barium swallow studies and their importance.pptx

emphasis on barium swallow and their study

1. BARIUM SWOLLOW, MEAL, FOLLOW THROUGH & ENEMA Dr. Prakash Singh Vasan Under the guidance of Dr. Rajesh S. Kuber and Dr.Suhas

2. Common Barium Procedures Barium swallow - Pharynx to Fundus of the Stomach Barium meal - Oesophagus to proximal jejunum Barium meal follow through – proximal jejunum to ileocecal valve. Barium Enema – Colon

3. Barium Swallow Barium swallow is radiological contrast study from oral cavity up to fundus of stomach.

4. 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 Pharyngo esophageal junction including - zenkers diverticulum Cricoid webs

5. Relative 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

6. Contrast TWO Types of contrast study Single contrast study Double contrast study

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

8. TECHNIQUE PHARNYX- 10 -15 ml contrast is given and act of deglutination is observed in frontal and lateral views with patient erect.

9. Patient positioning AND TECHNIQUE for a single-contrast esophagram MULTIPLE MOUTHFUL OF 80 % W/V BARIUM SUSPENSION IS GIVE IN SUPINE POSITION- under fluoroscopy to observe the barium bolus pass through the esophagus and observe peristalsis. THEN IN ERECT POSTION- One should place the cup of barium in the patient’s left hand, with the straw between the patient’s teeth and 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 FLIMS ARE EXPOSED WHEN OESOPHAGUS IS WELL DILATED WITH BARIUM – RAO LAO FRONTAL LATERAL NOTE-Place the patient in the right anterior oblique (RAO) position to offset the esophagus from the spine.

10. Double-contrast esophagram

11. The performance of the double-contrast esophageal examination is similar to that of a single-contrast examination. EXTRA STEPS- Contrast high density, low viscosity (200-250%W/V) - 15-20 ml given & asked to swallow. Then effervescent powder given with another mouthful of barium. In erect posture gas tend to stay up so adequate distention stays longer time. Inj. buscopan I.V given before the procedure to keep the oesophagus distended for longer time Patient positioning AND TECHNIQUE for a double-contrast esophagram

12. 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 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. Then patient drinks the barium with moderate rapidity (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

13. Xray views Lateral projection:- Place pt in lateral position. Bottom of cassette below xiphoid process. Pt must drink continuously before and during exposure.

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

15. Xray views RAO or LAO Positions:- To throw the esophagus clear of the spine. Pt should be rotated 35 - 40 degrees Bottom of cassette below xiphoid.

16. NORMAL OESOPHAGEAL CONSTRICTION SEEN Screenshot 2024-02-14 at 9.20.14 PM

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

18. SPECIFIC CONDITIONS

19. Foreign body impaction

20. DIFFUSE OESOPHAGAL SPASM “C orkscrew oesophagus" or "rosary bead oesophagus”

21. Gastro-esophageal reflux disease- feline esophagus.

22. Esophageal carcinoma

23. Oesophageal varices

24. Achalasia-birds beak appearance

25. Pharyngeal web

26. Zekers diverticulum

27. Barium meal Identifies lower half of esophagus, the stomach and all of duodenum. Method Double contrast – the method of choice to demonstrate mucosal pattern Single contrast-used in children (not necessary to demonstrate mucosal pattern) And very ill adults (only gross pathology)

28. INDICATIONS

29. Contra indications Suspected gastro duodenal perforation History or suspicion of aspiration- alternative contrast medium should be considered Complete large bowel obstruction- painful barium inspissation occurs in these cases. Fistulous communication with any organs other than parts of G.I.T. Recent biopsy - risk of barium granuloma formation at site

30. PATIENT PREPARATION- NPO 6 hours before examination In patients with Gastric outlet obstruction-prolonged fasting, or IV metoclopramide or nasogastric intubation and aspiration of contents may be necessary Not to take regular oral medications until after the test. CONTRAST MEDIUM : Double contrast-High density low viscosity 250 % W/V Single Contrast -Low density barium suspension 80-100% w/v-

31. Technique- S ingle contrast In conventional study, radiography is done at 80-90 kV . In erect position, fluoroscopy is done to visualise both domes of the diaphragm and lung bases to detect any pathology. The stomach and intestines are seen for fluid levels. 10-15 ml of 80-100% w/v barium suspension is given and patient is made to swallow while oesophagus is seen under fluoroscopy. The table is made horizontal, and the patient lying supine is rotated with the right side going up. In this way the patient is rotated in a continuous clockwise manner as seen from the foot end of the patient. A good coating of the entire stomach mucosa is thus obtained and radiography is done to show the mucosal relief .

32. Then patient is kept supine and about 100-250ml of barium is given. Spot films of the filled fundus in varying obliquity maybe taken..

33. THEN FOR DUODENAL LOOPS- With the table horizontal, patient is turned prone oblique right side dependent. In this position, barium enters the duodenum through the pylorus.

34. THEN-Patient is then turned prone and the spot films for duodenal bulb and C loop are taken in right anterior oblique position . GRADED COMPRESSION is given.

35. DOUBLE CONTRAST BARIUM STUDY This study is found very useful for small mucosal lesions like polyps, mucosal erosions and ulcers, recurrent tumours and post operative studies Preparation- A 'dry' fluid free stomach is essential. Double contrast study should not be done if secretions exist in the stomach. The secretions will prevent adequate mucosal coating and may mimic tumours. Hypotonic agent Buscopan (hyoscine butyl bromide,20 mg i.v ) or 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)

36. Technique Injection Buscopan IV OR IV glucagon should be given just before giving barium to study the stomach. About 100-150 ml of high density low viscosity barium is given. Gas forming agents( effervescent granules ) are given. Then patient is rotated slowly for mucosal coating, beginning from supine to right lateral to prone to left lateral and back to supine. Filming for various parts of stomach and duodenum is done with standard views as stated for single contrast study.. Note : kV range double contrast- 70-120 kV , single contrast-120-150kV

37. Sequences of f i l ms f or b a r i u m m e a l examination

38. SEQUENCES OF FLIMS FOR BARIUM .

39. RIGHT ANTERIOR OBLIQUE - Gastric antrum Greater curvature of stomach

40. AP projection- SUPINE- shows well filled fundUS portion and usually delineation of the body ,the antral portion and the duodenum

41. Right lateral position for stomach and duodenum Lateral projection-shows anterior and posterior aspects of the S tomach and duodenal bulb .

42. SPOT FILMS FOR DUODENAL LOOP

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

44. BEST IS- BIPHASIC STUDY Full column distension in single contrast phase Mucosal delineation in double contrast phase 60-100% low viscosity , of Barium is given orally with gas forming powder in the last few mouthfuls

45. Aftercare 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

46. Aspiration pneumonia. Leak from unsuspected perforation- Peritonitis. Barium impaction- converts a partial large bowel obstruction into complete obstruction Acute gastric dilatation . Barium embolization if bleeding ulcer present. Complications of Barium Meal

47. PATHOLOGIES SEEN IN BARIUM MEAL

48. BARIUM FOLLOW THROUGH EXAMINATION

49. I n t r od u ction – Barium F o ll o w THROUGH Barium Follow Through is designed to demonstrate the small bowel from the duodenum to the ileocecal region encompassing the duodenum, jejunum and ileum. Also known as barium meal follow through (BMFT) & small bowel follow through (SBFT) 35

50. Barium meal follow-through METHODS:- - SINGLE CONTRAST - 300-400ml 50% w/v barium suspension - DOUBLE CONTRAST- 300- 400 ml 80%w/v barium suspension with the addition of an effervescent agent. - INDICATION:- -Diarrhoea -Anaemia -Partial obstruction or complete obstruction of small bowel -Malabsorption - CHRONS DISEASE -Abdominal mass CONTRAINDICATION:- -Complete obstruction of COLON - Suspected perforation - Paralytic ileus

51. Barium meal follow-through 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. Patient preparation is mandatory:- Low residue diet for 2 days prior and NBM after midnight before exam. Colon should be cleaned – using PURGATIVE. Metoclopramide 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.

52. Technique Prone PA film of the abdomen are taken every 15-20min during the first hour. And subsequently every 20-30 min until barium reaches the colon. Spot film of the terminal ileum are taken in supine . Single AND double Contrast Technique- Patient is asked to drink Barium Suspension 50% W/V (600-900ml) 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 up at 15-30 minute intervals till ileocecal junction is opacified.

53. Compression is mandatory T o s e p a r a t e the b o w el lo o p s Assess mobility Define mucosal pattern Done by prone inflatable paddle

54. 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 ascending and proximal transverse colon, air is insufflated into the rectum and refluxed into distal ileum. Glucagon can be used to relax the ileocaecal valve.

55. Complications of BMFT 1. Leakage of barium from an unsuspected perforation. Aspiration . Conversion of partial large bowel obstruction into a complete obstruction by the impaction of barium. Barium appendicitis , if barium impacts in the appendix. Side effects of pharmacological agents used.

56. Interpretation 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 ILEUM JEJUNUM

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

58. pathologies

59. Meckel’s diverticulum A large out pouching from antimesenteric border of ilium

60. Crohn’s Disease Mucosal Granularity Stricture

61. Small Bowel Tumors : Irregular short segment narrowing with mucosal irregularity

62. Barium Enema Definition - It is the radiographic study of the large bowel by administration of the contrast medium through the rectum. Preparation- . Tab. dulcolax — 2 Days. Tap water enema on previous night and 7 a.m. on the day of investigation. Low residue diet — 2 Days. To come on empty stomach on the day of investigation Preparation of the Patient should not be done in 1.Diarrhoea. Total obstruction. Paralytic ileus. Children less than 8 yrs. of age

63. barium enema Indications Preferred method for routine examination. High risk patients — rectal bleeding , previous H/o carcinoma or polyp , family H/o colorectal cancer Demonstration of sinuses or fistulas . Patient with severe diverticulosis, polyposis or diarrhoea . Presence of obstruction . Reduction of an intussusception . Contraindication Allergy to barium suspension. Peritonitis . Acute or fulminating inflammatory colon disease. Debilitated, unconscious, inability to cooperate. History of recent rectal/colonic biopsy .

64. CONTRAST and technique 500 ML BARIUM IS USED. 1- SINGLE CONTRAST STUDY The colon is filled with barium(20 %W/V) which outlines the intestine and reveals large bowel abnormalities 2- DOUBLE CONTRAST (100% W/V )

65. 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 up to splenic flexure .Now air is introduced with patient prone. Air should push the barium column and never pass beyond the column. FIRSTLY- 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. Then patient is taken back in prone position with right side dependent and air is pumped into descending colon. Once barium comes into transverse colon turn the patient left side up barium enters ascending colon and reaches the ileocaecal Junction . Now , more air is pumped till air outlines the ileocaecal junction. Double contrast barium enema (DCBE)

66. P ositions 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 .

67. 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. Double contrast barium enema (DCBE)

68. 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.

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

70. 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

71. Pathologies seen on barium enema

72. Large Bowel Polyps:

73. Ulcerative Colitis: Lead pipe colon : tubular ahaustral featureless colon

74. Colorectal CA Apple Core Lesion

75. Hirschsprung’s Disease: Abrupt transition zone at recto sigmoid junction; inversion of recto sigmoid index

76. Diverticular Diseases: Multiple small rounded out pouching from the bowel wall Diverticular Diseases: