Enteroclysis

Radiological procedure

1. Enteroclysis Dr.N.Suriyaprakash JR,Dept of RD.

2. What is it ? Radiological study of small bowel from jejunum to ileocaecal junction by intubation of the jejunum and instillation of contrast through the tube. a/k/a Small bowel enema

3. When to do ? Partial small bowel obstruction Crohns disease Suspected meckels diverticulum Malabsorption Tumours of small intestine Occult GIT bleeding Equivocal BMFT but strong clinical suspicion

4. When not to do? Complete colonic obstruction Suspected perforation Massive dilatation of small bowel Duodenal obstruction and gastrojejunostomy Paralytic ileus

5. How to prepare the patient? Liquid diet for full day and over night fasting before the procedure. Dulcolax tablet in the evening preceding the procedure. No rectal enema. NO drugs like tranquilisers , sedatives , antispasmodics or anticholinergic .

6. WHAT is required for the procedure ? Bilbao Dotter Tube 22 F polyethylene tube 150 cm long Multiple side(8) holes at the tip with or without end hole

7. Contrast medium Single contrast enteroclysis : 20% w/v suspension of barium sulphate is used Double contrast enteroclysis : 200 to 250% w/v suspension of barium sulphate is used

8. How to perform the procedure? Preliminary plain radiograph Upright film Determine whether the patient is adequately prepared or not Determining the best radiographic method for evaluating the patient

9. Difficulties??? Prolonged examination Incomplete distension of bowel Prolapse of small bowel into pelvis Faecal material in terminal ileum

10. Single contrast enteroclysis Performed in patients with high grade partial small bowel obstruction with significantly dilatd bowel loops. Avg amount of BaSO4 – 1 to 1.5 litres Avg time to reach ileocaecal junction – 15mins Stenotic lesions are best identified at head of barium column.

11. 10 x 12 film kV – 120 to 140

12. Normal small bowel loops are well distended with folds in a parellel arrangement .

13. Double contrast enteroclysis 150 to 500 ml of barium suspension (80 to 100ml/min) is injected till proximal ileum is reached 0.5% carboxymethyl cellulose is injected at a rate of 75-120ml/min Ileocaecal spots taken when barium reaches the junction and then again when double contrast is in. Ileocaecal junction will be seen well in double contrast immediately after the patient defecates and spot films are taken.

14. Complete filming in 20 – 25 mins Erect filsms have no additional information

15. Air double contrast enteroclysis Preparation Laxatives night before examination NPO after 7pm the night before procedure Barium used : 50 to 70 % w/v barium sulphate Advantage : Better mucosal details Disadvantage : Difficult procedure Uncomfortable to patient Air may pass through minimal narrowing and it may be missed

16. ADVANtages of enteroclysis Quick. Tube may be left in place in patients with obstruction for better decompression . Better delineation of small bowel than BMFT. Sinuses and fistulas are better demonstrated . Contrast administration is not influenced by action of pyloric sphincter.

17. disadvantages Discomfort by placement of tube Rapid colonic emptying Operator dependent Failure to depict extra intestinal changes Nausea and vomitting due to inadequate tube placement

18. AFTERCare Warn patients about diarrhoea due to large volume of fluid infused. Aspiration Perforation Complications

19. diagnostic features in enteroclysis

20. Meckels diverticulitis MC congenital structural abnormality of GIT – Meckels diverticulum True diverticula Inflammation of Meckels diverticulum is meckels diverticulitis

21. Jejunal diverticula Small loops extending from the mesentric border of jejunal loop

22. Crohns disease IBD with widespread gastrointestinal involvement with skip lesions . a/k/a regional enteritis Radiological features Aphthous ulcer Creeping fat sign Thickened folds due to edema String sign

23. Target sign – Mucosal ulcer with surrounding translucent mound of edema

24. Thickened nodular folds in terminal ileum String sign

25. Celiac sprue T cell mediated autoimmune chronic gluten intolerance Loss of villi in proximal small bowel Radiographic features Small intestinal dilatation due to excess fluids Dilution of contrast Moulage sign Jejunoileal fold pattern reversal Segmentation

26. scleroderma Affects esophagus , small bowel and colon. Spares stomach Atrophy of muscular layer and replacement with fibrous tissue causing malabsorption . Small bowel dilatation Hide bound appearance Close aproximation of valvulae

27. Whipples disease Rare disorder Caused by Tropheryma whipplei Small bowel (jejunum) is a classical location – Intestinal lipodystrophy Hallmark findings Nodules Markedly thickened bowel wall – Picket fence thickening

28. Gist - leiomyoma Gastrointestinal tumor of mesenchymal origin arising from muscular layer of intestinal wall Solitary filling defect in the jejunum. Angles at the margin is obtuse depicting the intramural nature of the tumor. Normal mucosa /Bulls eye lesion .

29. Ct enteroclysis Hybrid technique combining conventional enteroclysis with that of abdominal CT. Can be combined with I V contrast study. Helical scanning done 70 secs after administration of I V contrast. Contrast media Neutral contrast Positive contrast Water/ Methyl cellulose IV contrast is usedwith neutral agents Sodium diatrizoate / Dilute barium No IV contrast is used with positive agents

30. CT vs conventional enteroclysis Better detection of intraluminal , intramural and extramural pathologies. Even small lesion can be detected. Measurement of bowel wall thickness possible. Detection of enteric fistulous tract and stenosis possible.

31. Mr enteroclysis Enteroclysis performed under MRI Methyl cellulose in water as enteric coated contrast agent with Gd -DTPA is preffered .

32. Thank you…