Learn Barium Meal & Follow Through

Learn Barium Meal & Follow Through for the beginners from a Radiology Resident.For some image description please go through the text book "David Sutton" because i have described these image during my presentation Verbally..There are many animations used inside this presentation so to see all the pictures which are placed layer by layer with the help of animations you simple need to download this presentation first.... Thanx.

1. Dr. Santosh Atreya Resident (Phase- A) Radiology & Imaging BSMMU,Dhaka from Nepal BARIUM MEAL & FOLLOW THROUGH

2. BARIUM MEAL

3. The study is called so because it is performed following barium meal INTRODUCTION The thin walled alimentary canal does not have sufficient density to be demonstrated through surrounding structures, so its radiographic demonstration requires the use of artificial contrast medium (Barium)

4. Contd … Barium sulphate is the radiopaque contrast media used for the gastrointestinal system. Barium examinations require use of high KVp technique to penetrate barium (not <90).

5. Taste Chalky Taste (Real Taste ) Different flavour these days – Banana Vanilla Pineapple lemon etc

6. Excellent coating of mucosa Cost effective High density Provides a positive contrast in x-ray Advantages of barium sulphate Radiopaque material Insoluble material Not absorbed or metabolized Eliminated from the body

7. Disadvantages High morbidity associated with barium in the peritoneal cavity Subsequent CT and U S are rendered difficult Complication Perforation Aspiration Intravasation

8. Why iodine is not used ? Water soluble Diminish blood volume 8

9. Gas agents Carbondioxide CO₂ is administered orally , in the form of effervescent granules Production of adequate volume of gas Non interference with barium coating No bubble production Rapid dissolution Easily swallowed Low cost Carbon dioxide - cause less abdominal pain Properties of this agent

10. Other pharmacological agents Hyoscine-N-butyl bromide ( Buscopan) antimuscarinic agent inhibits both intestinal motility and gastric secretion Glucagon smooth muscle relaxation Metoclopramide stimulates gastric emptying and small intestinal transit

11. Anatomy of the stomach Divided into two parts: -Cardiac and pyloric part Cardiac -Fundus and body Pyloric -Pyloric antrum and pyloric canal

12. Duodenum: C-shaped tube 25 cm long & width 3.75-4 cm Joins stomach to jejunum The first & shortest part of small intestine 12 The widest & most fixed part Curves around the head of Pancreas . Begins at pylorus on right side & ends at duodenojejunal junction on left side . Partially retroperitoneal

13. BARIUM MEAL Methods : 1. Double contrast – the method of choice to demonstrate mucosal pattern. 2 . Single Contrast – uses : a) Children -since it usually is not necessary to demonstrate mucosal pattern b) Very ill adults – to demonstrate gross pathology only Indications 1.Dyspepsia 2.Weight loss 3.Upper abdominal mass 4.Gastrointestinal haemorrhage or unexplained iron deficiency anaemia

14. Contd … 5. Partial obstruction 6. Assessment of site of perforation – it is essential that water soluble contrast medium e.g. Gastrografin or Dionosil aqueous is used. CONTRAINDICATIONS : Complete large bowel obstruction. CONTRAST MEDIUM : 120 ml of high density barium 250 % W/V (Double contrast) Sufficient 100 % W/V ( Single Contrast )

15. Patient Preparation Patients fast for 6 hrs prior to the examination Should abstain from smoking Should ensure that no contraindications to the pharmacological agents used H/O previous surgery

16. Procedure - The double contrast method Patient swallows effervescent agent (tablet form known from gastro) High density barium(250% w/v) is swallowed while lying on the left side Then to the supine position. If reflux is observed spot films are taken A hypotonic agent –Buscopan(20 mg I.V )or glucagon (0.1-0.2 mg) is administered Patient rolled from side to side so barium coats mucosal surfaces by washing mucus from the gastric mucosa

17. Sequences of films for barium meal examination

18. Patient supine position-AP view inferior portion of the body

19. Normal barium meal anatomy of stomach Area gastricae-2-4 mm polygonal islands ,varies from fine reticular pattern to coarse nodularity Longitudinal folds or rugae Transient fine transverse folds Gastric cardia –shows a rosette of short folds radiating from esophageal orifice

20. Supine –body and antrum

21. Right lateral position - fundus

22. Spot films for duodenal loop

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

24. DUODENAL CAP Symmetric and triangular Shows fine velvety pattern when coated with barium - when distended A fold pattern is seen in the inferior bend between the 1 st and 2 nd parts of the duodenum.When the duodenal cap is undistended ,a fold pattern is seen. The major papillae of vater minor papilla (of Santorini) Barium meal appearance of the duodenum

25. The normal duodenal cap seen by double contrast surface coating almost homogenous Fine velvety reticular pattern

26. Transient fine transverse mucosal folds A : Antrum C:duodenal cap

27. Double contrast barium meal supine right anterior oblique view The papilla of Vater (white arrow) has a longitudinal (arrowhead) and two oblique folds (black arrows) extending below it

28. Additional view of the fundus Spot films of the oesophagus

29. Modification technique for young children Indication Vomiting Technique Single contrast 30 % barium sulphate No paralytic agent

30. 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

31. Barium follow- through examination

32. Anatomy of small intestine length = 6-7 m (approx) Extent - From Pylorus to ileo-caecal valve Proximal 2/5 th constitute the jejunum and distal 3/5 th constitute the ileum The Valvulae conniventes -2 mm thick in jejunum and 1 mm thick in ileum.

33. JEJUNUM & ILEUM Jejunum begins at duodenojejunal flexure (L2) & ileum ends at ileocecalJunction . Jejunum & ileum = 6 to 7 m long (jejunum 2/5, ileum 3/5) 33 Coils of jejunum & ileum are suspended by mesentery from posterior abdominal wall & freely movable.Most jejunum lies in left upper quadrant & most ileum lies in right lower quadrant

34. Wall of small intestine is made of the following layers : a) Serosa coat b) Muscular coat c) Submucosa coat d) Mucosa coat 34

35. Introduction – Barium Follow Through Barium Follow Through is designed to demonstrate the small bowel from the duodenum to the ileoceacal region encompassing the duodenum , jejunum and ileum including the junctions superiorly with  the stomach and inferiorly with the ascending colon. Also known as barium meal follow through (BMFT) & small bowel follow through (SBFT) 35

36. Indications Contraindications Complete obstruction Suspected perforation Pain Diarrhoea Anemia Gastrointestinal bleeding Malabsorption Abdominal mass

37. M ethods Single contrast With addition of effervescent agent Contrast medium 300 ml of 100% w/v Barium suspension

38. Patient preparation NPO overnight A prokinetic agent metoclopramide(20 mg ) is given orally,atleast 30 mins before the study starts. Plain abdominal radiograph if perforation is suspected Preliminary film

39. Procedure A lower density barium suspension (50-100% w/v is ideal) 300 ml of 100% w/v barium suspension diluted with equal volume of water Patient lies on the right side after barium has been ingested F ilms Prone PA films of the abdomen are taken every 20 mins during the first hour Then every 30 mins until the colon is reached Spot films of the terminal ileum are taken supine

40. Compression is mandatory To separate the bowel loops Assess mobility Define mucosal pattern Done by prone inflatable paddle

41. Additional films To separate loops of small bowel Oblique view With X-ray tube angled into the pelvis With patient tilted head down To demonstrate diverticula Erect-will reveal any fluid level

42. Appearance of small bowel No reliable radiological demarcation between jejunum and ileum Luminal diameter decreases along the length of the small bowel Jejunal diameter should not exceed 3.5 cm on barium follow-through and 4.5 cm on enteroclysis Small bowel wall should not measure more than 1-2 mm thick when distended

43. Interpretation Jejunum Ileum Constitutes proximal 2/5 th of small intestine 3/5 th Position Upper left and periumblical region Lower right hypogastric and pelvic region Max. diameter 4 cm 3 cm Number of folds 4-7 per cm 3-5 per cm Pattern Feathery mucosa Less feathery or maybe absent Fold thickness 1-2mm 43

44. Mucosal pattern of small intestine The appearance of the mucosal folds depends upon the diameter of the bowel When distended the folds are seen as lines traversing the barium column known as Valvulae conniventes When relaxed folds appear feathery Mucosal folds are largest and most numerous in the jejunum and tend to disappear in the lower part of the ileum

45. Normal enteroclysis (small bowel enema). This technique gives good mucosal detail