Enteroclysis( small bowel enema)

small bowel enema

1. ENTEROCLYSIS (SMALL BOWEL ENEMA ) ANKIT KUMAR BRIT

2. DEFINITION :- It is a radiographical study of small bowel from jejunum to the ileocecal junction by intubation of the jejunum and instillation of contrast through the tube.

3. ANATOMY

4. INDICATION Partial obstruction Chron’s disease Suspected merckels diverticulum Malabsorption Tumor / malignancy of small intestine Occult GIT bleed Equivocal BMFT but strong clinical suspicion

5. COTRAINDICATION Complete obstruction Perforation Massive dilation Duodenal obstruction ( gasojejunostomy ) Paralytic ileus Equipment Bilboa – dottor tube 22f polyethylene tube (180 cm long) Multiple side holes Teflon coated guide wire(reduce friction)

6. Bilboa – dottor tube Teflon coated guide wire 22f polyethylene tube

7. CONTRAST MEDIA Baso4 – alkaline - It improves coating of valvulae connivents For single contrast - 20% w/v suspension of baso4 For double contrast - High density low viscosity baso4 suspension - 200 – 250 % w/v 95% microbar dilute to 70 % to decrease the viscosity 10 gm CMC ( carboxy methyl cellulose)+2 ltrs warm water Mix and refridge overnight

8. PREPARATION Liquid diet (2-3 ltrs ) for full day before examianation – called overnight fasting 2-4 dulcolax tablets in evening No rectal enema required –before the enema fluid may reflux into the small bowel and create confusing small bowel pattern when it mixes with Barium suspension Day before procedure – stop transquilisers ,sedative and antispasmodics Anticholinergics and Ganlion blocking drugs cause dialation of small bowel Narcotics affect mobility and appearance of folds of the small bowel.

9. FOR INFANTS 4 Hours fasting Turn baby to right side – to enhance gastric emptying sedation Decrease peristalsis – Compensated by 3-5 ml of metaclopromide CONTRAST DOSE AGE DOSE 3-5 Months 200 ml 5-8 Months 300 ml 8-11 Months 400 ml 1-3 Months 500 ml

10. TECHNIQUE PLAIN FILM - Adequately prepared and exclude the presence of Barium from previous exam UPRIGHT / ERECT FILM - Used to determine the amount of fluid present in stomach or bowel loops Also observed in PLAIN FILM - Free intraperitoneal air - Displacement of bowel loop by mass - Calcification - Abnormalities of bowel loop

11. PROCEDURE Patient sits upright on chair placed against the wall Those patient who cannot sit up ,then tube can be placed with patient supine or rt. Lateral on fluroscopic table 2-3 cc of 2% xylocaine jelly –introduced into the nostril patient neck hyper- extended B.D tube (bilbao-dotter tube) without guide wire is inserted through one of the nostril Advanced with the swallowing action of the patient till the tip reaches the stomach 5-7 cm of tube is passed in stomach then neck is flexed Guide wire used to stiffen the tube to assist advancement through the oesophagus into the stomach

12. Cont. Patient to cough by observating under fluroscopy Under fluroscopic control the tube is then advanced through the antrum of the stomach into the pyloric canal Guide wire -5cm proximal to the tube tip, tube is slowly advance till the tip enters the duodenal cap. Right side up – location of pyloric canal and duodenal cup seen outline by air Right side down oblq .- Tube to reach pyloric canal by gravity Tube tip enters the first part of duodenum ,advance the tube slowly keeping the guide wire 2-3 cm proximal to the PYLORIC SPHINCTER End – 4-5 cm distal to TRIETZ canal.

13. PROBLEMS Prolonged examination Incomplete distension of small bowel Prolapse of small bowel into pelvis Faecal material in the terminal ileum Reflux into duodenum and stomach

14. SINGLE CONTRAST ENTEROCLYSIS High grade partial small bowel obstruction Barium suspension – 20% w/v injected 75-120ml/min. No air goes during injecting 1-1.5 litres of Baso4 injected without interrupted Average time to reach the ileocaecal junction-15 min. Use interrupted fluroscopy to follow the head of the barium column Stenotic lesion – Best identifiable at the head of the barium column FILMING 10 *12 spot film- jejunal loop Another for entire bowel loop Ileocaecal junction – with and without compression Filming done with high kvp technique (120-140 kv )

15. DOUBLE CONTRAST ENTEROCLYSIS 150 -500 ML –Barium suspension injected at 80-100 ml/min. till the proximal ileum is reached Intermittent fluoroscopy 0.5% supension of CMC injected at 75- 120 ml/min. using a mechanical injector FILMING Upper abdomen – Jejunum seen in double contrast Full abdomen – Entire small bowel is in double contrast Ileocaecal spot – In single and double contrast

16. AIR DOUBLE CONTRAST ENTEROCLYSIS Preparation Laxative – before the night examination NPO after 7pm the night before the examination

17. Procedure

18. ADVANTAGE

19. DISADVANTAGE

20. COMPARISON Methyl cellulose DC Enteroclysis Air DC Enteroclysis 1 Less information compared to air More clear detail 2 Simple procedure , can be done by inexperienced radiologist Operator dependent 3 Less time (20 minutes) More time

21. AFTER CARE :- The patient should be warned that diarrhoea may occur as a result of the large volume of fluid given. Patient can take full diet following the procedure . COMPLICATION Aspiration Perforation of the bowel

22. Anatomical differences between small bowel and large bowel Small bowel Large bowel Valvulae connventes Present Absent Number of loops Many Few Distribution of loops Central Peripheral Haustra Absent Present Diameter 3-5 cm 5 cm Solid faeces Absent Present

23. CAPSULE ENDOSCOPY Capsule endoscopy is a procedure used to record internal images of the gastrointestinal tract   Capsule Endoscopy involves swallowing a small (the size of the large vitamin pill) capsule, which contains a colour camera, battery, light source and transmitter It offers high diagnostic results in IBD(inflammatory bowel disease) , Ulcers, Polyp, Erosions

24. ADVANTAGE No radiation exposure Minimal patient discomfort Less operator dependent DISADVANTAGE Inability to control the camera Biopsy can not be taken Capsule may not reach caecum in case of stricture hence incomplete examination

25. ILEOSCOPY I l eoscopy  is an endoscopic procedure that uses a tiny camera attached to a scope to examine the lower portion of the small intestine (the ileum). Endoscopy examination limited to distal ileum ADVANTAGE Biopsy can be taken DISADVANTAGE Inability to reach caecum Inability to intubate during colonoscopy