Barium follow through & small bowel enema ranju

BARIUM FOLLOW THROUGH & SMALL BOWEL ENEMA

PRESENTED BY:RABIN PAUDEL

B.Sc. MIT 2ND YEARROLL NO:49

IOM, MAHARAJGUNJ MEDICAL CAMPUS

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Introduction

• Because the thin walled alimentary canal doesn't have sufficient density to be demonstrated through surrounding structures, its radiographic demonstration requires the use of artificial contrast medium (barium).

• Barium examinations require use of high KVp technique to penetrate barium (not <90).

• Barium follow through & small bowel enema are two basic types of small bowel examination to examine small bowel in its entirety i.e. to evaluate functional capabilities as well as morphological abnormalities.

Barium follow through & small bowel enema

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Anatomy of the small intestine

• Extends from pyloric sphincter of stomach to ileoceacal valve, where it joins large intestine at right angle.

• Lies in abdominal cavity surrounded by large intestine• About 6.5 m long & diameter gradually decreases from about

3.8 cm in proximal part to approximately 2.5 cm in distal part.• Wall contains 4 layers- serosa, muscle layer, submucosa &

mucosa. Mucosa contains finger- like projections called villi.• Divided into 3 portions:

a) Duodenum,b) Jejunum &c) Ileum


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Duodenum

• About 25 cm long & widest part.• Begin at pylorus & curves around the head of pancreas as “C”.• Constitute 4 portions:1. First (superior): duodenal bulb2. Second (descending): common bile duct & pancreatic duct

usually unites to form hepatopancreatic ampulla, which opens on greater duodenal papilla.

3. Third (horizontal or inferior)4. Fourth (ascending): joins jejunum at a sharp curve called

duodenojejunal flexure & is supported by suspensory muscle of duodenum (ligament of Treitz)


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Jejunum & Ileum

• Jejunum is the middle section of small intestine & is about 2.5 m long.

• Ileum is the terminal section about 4 m long, leads into large intestine at ileoceacal valve.


May 3, 2023 Barium follow through & small bowel enema

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BARIUM FOLLOW

THROUGH


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Introduction

• 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 by oral administration of contrast media (Barium)

• may be performed as a continuation of an upper gastrointestinal (UGI) series or as a separate ,dedicated study of the small bowel.

• Also known as barium meal follow through (BMFT) & small bowel follow through (SBFT)

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Methods

• Single Contrast • Double Contrast (with addition of an effervescent agent)• Peroral Pneumocolon. Note: Double contrast technique is normally adopted.


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Indications

• Crohn’s disease (most common)• Pain• Diarrhoea• Loss of weight• Anaemia (Gastro-intestinal Bleeding)• Partial Obstruction• Mal-absorption (Dyspepsia)• Abdominal Mass• Suspected Tubercular Lesion• Lesions such as strictures, neoplasms, Mekels diverticulum


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Contraindications

• Complete Bowel Obstruction• Suspected Perforation• Paralytic ileus• Very ill Patient• Recently Operated Patient


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Contrast medium

• 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. • In children,3-4 ml/kg is suitable volume of contrast.• In situations where barium is contraindicated, non-ionic water

soluble solutions are used.


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Equipment

• High power x-ray generator• Spot film device• Fluoroscopic unit with II TV system• Tilting type of x-ray table• Over- couch x-ray tube.


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Patient preparation

• Accurate & clear history must be obtained from pt. for e.g., in the case of insulin- dependent diabetes, the best time for stopping eating can be arranged.

• A low residue- diet for 2 days prior to the examination.• A laxative should be taken on the evening prior to the examination.• NPO for 6 hrs prior to examination• Metoclopramide 20 mg orally given 20 min before or during the

examination to enhance gastric emptying.• Pt’s bladder must be empty before & during procedure to avoid

displacing or compressing ileum.• Pt must be informed that the barium may taste chalky.• Pt must remove all the clothing & jewelry & wear a hospital gown.


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Preliminary Film

Plain radiograph of the abdomen.• To see bowel preparation.• To rule out contraindication.• helps in assessing any abnormalities of gas filled bowel loops.• If residual fecal matter presence-examination should be

cancelled.


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Single Contrast Technique

• Patient is asked to drink Barium Suspension as rapidly as possible and then put the patient on right side.

• Give dry food if transit time is slow.• If follow through is combined with barium meal, glucagon is

used instead of buscopan for duodenal cap view.


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Filming

• Prone PA films of the abdomen are taken. The first radiograph is taken 10 min following the drink,

with the second image at 30 min stage. Then the radiographs are taken at 30 min intervals until the barium has reached terminal ileum.

Pressure on the abdomen helps to compress abdominal contents so that the loops of small bowel are separated. Thus for better radiographic quality, prone position is used.

• Spot films of the terminal ileum are taken supine.


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15 min post contrast film


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30 min post contrast


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1 hour post contrast film


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Supine films

• Compression pad is used in right iliac fossa to displace any overlying loops of small bowel that are obscuring terminal ileum.

• Supine position is used for Superior & lateral shift of barium filled stomach For visualizations of retrogastric portions of duodenum &

jejunum To prevent possible compression overlapping loops of

intestine.



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The leading edge of barium normally takes 1/2 to 4-hours to reach ileoceacal junctions.

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Additional Films

To separate loops of small bowel-compression with fluoroscopy-Oblique view -x-ray tube Angled into the pelvis.-Patient tilted head down.

To demonstrate Diverticula-Erect (Reveals fluid level within the

diverticulum by CM).


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Double contrast Technique

• Same as single contrast study.• Gas producing agent is given when head of Barium column

reaches the caecum. This should generate about 750-1000 ml of gas.

• Pt is placed on the left side slightly head down (Tredelenberg position) to allow the gas to leave the stomach & enter the small bowel.

• Compression radiographs with patient in supine or oblique positions are taken.

Modifications: Lacquer- coated effervescent tablets to provide a select release of gas in small bowel.


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Advantages of DC

• Better distension.• Separation of loops.• Improved mucosal detail.• Effective for young patients & those who are in able to

swallow the enema tube.


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Peroral pneumocolon

• The peroral pneumocolon examination is a method for obtaining a double-contrast image of the terminal ileum and right colon by insufflating air in conjunction with a conventional barium follow-through examination.

• The indications for the peroral pneumocolon examination are(1) a poorly seen terminal ileum, (2) clinically suspected inflammatory bowel disease with an apparently normal terminal ileum, and (3) an abnormal terminal ileum with equivocal fistulae


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Technique

• When orally ingested barium reaches the right colon, air is advanced through a small catheter inserted into the rectum. Spot views of the different areas of small bowel especially the terminal ileum are taken. Compression may be used.


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A, Terminal ileum was poorly demonstrated on conventional spot films. B, It was seen well on Peroral pneumocolon, which shows

deformed, irregular caecum, ileoceacal valve, and distal terminal ileum.


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Disadvantages

• Requires colon cleaning for an adequate study.• Uncomfortable procedure for the patient.• Reflux sometimes not possible in~10% cases.• Long procedure time.


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Barium Meal + Follow-Through


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After-Care

• Inform the pt that his bowel motions will be white for few days after the examination & may be difficult to flush away.

• Advise to drink adequate volume of water to avoid Barium impaction. (Laxative may be taken if required)

• Pt should not leave the department till any blurring of vision produced has resolved.


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Complication

• Leakage of Barium suspension from unsuspected perforation.• Aspiration of Barium.• Conversion of partials obstruction into complete obstruction

by impaction of Barium.• Barium Appendicitis (if Barium impacts in Appendix)• Side effect of pharmacological agents used.


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Advantage of BMFT

• Easily performed.• No discomfort/intubation to the patient like Enteroclysis.• It is a physiological process. Hence transit time can be

assessed.

Disadvantage of BMFT• Overlapping of Barium filled bowel loops in the pelvis.• Poor distension of bowel loops.



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Ileo-vesical Fistula


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Meckel’s diverticulum


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Early Crohn's disease


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SMALL BOWEL ENEMA

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Introduction

• Small bowel is demonstrated following duodenal intubation rather than by oral administration of contrast as in BMFT.


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Indications & Contraindications

• Same as barium follow through– Crohn’s disease (most common)– Pain– Diarrhoea– Loss of weight– Anaemia (Gastro-intestinal Bleeding)– Partial Obstruction– Mal-absorption (Dyspepsia)– Abdominal Mass– Suspected Tubercular Lesion– Lesions such as strictures, neoplasms, Mekels diverticulum

• Usually in case of equivocal follow through


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Methods

• Single contrast- Enteroclysis• Double contrast


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Contrast medium

• Enteroclysis: Barium sulphate solution 70 % w/v is diluted to give 1500 ml of 20 % solution.

• Double contrast: 600 ml of 0.5 % methylcellulose after 500 ml of 70 % w/v barium sulphate solution.


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Equipment

• Same as barium follow through.• For contrast administration, two types of tubes are available:

Bilbao- dotter tube with guide wire

Silk tube with tungsten filled guide-tip.It is made up of polyurethane & thestylet & internal lumen of the tube arecoated with water- activatedlubricant to facilitate the smooth removal of the stylet after insertion.


Silk tube

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Patient preparation

• A low residue- diet for 2 days before the examination.• A laxative should be taken on the evening prior to the

examination.• NPO for 6 hrs prior to examination• If the patient is taking any antispasmodicdrugs, they must be

stopped 1 day prior to examination.• Amethocaine lozenge 30 mg, 30 min before the examination.


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Preliminary film

• Plain abdominal film if a small bowel obstruction is suspected.


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Intubation technique

• The patient sits on the edge of x-ray table. The pharynx is anaesthetized with lignocaine spray.

• The tube is then passed through nose or mouth with brief lateral screening. If per nasal approach is planned the patency of the nasal passage is checked by asking the patient to sniff with one nostril occluded. The Silk tube should be passed with the guide wire pre-lubricated &

fully within the tube. For Bilbao- dotter tube, the guide wire is usually introduced after

the tube tip is in stomach.• The patient is asked to swallow with neck flexed as the tube is passed

through the pharynx. The tube is then advanced into the gastric antrum.


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Intubation technique

• The pt then lies down & the tube is passed into duodenum. Lie the pt on the left side so that the gastric air bubble rises to

the antrum, thus straightening out the stomach. Advance the tube whilst applying clockwise rotational motion

(as viewed from the head of the pt looking towards feet). In the case of the Bilbao-Dotter tube, introduce the guide wire. In the case of the silk tube, lie the pt on right side, as the tube

has a tungsten-weighted guide tip which will then tend to fall towards antrum.

Get the pt to sit up to overcome the tendency of the tube to coil in the fundus of stomach.

Metoclopramide (20 mg i.v.) can be used.



Intubation techniqueWhen the tip of the tube has been passed through pylorus, the guide wire tip is maintained at the pylorus & the tube is passed over it along the duodenum to the level of ligament of Treitz. The tube is passed as far as the duodenojejunal flexure to diminish the risk of aspiration due to reflux of barium into stomach.

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Single contrast technique•Barium is then run in quickly at the rate about 75 ml/min & spot films are taken of the barium column & its leading edge at the regions of interest until the colon is reached.

•Fluoroscopy is performed during infusion & images are recorded using digital acquisition, 100/105 mm film or full size radiographs as required.


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Double contrast:•Methylcellulose is infused continuously(100 ml/min) after initial bolus of barium (100ml/min), until the barium has reached the colon.

•The tube is then withdrawn, aspirating any residual fluid in the stomach.

•Finally, prone & supine abdominal films are taken.


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Following single contrast method, air may be introduced via catheter once barium has reached caecum to provide double contrast effect.

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Modification of technique

• In patients with malabsorption, especially if an excess of fluid has been shown on the preliminary film, The volume of barium should be increased (240-260 ml). Compression views of bowel loops should be obtained

before obtaining double contrast. It is important to obtain the images of duodenum & the

catheter tip should be sited proximal to the ligament of Treitz.


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Aftercare

• Nil orally for 5 hrs after the procedure • The patient should be warned that diarrhoea may occur as a

result of large volume of fluid given.


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Complications

• Aspiration• Perforation of the bowel owing to manipulation of the guide

wire.


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Advantages

• Gives better visualization of the small bowel unobstructed by overlying barium filled stomach & duodenum.

• Rapid infusion of large, continuous column of contrast directly into jejunum avoids segmentation of barium column & does not allow time for flocculation to occur.

• Hypotonia caused by fluid overload makes demonstration of lesions easier because abnormalities are more clearly visible when the intestine is distended rather than contracted.

• As a result of the dilatation, minimal strictures, small sinus tracts and fistulas, and minimal extrinsic compressions can be visualized.


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Disadvantages

• Intubation may be invasive & unpleasant for the patient & may occasionally prove difficult.

• It is more time-consuming for the radiologist.• There is higher radiation dose to the patient (screening the

tube into position).


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References

• A guide to radiological procedures- Chapman & Nakielny

• Clark’s special procedures in diagnostic imaging

• Merrill's atlas of radiographic positioning & procedures

• Encyclopedia of radiographic positioning, vol.2

• Various internet sources


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Questions???

• What are the contrast medium for barium follow through & small bowel enema?

• What are the indications for barium follow through & small bowel enema?

• What are the contraindications for barium follow through & small bowel enema?

• What are the main differences between barium follow through & small bowel enema?

• What are the complications of barium follow through & small bowel enema?

• Describe the film sequence for BMFT.• What is the role of compression pad in BMFT?



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THANK YOU!!!

Barium follow through & small bowel enema ranju

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