BARIUM STUDIES ON BARIUM MEAL AND FOLLOW THROUGH.pptx

BARIUM STUDIES

1. RAD 432: RADIOGRAPHIC PROCEDURES IV CONTRAST EXAMINATION OF THE STOMACH & DUODENUM (BARIUM MEAL) BY Dr. Alhaji Modu Ali 28/8/2024

2. TABLE OF CONTENTS Learning outcomes Introduction Brief anatomy of the stomach & small bowel MICCEPTAC Barium studies VS other methods Conclusion

3. LEARNING OUTCOMES At the end of this lecture, students should be able to: remember the gross anatomy of the stomach & small intestine list the various indications and contraindications of the Barium meal perform contrast examination of the stomach & duodenum list the advantages & disadvantages of the various study approaches Understand the roles of the other imaging modalities

4. INTRODUCTION Plain abdominal radiography is the first imaging modality of choice in the assessment of the stomach & small bowel especially in the cases of obstruction or foreign body. Barium studies are widely used for the examination of the stomach & small intestines because of its availability, affordability & some level of sensitivity. Fibre optic endoscopy plays a significant role in the examination of the stomach & small intestine & this has resulted in marked reduction in the number Barium studies being requested.

5. INTRODUCTION… Fibre optic endoscopy is excellent in the assessment of GIT wall. Radio nuclide is most commonly used to assess the gastric emptying rate & inflammatory bowel diseases Angiography is good for the assessment of the GIT in cases of acute bleeding CT has a limited role as a first line imaging modality.

6. INTRODUCTION… However, CT with oral CM has a significant role to play in the assessment of masses involving the GIT & other associated structures such as the pancreas. Ultrasound (US) also has a limited role to play in the assessment of the GIT lesions because of the problem posed by the associated gaseous interface. US has a role to play in cases of pyloric stenosis to measure the antral wall thickness. US is not the best imaging modality of choice except in neonates.

7. INTRODUCTION… Magnetic resonance imaging(MRI) with oral CM has an important role to play in the GIT assessment. MRI has change the concept of GIT imaging with the advent of capsule endoscopy. This have made it possible to provide direct GIT mucosal visualization. However, it has a limitation of disease localization & contra-indicated in patients with suspected bowel stricture or obstruction.

8. BRIEF ANATOMY Stomach The term stomach was derived from Greek word, “ gaster “ hence the term gastro . It is J in shape & most dilated portion of the alimentary tract. It is located in the epigastric, umbilical & left hypochondriac regions of the abdominal cavity. It connect oesophagus above & duodenum below. It tends to collapse when empty It stretches or expands to what would appear to be almost the point of rupture after a heavy meal. In adults, it can accommodate about 1.5 litres of food or more.

9. BRIEF ANATOMY… Stomach… Its location or orientation varies slightly with the type of body habitus: Hypersthenic (massive, 5%)-: Long abdomen with short/broad thorax, stomach is high, transverse & in the middle. Sthenic (average, 50%)-: Athletic build similar to hypersthenic , but modified by elongation of abdomen & thorax with stomach is high & upper left. Hyposthenic (slender, 35%)-: Intermediate between the sthenic & asthenic body habitus, the stomach is located higher Asthenic (very slender, 10%)-: Body is slender & light, bony framework is delicate with the stomach low & medial, in the pelvis when standing ( Plate 1).

10. BRIEF ANATOMY… . Figure 1: Body habitus types. Hypersthenic (A), Sthenic (B), Hyposthenic (C) and Asthenic (D). A B C D

11. BRIEF ANATOMY… Stomach… Anatomical relations Anteriorly : left lobe of liver & muscles of the anterior abdominal wall. Posteriorly : abdominal aorta, pancreas, spleen, left kidney & adrenal gland. Superiorly : diaphragm, oesophagus & left lobe of liver. Inferiorly : transverse colon & small intestine. Left laterally : diaphragm & spleen. Right laterally: liver & duodenum ( Plate 2).

12. BRIEF ANATOMY… Plate 2: Showing the stomach & its relationship with other organs

13. BRIEF ANATOMY… Stomach… Stomach has four parts or regions: - Cardia : Surrounds the superior opening @ T11 level - Fundus : Gas filled portion superior & left to the cardia - Body : Largest central portion - Pylorus : Lowest part that connect the stomach to the duodenum & it is divided pyloric antrum, canal & sphincter @ L1 level ( Plate 3).

14. BRIEF ANATOMY… Stomach… Stomach has two openings or orifices: - Cardiac orifice which is the proximal opening of the stomach. -It has a small, circular muscle, called the cardiac sphincter, allows food & fluid to pass through the cardiac orifice - Pylorus or pyloric orifice which is the distal opening of the stomach. It has a thickened muscular ring called Pyloric sphincter, relaxes periodically during digestion to allow stomach or gastric contents to move into the duodenum.

15. BRIEF ANATOMY… Stomach… Stomach has two curvatures: Lesser curvature , which is situated along the medial border of the stomach. It forms a concave border as it extends between the cardiac & pyloric orifces . Greater curvature , which is situated along the lateral border of the stomach. It is 4-5 times longer than the lesser curvature. It extends from the cardiac notch & the pylorus (Figures 3 & 4).

16. BRIEF ANATOMY… Plate 3: Anterior view of the stomach showing its various parts

17. BRIEF ANATOMY… Plate 4: Longitudinal section of the stomach showing its various parts

18. BRIEF ANATOMY… Stomach… Walls of the stomach is made up of four tissue layers (three smooth muscle & one mucosa layers: Outer layer of longitudinal fibres Middle layer of circular fibres Inner layer of oblique fibres Mucosa layer; thrown into longitudinal folds or rugae & when full the rugae are ‘ironed out or smoothen’ NB: Mucosa layer contains some gastric glands that gastric juice, hormones etc ( Plate 5)

19. BRIEF ANATOMY… Plate 5: Longitudinal section of the stomach showing the different tissue layers

20. BRIEF ANATOMY… Stomach… Arterial supply Left gastric artery from celiac axis Right gastric & gastroepiploic arteries from the common hepatic artery. Left gastroepiploic & short gastric arteries from the splenic artery Venous drainage Right & left gastric veins drain into hepatic portal vein Short gastric, left & right gastroepiploic veins drain into superior mesenteric vein.

21. BRIEF ANATOMY… Plate 6: Anterior view of the stomach showing the arterial supply to the stomach.

22. BRIEF ANATOMY… Stomach… Nerve supply Parasympathetic nerve (vagus nerve) Sympathetic nerve (T6-T9 spinal nerve) Lymphatic drainage Gastric & gastro- omental lymph nodes at the curvatures. Coeliac lymph nodes.

23. BRIEF ANATOMY… Small intestine (small bowel) The continuation of the stomach at the pyloric sphincter is the stomach. It measures 5-6 metres long & leads into the large intestine at the ileocaecal valve. It has a diameter of 2.5cm (1“). It is surrounded by the large intestine in abdominal cavity. Chemical digestion of food is completed & absorption of most nutrients takes place there.

24. BRIEF ANATOMY… Small intestine (small bowel)… Small intestine is divided into three parts Duodenum It measures about 25-30 cm long & forms a circumferential border with the pancreatic head. Located at the level of L1-L3 It is divided in to four sections: -Superior (1 st ) part: Located intraperitoneally & forms the duodenal bulb or cap, measures about 2cm long -Descending (2 nd ) part: Retroperitoneally, 7-10 cm long -Horizontal (3 rd ) part: Retroperitoneally, 10-12 cm long -Ascending (4 th ) parts: Retroperitoneally, 5-7cm long

25. BRIEF ANATOMY… Plate 7: Anterior view of duodenum showing the four parts Fourth part (ascending part)

26. BRIEF ANATOMY… Plate 8: Anterior view of the upper abdomen showing duodenum & its associated structures..

27. BRIEF ANATOMY… Plate 9: Anterior view of the abdomen showing jejunum, ileum & other associated structures..

28. BRIEF ANATOMY… Small intestine (small bowel)… Common bile & pancreatic ducts merge at the hepato-pancreatic ampulla or ampulla of vata before emptying their content in to duodenum. The opening is guarded by hepato-pancreatic sphincter (of Oddi )

29. BRIEF ANATOMY… Plate 10: Showing the relationship between the duodenum and accessory digestive organs and flow of secretions

30. BRIEF ANATOMY… Small intestine (small bowel)… B) Jejunum It is the middle section of the small intestine It measures about 2 metres long. C) Ileum It is the terminal section and ends at the ileo-caecal valve, which controls the flow of material from the ileum to the caecum. It measures about 3 metres long.

31. BRIEF ANATOMY… Table 1: Anatomical differences between Jejunum & Ileum S/N Jejunum Ileum 1 Proximal 2/5 th of small intestine (100-110 cm) Distal 3/5 th of small intestine (150-160 cm) 2 Thicker and more vascular wall Thinner and less vascular wall 3 Wider and often empty lumen Narrower and often loaded lumen 4 Larger and closely set circular folds Smaller and few circular folds 5 Villi are larger in number Very few villi 6 Peyer's patches are absent Peyer's patches are present.

32. BRIEF ANATOMY… Small intestine (small bowel)… Generally, small intestine is made up of four tissue layers: Serosa (outer) layer: secrete serous fluid for lubrication Muscularis layer: muscle adjacent to the sub- serosa membrane & responsible for peristalsis. Sub-mucosa layer: connective tissue that support mucosa Mucosa (innermost) layer: Secretes digestive enzymes & hormones

33. BRIEF ANATOMY… Arterial supply Superior mesenteric artery (SMA) Venous drainage Superior mesenteric vein (SMV)

34. MICCEPTAC Method Barium meal is the radiological study of distal oesophagus, stomach, duodenum & proximal jejunum. It is performed following the oral administration of CM. Indications (acquired) Symptoms based indications: -Epigastric pain suggestive of peptic ulceration. -Anorexia. -Unexplained weight loss. -Vomiting. -Anaemia. -Heart burn. - Upper abdominal mass.

35. MICCEPTAC Indications (acquired)… Gastro-intestinal haemorrhage. Gastric outlet or duodenal obstruction. Malignancies of oesophago -gastric junction, stomach & duodenum. Systemic diseases such as the upper GIT tuberculosis Motility disorders of GIT Perforation/fistulas Post pyeloplasty Failed upper GI endoscopy or patient unwilling to undergo endoscopy In children to identify a cause for vomiting due to: Gastro­oesophageal reflux Pyloric obstruction

36. MICCEPTAC Indications (congenital) Duodenal malrotation Gastric hernias Bile stained vomiting Congenital gastric outlet obstruction(GOO) or duplication Duodenal atresia

37. MICCEPTAC Contra-indications • Suspected cases of gastro-duodenal perforation • History or suspicion of aspiration • Large bowel obstruction to avoid Barium inspissation • Fistulous communication with any organs other than parts of GIT. • Recent biopsy from GIT, as barium granuloma may form at biopsy site.

38. MICCEPTAC Contrast media & premedication Single Contrast Study Low density barium suspension (80-100% w/v) is used. Water soluble CM in patient with suspected GIT perforation preferably, non ionic when there is risk of aspiration. Double contrast study -High density (250% w/v), low viscosity barium suspension produces best mucosal coating & detail. - About 100-150 ml of barium suspension is usually necessary to achieve adequate double contrast studies.

39. MICCEPTAC Contrast media & premedication… Double contrast study… Antifoaming agents are added to barium suspension to prevent air bubble formation which can mimic polyps. Gas forming agents are required to produce gas in the stomach, Na 2 CO 3 & Citric acid are given orally. When they come in contact in the stomach, CO 2 is produced which acts as negative contrast agent. Commercially available powders like gastrovision , eno , fruit salt etc. give good & rapid gas release. Ryle's tube is placed in the stomach to inject air. Smooth muscles relaxant (Hyocine 20mg/1ml) to relax mucosal fold.

40. MICCEPTAC Contrast media & premedication… Double contrast study… IV Buscopan/Hyocine is contraindicated in patients with : Glaucoma Urinary retention Tachycardia Cardiac diseases Poor general condition Haemodynamic imbalance.

41. MICCEPTAC Plate 11 : Digital fluoroscopy unit

42. MICCEPTAC Plate 12: Digital fluoroscopy unit turned to semi erect position

43. MICCEPTAC Patient preparation Nil per oral (NPO) for atleast six (6) hours. Patient should restrain from cigarette smoking as this may interfere with optimum mucosal coating as secretion may mimic tumours. Early morning appointment arrangement is recommended for diabetic patients as prolonged fasting is harmful. However, prolonged fasting or IV Metaclopraride is recommended for patients with GOO. Sometimes naso -gastric intubation & aspiration of the contents may be necessary for patients with GOO.

44. MICCEPTAC Technique Table 1: Standard views Part of the stomach Single contrast study Double contrast study Fundus Supine Erect with two views 90° to each other or right anterior oblique Body Erect or prone Supine with 60° head & upper part of the trunk elevation Antrum and pylorus Prone, right anterior oblique Left posterior oblique First part and the C-loop of the duodenum Prone, right anterior oblique Left posterior oblique Fourth part of the duodenum Supine Right anterior oblique

45. MICCEPTAC Plate 13: Various positions of stomach with their corresponding appearance

46. MICCEPTAC Plate 14: Various positions of stomach and duodenal cap with their corresponding appearance

47. MICCEPTAC Plate 15: Various positions of upper GI with their corresponding appearance

48. MICCEPTAC Plate 16: Various positions of upper GIT. B A C D

49. MICCEPTAC Technique… 1A) Conventional single contrast study (80-90 kV) A fluoroscopic screening is with the patient standing erect to visualize domes of the diaphragm & lung bases to detect any pathology. The stomach & intestines are visualize for fluid levels. About 10-15 ml of 80-100% w/v barium suspension is given & the patient is asked to swallow while oesophagus is seen under fluoroscopy. The couch is turned horizontal ,& the patient lying supine. The patient is now asked to continuously roll in clockwise manner as seen from the foot end of the patient.

50. MICCEPTAC Technique… 1A) Conventional single contrast study (80-90 kV)… A good mucosal coating of the entire stomach is thus obtained & the exam is performed. If the coating is inadequate, the patient is rolled again in the same direction before taking the film. The patient is kept supine & about 100-250 ml of barium is given. Spot films of the filled fundus in varying obliquity may be taken if any abnormality is detected. With the couch horizontal, patient is turned right anterior oblique (RAO).

51. MICCEPTAC Technique… 1A) Conventional single contrast study (80-90 kV)… In this position, barium moves into the duodenum through the pylorus. Spot films for duodenal bulb & C-loop can be taken after adjusting the obliquity to avoid overlap. Spot films are taken, both in distended & empty states. Patient is then turned supine & the table is made erect. The spot films for duodenal bulb and C-loop are taken in RAO position. Compression spot films of duodenum may be taken if required.

52. MICCEPTAC Technique… 1A) Conventional single contrast study (80-90 kV)… More barium is given to distend the stomach wall. Standard filming of oesophagus may be done now while giving the barium. Graded compression is given to see the mucosal folds & spot films may be taken if required. Gastric peristalsis & rate of emptying through the pylorus is observed. The patient is rotated under fluoroscopy to observe all margins of the stomach so that anteriorly or posteriorly placed lesions are not missed.

53. MICCEPTAC Technique… 1A) Conventional single contrast study (80-90 kV)… In erect position, RAO view of stomach will show incisura angularis & proximal jejunum. Retro-gastric space can be evaluated by giving 200-250 ml . In supine position (dorsal decubitus), trans-lateral film is taken to demonstrate the retro-gastric space. The disadvantage of the conventional single contrast study is that small mucosal lesions like polyps or early carcinoma may not be demonstrated. This can be partly overcome by a single high kV technique

54. MICCEPTAC Technique… 1B) Single contrast high kV study (120-130 kV) Barium sulfate 30% w/v is used. High kV permits visualization through the barium column so that lesions will not be drowned by the low density barium. Adequate mucosal relief study is not possible with such low density barium. Remaining aspects of barium meal are similar to conventional single contrast study.

55. MICCEPTAC Plate 17: Single contrast barium meal showing duodenal cap & other parts a b

56. MICCEPTAC Technique… Advantages of single contrast studies It is optimal for patients who are immobile or unable to swallow gas forming tablets. It best demonstrates pylorospasm , fistulae & enlarged gastric rugae . Filling defects due to large masses in pyloric & duodenal region are more easily identifiable by single contrast study. These are less obviously identifiable on double contrast. It is best to examine patients with suspected gastric or duodenal obstruction.

57. MICCEPTAC Technique… Disadvantages of single contrast studies It has low sensitivity for detecting small erosion/linear ulceration, superficial gastric carcinomas & subtle mucosal abnormalities.

58. MICCEPTAC Technique… 2. Double contrast barium meal This technique was perfected in Japan where as a result of high incidence of gastric malignancy. Its objective was for mass screening of the citizen to rule out gastric tumours for early detection. This technique relies much less on fluoroscopy & more on filming which is done over couch for better image quality. This was subsequently found to be very useful for small mucosal lesions like polyps, mucosal erosions & ulcers, recurrent tumours & post operative studies.

59. MICCEPTAC Technique… 2) Double contrast barium meal… IV Buscopan just prior stomach study. To study the stomach & duodenum, IV is given when barium enters the duodenum. About 100-150 ml of high density low viscosity barium is given. Gas forming agents are given. Then patient is rotated slowly for mucosal coating, beginning from supine to right lateral to prone to left lateral & back to supine. Filming for various parts of stomach & duodenum is done with standard views as stated earlier

60. MICCEPTAC Technique… 2) Double contrast barium meal… Advantages of double contrast study -Highly accurate method of detecting abnormalities following gastric surgery, bile reflux gastritis, marginal ulceration, recurrent carcinomas & abnormalities of the efferent loop. Disadvantages of double contrast study -Probably misses some polyps, ulcers, erosions, superficial carcinoma. Biphasic study overcomes all these problems & is the best & most accurate method of evaluation of upper GIT. If meticulously performed , it gives very good anatomic, as well as physiologic information & has an accuracy which is comparable to endoscopy.

61. MICCEPTAC Plate 18: Comparing single (a) & double contrast(b) barium meal

62. MICCEPTAC Technique… 3) Biphasic study of upper GIT Both single & double contrast incorporated together Gives good anatomic & physiologic information & has accuracy comparable to endoscopy. Aim is to have both mucosal delineation in double contrast phase & full column distention in single contrast phase. An additional quantity of dilute barium is given toward the end of an examination & further films are obtained of the compressible parts of stomach & duodenum.

63. MICCEPTAC Technique… 3) Biphasic study of upper GIT… About 60-100% low viscosity, 200-250 ml of Barium is given orally with gas forming powder in the last few mouthfuls. The advantage of this method is that it images some lesions better than by double contrast alone.

64. MICCEPTAC Technique… Table 2: Duodenal spot filming is done first to avoid flooding of the bowel (biphasic upper GIT studies) Patient position Demonstrated structure a RAO Duodenal cap, C-loop b LPO Duodenum c Erect Gastric fundus d Supine with 60 head up Upper gastric body e Supine Lower gastric body, pyloric antrum f LPO Pyloric antrum & Canal.

65. MICCEPTAC Technique… 4) Hypotonic (low osmolar pressure) Duodenography A)Tubeless method is performed as part of routine double contrast barium meal or as a specific examination of the duodenum, With IV line fixed, about 100 ml of high density low viscosity barium is administered orally. The patient is turned to RAO position. As soon as the fully distended duodenal cap is seen, Buscopan is injected IV. Gas producing powder is then given after turning the patient LPO position. 1 st & 2 nd part is seen in DC & CM enters 3 rd & 4 th part Filming same as DC study.

66. MICCEPTAC Plate 19: Tubeless method duodenogram

67. MICCEPTAC Technique… 4) Hypotonic (low osmolar pressure) Duodenography B)Tube method: - Bilbao-Dotter tube is passed into the 1 st part of the duodenum. IV line is fixed. With the patient in supine position, 50 ml of barium is injected through the tube & followed by IV Buscopan. The patient is turned so that the left lateral decubitus & air is injected through the tube. Films are taken in RAO position (1 st & 2 nd part of duodenum).

68. MICCEPTAC Technique… Hypotonic (low osmolar pressure) Duodenography B)Tube method:… Then the patient is turned prone and more air is injected till air reaches the 3 rd part & a film is taken. Then the patient is turned to left lateral decubitus & a film for double contrast of 2 nd part of duodenum is taken. Patient is then turned supine & a film is taken for overview of duodenum on a large film.

69. MICCEPTAC Plate 20: Duodenography (tube method)

70. MICCEPTAC Advantages of hypotonic duodenography • Reliable results are obtained. • Duodenal lumen is separable easily • There is no overlap of stomach Disadvantages of hypotonic duodenography • Pylorus is not assessed • Uncomfortable to patient • Amount of barium entering cannot be controlled.

71. MICCEPTAC After care • The patient should be warned that his/her bowel motion will be white for few days after the examination •The patient should be given laxative to avoid barium impaction which can be painful. • The patient must not leave the department until any blurring of vision produced by Buscopan has resolved.

72. MICCEPTAC Complication • Leakage of barium from an unsuspected perforation-peritonitis. • Aspiration pneumonia. • Barium impaction-converts a partial large bowel obstruction into a complete obstruction. • Side effects from the pharmacological agents used along with barium. • Acute gastric dilatation. • Barium embolisation if a bleeding ulcer is present.

73. Comparison of barium studies with other methods Endoscopy Barium meal 1 Procedure of choice as diagnostic accuracy is very high (Almost 100%) It has low diagnostic accuracy (Around 83 %). Hence , it is done when endoscopy is contraindicated 2 Ideal for erosive ulcers, small recurrent ulcers & early detection of tumour & biopsy can also be taken from the lesion. Ideal when endoscopy is contraindicated (in severe acute cardiac or pulmonary diseases.) . It is best to study the physiology i.e. peristalsis & emptying time

74. Comparison of barium studies with other methods A) Endoscopic Ultrasound - It is ideal to assess the extent of growth & its extension into the wall of oesophagus. -It is useful in early detection of lymph nodes. Biopsy can also be taken for confirmation of diagnosis. B) Computed Tomography - Main role of CT is in staging the malignant disease process. It is the modality of choice to assess the structure outside stomach wall. Good for gastric masses

75. Comparison of barium studies with other methods… Plate 21: Axial abdominal CT image at the level of L2

76. Comparison of barium studies with other methods… Plate 22: Axial abdominal CT image  A-Dilated stomach ( st ) & duodenum (d), peritoneal thickening (arrows) and encased small bowel segments in the pelvis; B-Dilated stomach, encased jejunal (2) and ileal (3) segments.

77. CONCLUSION In conclusion, Barium meal remains one of the best imaging method to study stomach & duodenum

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