show the polyps to best advantage. 2. Diverticulosis : Delayed films may show persistence of barium in the diverticulae . Erect position will reveal any fluid levels caused by contrast media retained within the diverticulae . 3. Large ulcers : Large collection of barium may be seen in the delayed film after the bowel loops have emptied the barium. 4. The transit time through the small bowel can vary greatly ranging between 15 minutes and 5 hours

63. Peroral Pneumocolon Done at the end of B.M.F.T. when distal ileum is suspicious and needs clarification. Preparation - Colonic preparation is similar to barium enema. Technique Barium is administered orally When barium has reached the right and proximal transverse colon, air is insufflated into the rectum and refluxed into distal ileum. Glucagon can be used to relax the ileocaecal valve.

64. Advantages OF BMFT Easily performed. No discomfort / intubation to the patient unlike in enteroclysis . It is a physiological process. Hence transit time can be assessed. Disadvantage of BMFT 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.

65. Complications of BMFT 1 Leakage of barium from an unsuspected perforation. 2. Aspiration. 3. Conversion of 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.

66. Appearance of small bowel No reliable radiological demarcation between jejunum and ileum Luminal diameter decreases along the length of the small bowel Jejunal diameter should not exceed 3.5 cm on barium follow-through and 4.5 cm on enteroclysis Small bowel wall should not measure more than 1-2 mm thick when distended

67. Mucosal pattern of small intestine The appearance of the mucosal folds depends upon the diameter of the bowel When distended the folds are seen as lines traversing the barium column known as Valvulae conniventes When relaxed folds appear feathery Mucosal folds are largest and most numerous in the jejunum and tend to disappear in the lower part of the ileum

68. Interpretation Small intestine extends from duodenojejunal flexure (ligament of treitz ) to the ileocaecal valve. • Length — 6-7 metres. • Calibre gradually diminishes. Anatomical differences between jejunum and ileum Jejunum Ileum Proximal 2/5th of small intestine (100-110 cm) Thicker and more vascular wall Wider and often empty lumen Larger and closely set circular folds Villi are larger in number Payers patches are absent Upper left & periumbilical region Feathery appearance Distal 3/5th of small intestine (150-160 cm) Thinner and less vascular wall Narrower and often loaded lumen Smaller and few circular folds Very few villi Peyer’s patches are present Lower right hypogastric and pelvic region and Featureless

69. Aftercare The patient must not drive until any blurring of vision produced by the Buscopan has resolved. The patient should be warned that their bowel motions will be white for a few days after the examination and may be diffcult to flush away. The patient should be advised to eat and drink normally but with extra fluids to avoid barium impaction. Occasionally laxatives may also be required.

70. Complications:- Leakage of barium from an unsuspected perforation. Aspiration of stomach content due to the Buscopan . Conversion of partial obstruction into a complete obstruction by the impaction of barium. Barium appendicitis, if barium impacts in the appendix.

71. Small Bowel Enema

72. Introduction Small bowel is demonstrated following duodenal intubation rather than by oral administration of contrast as in BMFT. Indications & Contraindications Mostly Same as barium follow through Crohn’s disease (most common) Pain Diarrhoea Loss of weight Anaemia (Gastro-intestinal Bleeding) Partial Obstruction Mal-absorption (Dyspepsia) Abdominal Mass Suspected Tubercular Lesion Lesions such as strictures, neoplasms, Mekels diverticulum

73. Methods Enteroclysis: Barium sulphate solution 70 % w/v is diluted to give 1500 ml of 20 % solution. Double contrast: 600 ml of 0.5 % carboxy methylcellulose (CMC ) after 500 ml of 70 % w/v barium sulphate solution.

74. Equipment For contrast administration, two types of tubes are available: Bilbao- dotter tube with guide wire Silk tube with tungsten filled guide-tip. It is made up of polyurethane & the stylet & internal lumen of the tube are coated with water- activated lubricant to facilitate the smooth removal of the stylet after insertion. Silk tube

75. Patient preparation The patient is subjected to liquid diet (2-3 litres) for a full day before the examination and is called after overnight fasting for the procedure. Two to four Dulcolax tablets in the evening preceding the enteroclysis are given. The above said preparation is very important because a full caecum or a food filled ileum seriously retards intestinal flow and produces artifacts and more fluid is needed to reach the caecum quickly. No rectal enema should be given because the enema fluid may reflux into the small bowel and create confusing small bowel patterns when it mixes with the Barium suspension. Drugs such as Tranquilisers, Sedatives and Antispasmodics should be discontinued the day before the examination. Anticholinergics and Ganglion blocking drugs tend to cause dilatation of the small bowel mimicking the sprue pattern. Narcotics affect both the motility and appearance of folds of the small bowel . Immediately before the examination, the pharynx is anaesthetised with lignocaine jelly.

76. Patient preparation – For Infant 4 hours fasting. To enhance gastric emptying, turn the baby to his right side. Sedation . Decreased peristalsis— compensated by 3-5 ml of metaclopromide Contrast dose for infants Age Dose 3-5 Months 200 ml 5-8 Months 300 ml 8-11 Months 400 ml 1 -3 Years 500 ml

77. Preliminary film Plain abdominal film is done I f a small bowel obstruction is suspected. To rule out any barium residues from previous examinations. To rule out large amount of fluid from the stomach or small bowel loops , as it will need to be aspirated before the procedure is done.

78. Intubation technique The patient sits upright on a chair placed against the wall so that he cannot move away from the advanced tube. Alternatively, in a patient who cannot sit up, the tube can be placed with patient supine or right lateral on the fluoroscopy table. 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 block or mass. Patients’ neck is hyper-extended. After this, the Bilbao-Dotter tube without the guide wire is inserted through one of the nostrils and advanced with the swallowing action of the patient till the tip reaches the stomach. About 5— 7 cm of tube is passed in stomach and then neck is flexed . The guide wire may be used to stiffen the tube to assist advancement through the oesophagus into the stomach. Make sure the tube is in the oesophagus and not in the trachea by asking the patient to cough and by observing under fluoroscopy.

79. Intubation technique After 2/3rd of the tube is passed, tip must be in the stomach Under fluoroscopic control, the tube is then advanced through the antrum of the stomach into the pyloric canal. Now, with the guide wire 5 cm proximal to the tube tip, the tube is slowly advanced till the tip enters the duodenal cap. This may be facilitated by turning the patient supine with right side up so that the location of the Pyloric canal and duodenal cap can be seen outlined by air. If this fails, turning the patient Prone with right side down oblique may help the tube to reach pyloric canal by gravity . Once the tube tip enters the first part of the duodenum, advance the tube slowly keeping the guide wire 2-3 cm proximal to the Pyloric sphincter. Withdraw the guidewire after each advancement. At the end, the tube will be beyond duodeno-jejunal flexure and the guidewire in the Pyloric canal. Finally, the tube tip should be approximately 4-5 cm distal to Trietz ligament. Such a placement prevents reflux of Barium and carboxymethyl cellulose into proximal parts of duodenum and stomach.

80. Single contrast technique Barium is then run in quickly at the rate about 75 to 120 ml/min & spot films are taken of the barium column & its leading edge at the regions of interest until the colon is reached. Fluoroscopy is performed during infusion & images are recorded using digital acquisition, 100/105 mm film or full size radiographs as required.

81. Double contrast technique CMC is infused continuously ( 75 to 120ml/min) after initial bolus of barium (80 to 100ml/min), until the barium has reached the colon. The tube is then withdrawn, aspirating any residual fluid in the stomach. Finally, prone & supine abdominal films are taken.

82. Double contrast technique Filming : Upper abdomen when jejunum is seen in double contrast. Full abdomen when entire small bowel is in double contrast. Ileocaecal spots in single and double contrast .

83. Air double contrast enteroclysis Preparation - Laxatives are given the night before the examination. NPO after 7 pm the night before the examination. Procedure - Barium : A 50% to 70% w/v Barium sulphate. At a rate of approximately 60 ml/min, using a 100 ml syringe, 150 to 200 ml of barium suspension is injected slowly. The progress of the barium column is observed by interval fluoroscopy.

84. Air double contrast enteroclysis Advantages The mucosal detail seen on the contrast study of the small intestine is superior to to any other examination. Apthoid ulcer and minute scar can be picked up easily Disadvantages Difficult to reproduce Uncomfortable to the patient Air may pass through the minimal narrowing and mild narrowing may be missed

85. Advantages of SBE 1. Contrast material is administered at a desired rate and not influenced by,the action of pyloric sphincter. 2. Direct infusion at a rate that produces hypotonia , completely dilates the entire small intestine and therefore the fold patterns and mucosal abnormality can be easily assessed The frequent intermittent flucroscopic monitoring during the enteroclysis examination together with the volume challenge induced by the infusion, facilitates the recognition of fixed & non distensible segments. 3. Because the distensibility of bowel lumen is challenged by enteroclysis , the bowel proximal to stenosis dilates— thus facilitating recognition of even a minimal narrowing. 4. Sinuses and fistulous tracts can be demonstrated by enteroclysis . 5. The time taken for the examination is not more than 20-30 minutes. 6. Enteroclysis tube may be left in place in patients with obstruction to achieve better decompression. 7. Enteroclysis permits better delineation of the small bowel than that achieved by Barium meal follow through. Segmentation of the barium column and flocculation is avoided

86. Dis a dvantages of SBE Placement of Nasogastric tube for enteroclysis causes discomfort which can be minimized by tranquillisers. Extrapyramidal symptoms of Metaclopramide can be made to subside by giving benadryl (or Atropine ). Nausea and vomiting due to inadequate tube placement proximal to treitz ligament -Treatment :Aspiration of contents by withdrawing the tube into the stomach . Rapid colonic emptying. Use of Barium as primary contrast agent. Operator dependent. Failure to depict extra-intestinal changes.

87. Aftercare Nil orally for 5 hrs after the procedure The patient should be warned that diarrhoea may occur as a result of large volume of fluid given. Aspiration Perforation of the bowel owing to manipulation of the guide wire. Complications

88. Barium Enema Definition - It is the radiographic study of the large bowel by administration of the contrast medium through the rectum . Preparation There are different regimes of bowel preparation and most regimes rely on a combination of dietary restriction, purgation and overhydration with the possible addition of cleansing water enema. Diet Patient should be given a low residue (low fibre) diet for 2 days prior to the examination. Patient should not have any fatty fried foods. He should not have vegetables and fruits. Patient can have egg, meat, dal and soups. 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.

89. Preparation of Patient 1 . Tab. dulcolax 2 HS — 2 Days . 2. Tap water enema on previous night and 7 a.m. on the day of investigation. 3. Low residue diet — 2 Days . 4. To come on empty stomach on the day of investigation Preparation of the Patient should not be done in 1.Diarrhoea . 2. Total obstruction. 3. Paralytic ileus. 4. Children less than 8 yrs. of age

90. Double contrast barium enema (DCBE) Preliminary Films Plain radiograph of the abdomen is essential and helps in assessing any abnormalities of gas filled bowel loops. In the presence of regidual faecal matter, double contrast examination should be cancelled. In many centres, barium enemas are performed after an excretory urogram . This not only reduces the time of hospitalization but also gives relationship of the urinary system to the colon. It also helps in visualization of the bladder in frontal and lateral projections and this permits the study of the space between bladder and rectum.

91. Double contrast barium enema (DCBE) Indications 1. Preferred method for routine examination. 2. High risk patients — rectal bleeding, previous H/o carcinoma or polyp, family H/o colorectal cancer or polyposis. 3. Demonstration of sinuses or fistulas. 4. Patient with severe diverticulosis, polyposis or diarrhoea. 5 . Presence of obstruction. 6. Reduction of an intussusception.

92. Double contrast barium enema (DCBE) Contraindication 1. Allergy to barium suspension. 2. Peritonitis. 3. Acute or fulminating inflammatory colon disease. 4. Debilitated, unconscious, inability to cooperate. 5 . History of recent rectal/colonic biopsy.

93. Double contrast barium enema (DCBE) 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 and barium suspension is allowed to flow upto splenic flexure. Now air is introduced with patient prone. Air should push the barium column and never pass beyond the column. Frontal view of rectum is taken in prone position and then the patient is turned left lateral to take the lateral view. Then oblique right side down view for rectosigmoid junction is taken. The patient is taken back in prone position with right side dependent and air is pumped into left sided colon. Once barium comes into transverse colon turn the patient left side up — barium enters right sided colon and reaches the ileocaecal Junction. Now with the right side up, more air is pumped till air outlines the ileocaecal junction. Spot films for flexures and ileocaecal junction are taken. F ull films in supine, both decubitus are taken.

94. Double contrast barium enema (DCBE) Advantages of Double Contrast Over Single Contrast • Better surface details. • Surface lesions can be demontrated 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 submucosal detail of the colon and overlooking of annular/polypoid lesion is possible.

95. Single contrast barium enema (SCBE) Procedure Barium suspension : Low density (to promote see through effect with a high kV or compression) 15% to 20% w/v . Tube is placed in the rectum with the patient in left lateral position. The height of the enema should not be more than 1 metre above the table top. In case there is gas in the rectum, the patient is kept supine and infusion is started. Otherwise the patient is kept in left lateral position. As soon as the entire rectum is full, the tube is clamped and a lateral view is taken. Then the patient is put prone and with the infusion running, the frontal view film of the rectum is exposed.

96. Single contrast barium enema (SCBE) In the prone position, pelvis tilts forward, sacrum lies parallel to the film and foreshortening of rectum is prevented. The patient is kept prone with right side down oblique position. This position helps in the opening up the curve of rectosigmoid junction. Spot views of rectosigmoid junctions with barium flowing are taken. Now the patient is kept prone oblique with left side down. Splenic flexure opens out and spot view of splenic flexure is taken. As barium flows towards hepatic flexure, patient is turned right side down oblique and spot films of hepatic flexure. With continuous flow of barium caecum fills up. As soon as the reflux across ileocaecal junction takes place, the tube is clamped and ileocaecal spot films are exposed. A full film is now exposed to show entire colon. After evacuation, mucosal relief film is exposed. Polyposis and diverticulosis can be better visualized on post-evacuation films.

97. Positions Part of the bowel Patient position Rectum and presacral space Left lateral Frontal-prone Rectosigmoid Prone right side down oblique Splenic flexure Prone left side down oblique Hepatic flexure Prone right side down oblique Entire colon Supine Table showing bowel parts visualized in various patient positions.

98. 10 – Miller’s Routine Sequence of Radiographs AP – to include flexures Left lateral rectum AP – 15 – 25 degs. Cephalic(CR) to include rectum. 15 – 25 degs.RPO – to include Left colic Right lateral – to include rectum Prone PA – to include flexures Prone PA with 15 – 25 degs caudal angulation (Angle Prone)– to include rectum. 15 – 25 degs LPO- to include the right colic flexure. Supine – AP tightly collimated ileocecal region proj . taken in 2 – 3 degs obliquity. Using horizontal central ray, upright proj . of both flexures and lateral rectum.

99. Modification of Positions for Barium E nema Usually used in the hospital

100. Scout Film First exposure of the procedure should be a plain radiograph of the abdomen area. Advice the patient to lie down on the radiographic table, the MSP of the patient should be inline with the MSP of the Table. Center the CR at the level of the L4 or the level of the iliac crest. Respiration is suspended during expiration. L4

101. Sim’s Position

102. Left/Right position of the recto sigmoid area Film: 10x12cm lengthwise True lateral position of the Recto sigmoid CR should be 5-7cm above the level of the pubic symphysis in the midaxillary plane

103. AP (recto sigmoid area) Film: 10x12cm crosswise AP view of the Rectum & Sigmoid should be included CR 5-7 cm above the level of the pubic symphysis 5-7cm above pubic symphysis

104. AP (Single Contrast) Film: 14x17cm An Entire colon filled with contrast media should be demonstrated including the splenic flexure and the rectum. CR is at the level of the L4 or at the level of the iliac crest L4

105. AP Double Contrast Film: 14x17cm lengthwise Patient lies in a supine position MSP is in line with th e MSP of the table An Entire colon filled with positive and negative contrast media should be demonstrated including the splenic flexure and the rectum. CR is at the level of the L4 or at the level of the iliac crest L4

106. RPO Position(optional ) Film: 14x17cm lengthwise Instruct the patient to lie on his right side making an angulation of 35-45deg It is taken primarily to demonstrate the Left Colic(splenic) flexure and de cending colon should be visualized. CR is at the level of the L4 or at the level of the iliac crest

107. LAO Position (optional) Film: 14x17cm lengthwise It is taken primarily to demonstrate the right colic (hepatic) flexure and sigmoid portion of the colon CR is a t the level of the L4 or at the level of the iliac crest

108. Right Lateral Decubitus Film: 14x17cm lengthwise Best demonstrate the “up” medial side of the ascending colon and the lateral side of the descending colon, when the colon is inflated with air due to gravity. CR at the level of the L4 or at the level of the iliac crest

109. Left Lateral Decubitus Film: 14x17cm lengthwise Best demonstrate the “up”, medial side of the descending colon and the lateral side of the ascending colon, when the colon is inflated with air. CR is a t the level of the L4 or at the level of the iliac crest

110. Ventral Decubitus Film: 10x12cm lengthwise A cross table view of the recto sigmoid area Demonstrate the air-fluid level of the recto sigmoid area CR is at 5-7 cm above the level of the pubic symphysis in the midaxillary plane

111. PA Axial position (Angle Prone) Film: 10x12cm or 11x14cm crosswise Rectosigmoid area must be less superimposition than in the PA projection because of the angulation of the CR Center it the midline of the body with an angulation of 30-40 caudad at approximate level of the anterior superior iliac spines.

112. Supine position Film: 14x17cm lengthwise A postevacuation radiograph view of the colon is taken after the procedure is done If inadequate satisfactory delineation of the mucus the patient may be given hot beverage (tea/coffee) to stimulate evacuation

113. Special barium enema studies Absolute Contraindications for Both DCBE and SCBE Toxic megacolon. Pseudomembranous colitis. If rectal biopsy has been done in the previous 5 days, it is preferable to wait for 7 days. Paralytic ileus. Difficulty to pass tube in rectum. Relative Contraindication • Incomplete bowel preparation.

114. Special barium enema studies Sigmoid Flush It is used in patients with severe diverticular disease to improve visualization of affected bowel. 500-700 ml of dilute barium suspension is run in at the end of standard DCBE and spot radiographs are taken of the filled sigmoid and descending colon .

115. Special barium enema studies Colostomy Enema A non-wash out bowel preparation is strongly advised in patients with a colostomy. Standard barium suspension may be used. Cut the balloon of a Foley’s catheter and then fit an infant bottle feeding nipple over this after having cut a suitably sized hole in the end. Catheter is advanced for about 15 cm through the nipple and is then inserted into the stoma until nipple acts as a bung in the stoma. Some guaze swabs with a central cut are placed around the nipple and the patient’s hand is used to hold this in place. The suspension is run through the main tube and gas is introduced through the side arm. Colon is filled till mid-transverse colon. Then patient is turned to right side and gas is insufflated . Rotate the patient to manipulate the column around the hepatic flexure and bring the barium to ascending colon. It is important to turn the patient prone. Spot radiographs taken are supplemented by two decubitus views.

116. Special barium enema studies Instant Barium Enema It is done to show the extent and severity of known colitis. No bowel preparation is required as residue does not accumulate in a segment of active colitis. Technique works best in ulcerative colitis where disease is continuous but gives acceptable results in Crohn’s disease . A preliminary plain radiograph is recommended to exclude toxic megacolon or perforation which are absolute contraindications to an instant barium enema. Colon should be filled until residue is encountered or the transverse colon is reached. Rectum is drained and gas is very gently insufflated turning the patient as required. A prone radiograph is taken. Lateral pelvic view will show size of rectum and an erect radiograph will show, the flexures and transverse colon in double contrast .

117. Special barium enema studies Water-Soluble Contrast Enema Gastrografffin or similar products are used as enema contrast media for certain conditions. Indications 1. Intestinal perforation due to diverticulosis, perforated carcinoma , leaking anastomosis and abdominal stab wounds communicating with colon. 2. Fistulas ( vesicocolonic , vaginocolonic ) 3. Softening of meconium in newborns and to relieve faecal impaction in adults. Hyperosmolar nature of gastrograffin may produce severe dehydration, shock and death in hypovolemic infants.

118. Barium enema - Aftercare The patient should be warned that his bowel motion will be white for a few days after the examination. Laxatives should be used to avoid barium impaction in patients with constipation.

119. Barium enema - Complications Perforation Inspissation of Barium - Causing severe constipation to the patient. Water Intoxication and Electrolyte Imbalance - Due to preparation with cleansing water enema Transient Bacteremia - Following instrumentation / dilatation of the colon