Barium studies in git

barium studies git radiology xray fluoroscopy

1. BARIUM STUDIES IN GIT DR. DEV LAKHERA

2. Barium studies in GIT Barium swallow Barium meal Barium meal follow through Small bowel enema Barium enema

3. Barium Barium sulphate Barium carbonate is toxic Properties Atomic number 56 – makes it radioopaque Non absorbable / Non degradable /non toxic Inert / Water insoluble

4. Properties - contd Barium sulphate – suspension Suspension – Heterogenous mixture (particle size >1micro m) Suspension settles – therefore shaking is important Ba sulphate particle size 0.3-12 micro m Solution – Homogenous mixture (solvent / solute)

5. Microbar suspension 95% wv Moderate density and viscosity Microbar paste 100 % wv Pharyngeal lining Microbar HD High density , low viscosity Power + 70 ml water Double contrast studies Effervescent (Sodium bicarbonate / citric acid / eno / fruit salt/ RT insuffulation )

6. Additives Carboxymethylcellulose – Decrease settling – Hygroscopic Sodium citrate - Prevents flocculation – makes alkaline Simethicone - Anti foaming. Not used in HD since air is needed in double contrast studies. Erythrocin – Color Saccharin – Palatable . Sweet taste. Too much inreases viscosity and decreases movement

7. Disadvantages Extravastation – peritonitis, pneumonitis, mediastinitis Inspissation Obscures follow up CT studies Embolism / Encephalopathy / Deposits - carcinogenic Indications Suspected perforation Possible aspiration Recent biopsy DETAILS ARE NOT AS GOOD Other GI contrasts Gastrographin – Diatrazoate meglumine 66%

8. Mucosal relief Collapsed lumen obtained with a small volume of barium Visualization of the folds Abnormalities involving the submucosa Double contrast Subtle mucosal lesions eg . early changes of inflammatory bowel disease and early neoplastic lesions. Single contrast Large volume of low-density barium Contour abnormalities, strictures, and large polypoid defects. normal longitudinal folds barium-filled esophagus smooth, featureless surface of the esophagus

9. Barium swallow Oral cavity to fundus of stomach Indications Dysphagia Odynophagia Fullness Heart burn C/I Perforation / TOF Preparation 4 hr fasting Avoid smoking

10. Technique Start in erect position Right anterior oblique position Initially 10-15 ml Follow bolus under fluoroscopy to clear oesophagus of spine

11. Technique Pharynx After thick suspension (20ml) frontal and lateral Valsalva / phonation V-vallecula, p –pyriform fossa, h-hypopharynx, p- posterior pharyngeal wall, tf - tonsillar fossa, a –aryepiglottic folds trigger – hyoid bone highest tonsillar fossa

12. Esophagus - Single contrast 40-50 ml mouthful followed in supine RAO erect – distended Collapsed – dense barium coating Spot - full length view / UM and ML

13. Mucosal relief / coating Longitudinal folds - esophagus partially collapsed Transverse folds.-contraction of the longitudinally oriented muscularis mucosae - associated with gastroesophageal reflux.

14. Double contrast - technique 15-20 ml HD barium initially Followed by Effervescent with another mouthful erect/ prone Buscopan i /v for hypotonia Frontal / lateral / RAO

15. Impressions A. Normal impressions: 1, aortic arch; 2, left main bronchus; 3, heart; and 4, esophageal hiatus. B. Abnormal extrinsic impression on the posterior wall of the esophagus caused by a large thoracic osteophyte.

16. MODIFICATION - techniques Suspected perforation / risk of aspiration: Gastrograffin / gastromiro - Water soluble contrast medium Ionic Contrast Media – Gastrografin // Non-Ionic Contrast Media – Gastromiro ( iopimadol ) Barium potential to stimulate a fibrotic reaction

17. MODIFICATIONS Foreign body – Marshmallow / cotton / bread coated in barium Hiatus hernia – Strain to raise intra- abdominal pressure

18. 4) Varices : Prone RPO position. High density barium /Single contrast Mucosal Relief. Buscopan i.v . is given to enhance variceal filling by making esophagous atonic. valsalva Reflux Patient lies in LPO position and drinks Barium through a straw. Spot films of lower esophagus and gastro-esophageal junction are taken, when they distend when barium passes through them.

19. Motility Disorder : Swallow in lying down position Patient is asked to take single swallow at a time. First 5 swallows are monitored to evaluate motility Methylcholine / amyl nitrate – streak of barium passage.

20. Barium meal Oesophagus to proximal jejunum Indications Epigastric pain Anorexia Weight loss Vomiting Dyspepsia Obstruction C/I Suspected perforation / Active upper GI bleed. Preparation 8-12 hr fasting Avoid smoking GOO - Aspiration

21. SINGLE VS DOUBLE CONTRAST Pylorospasm , fistulae , enlarged gastric rugae , filling defects due to large masses, obstructive features better on single contrast

22. BARIUM MEAL ANATOMY

23. GASTRIC MUCOSA ON BARIUM GASTRIC RUGAE AREA GASTRICAE Gastric rugae – longitudinal folds seen in mucosa of fundus and body. More prominent in GC. Fine reticular network of barium coated groves between 1-5 mm islands of mucosa. More visible in old patients. Absent in atrophic gastritis, enlarged in gastritis. More obvious in distal 2/3 rd .

24. Technique Single contrast – 95% barium suspension Initially 30-40 ml suspension follow on fluoroscopy Make table horizontal Rotate right side up twice - Mucosal coating films - supine

25. Mucosal pattern Supine Upper body Left lateral / LAO - Fundus RAO Body and antrum Single contrast Double contrast Fundus Supine Erect Body Erect / prone Supine Antrum and pylorus Prone rt side down Supine right side up

26. Angular Notch Incisura Angularis Barium Meal, Double Contrast (Supine Position) Body Antrum Supine Position: Note Barium Distribution in the Fundus due to gravity

27. Compression can be applied. Ant and post walls of the body and antrum of the stomach are compressed against the spine Protuberant lesions are often shown best with compression. Areae gastricae can be identified on compression.

28. Table erect Make RAO / Left posterior oblique

29. Double contrast view of a normal duodenal cap and loop

30. Biphasic contrast study 60-100 % low viscosity barium is given orally with gas forming power along with last few mouthfuls Advantages of both

31. Endoscopy High diagnostic accuracy (around 100%) Beeter for erosive lesions, early tumor detection and biopsy taking Barium swallow/ meal Low diagnostic accuracy Physiology better detected (peristalsis)

32. Barium in small bowel Barium meal follow through Small bowel follow through Enteroclysis Peroral pneumocolon Retrograde small bowel examination ‘ Barium studies are still mainstay for small bowel ’ Overhead radiograph enteroclysis (small bowel enema) shows the jejunum (J) in the left upper quadrant and the ileum (I) in the right lower quadrant

33. Barium meal follow through Oesophagus upto ileocecal junction Different from dedicated small bowel follow through Indications: Suspected small bowel obstruction Crohn’s disease Failed enteroclysis intubation. Contraindications: Colonic obstruction Perforation Paralytic ileus Following normal barium meal study

34. Technique : Following barium meal - 400 ml of 50-60 % of barium administered. After 15-20 minutes , film is taken with patient in prone to demonstrate jejunum and proximal ileum Subsequent films are taken at 15-30 minute intervals till ileocecal junction is opacified Small bowel follow through - Straightaway give 600 ml barium

35. Barium Meal + Follow-Through (Erect Position) Barium Meal Barium Follow-Through Duodenal Cap Pyloric Canal 2 nd Part of Duodenum 3 rd Part of Duodenum Body Antrum DJJ: Normal Position= Left side Angular Notch Incisura Angularis Jejunum: Plica Circularis on the outer border Ileum

36. IC junction Supine with right side up

37. ENTEROCLYSIS Jejunum to IC junction Tubes used are- Bilbao Dotter ( most common) – 22F Polyethylene, 150 cm (5cm longer than guidewire to prevent perfration from protruding tube ), 8 side holes, Guide wire (Teflon coated) Maglinte / Nolans / Harlinger

38. Technique Patient sits with chair to the wall/supine/right lateral Bilbao-Dotter tube without guide wire introduced into nostril Advanced with swallowing action till it reaches stomach Adjust air content (insufflation / aspiration) Barium introduced directly into the small intestine making it easier to identify morphological abnormalities

39. Single Contrast Barium suspension – 20%w/v injected @ 75-120ml/min Average time to reach IC junction is 15min Follow head of barium column on fluoroscopy One spot film for the jejunal loops and one for the entire small bowel

40. Advantages Desired rate of contrast administration Pylorus bypassed Controlled infusion –better dilatation Even minimal narrowing can be detected. Lesser segmentation and flocculation Tube can be used for decompression Disadvantages : 1. Intubation unpleasant for the patient, and may occasionally prove difficult. 2. More time-consuming. 3. There is a higher radiation dose to the patient (screening the tube into position)

41. Jejunum Ileum Proximal 2/5 th Distal 3/5 th Valvulae conniventies Featureless 4-7 fold/cm 2-4 Larger lumen Smaller

42. ENTEROCLYSIS v/s BMFT Contrast administered at desired rate, Pylorus bypassed Distension of bowel can be assessed Bowel proximal to stenosis dilates-stands out Time taken 20 to 30 min Direct rapid infusion produce hypotonia Reliability high superior Critically ill,elderly No discomfort Transit time assesed Overlapping & poor distension of bowel loops Prolonged study

43. Double Contrast 150 – 500 ml of HD barium injected @ 80–100 ml/min Head of barium is visualised under fluro Air contrast shows detailed mucosal changes like small ulcers Doesn’t distend the intestine or dilute the barium Sinuses and fistulae and stenosis may be overlooked

44. PERORAL PNEUMOCOLON : Mainly to evaluate distal ileum and IC junction Air insufflated after oral barium reaches transverse colon

45. BARIUM ENEMA - INDICATIONS Rectal bleeding Polyps on proctoscopic examination / familial history Change in bowel habits / weight loss Long-standing inflammatory bowel disease Contraindications Suspected Perforation Toxic megacolon Acute colitis Diverticulitis Recent rectal or colonic surgery/biopsy

46. Pre-requisite Adequate bowel preparation-NBM for 12 hrs Low residue diet for previous two days Plenty of fluids orally on previous day (prevents dehydration) Oral laxatives previous day Soap water enema previous night Plain water enema same morning

47. Methods 1. Double contrast – the method of choice to demonstrate mucosal pattern. 2. Single contrast – uses: (a) localization of an obstructing colonic lesion (b) children – since it is usually not necessary to demonstrate mucosal pattern (c) reduction of an intussusception

48. DOUBLE CONTRAST STUDY Technique Prone – left side down oblique Air introduced in prone position Frontal view in prone position followed by left lateral for lateral view Oblique right side down for rectosigmoid

49. Technique Patient - left lateral - catheter is inserted into the rectum. i.v. injection of Buscopan (20 mg). Barium infusion is commenced. Upto splenic flexure in the left lateral position and then the patient is turned prone. Contrast is then run to the hepatic flexure and is stopped when it tips into the right colon. The patient rolls onto their right and quickly onto their back. .The catheter tube is occluded and air is gently pumped into the bowel to produce the double-contrast effect.

50. SPOT RADIOGRAPHS Prone - Rectum Left lateral - Rectum Left posterior oblique - Sigmoid colon Supine - Rectum and cecum Upright - Hepatic and splenic flexures Supine, supine obliques - All remaining colonic segments

51. IMAGES

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