Dr. Santosh Atreya Resident (Phase- A) Radiology & ImagingBSMMU,Dhaka from Nepal

BARIUM MEAL &

FOLLOW THROUGH

BARIUM MEAL

• 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)

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).

Taste• Chalky Taste (Real

Taste )

• Different flavour these days – Banana

Vanilla

Pineapple

lemon etc

Excellent coating of mucosaCost effectiveHigh density Provides a positive contrast in x-ray

Advantages of barium sulphate

Radiopaque material Insoluble materialNot absorbed or metabolized Eliminated from the body

Disadvantages

High morbidity associated with barium in the peritoneal cavity

Subsequent CT and US are rendered difficult

Complication

PerforationAspirationIntravasation

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Why iodine is not used ?

Water soluble Diminish blood volume

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

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

Anatomy of the stomach

Divided into two parts: -Cardiac and pyloric part

Cardiac -Fundus and body Pyloric -Pyloric antrum and pyloric canal

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Duodenum:• C-shaped tube • 25 cm long & width 3.75-4 cm• Joins stomach to jejunum• The first & shortest part of small

intestine

•The widest & most fixed part Curves around the head ofPancreas . •Begins at pylorus on right side & ends at duodenojejunal junction on left side . Partially retroperitoneal

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

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 )

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

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

Sequences of films for barium meal examination

Patient supine position-AP viewinferior portion of the body

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

Supine –body and antrum

Right lateral position - fundus

Spot films for duodenal loop

Spot film of the abdomen with the patient in prone position

DUODENAL CAPSymmetric and triangularShows fine velvety pattern when coated with

barium - when distendedA fold pattern is seen in the inferior bend between

the 1st and 2nd 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

The normal duodenal cap seen by double contrastsurface coating almost homogenous

Fine velvety reticular pattern

Transient fine transverse mucosal folds

A: AntrumC:duodenal cap

Double contrast barium mealsupine right anterior oblique view

The papilla of Vater (white arrow) has a longitudinal (arrowhead) and two oblique folds (black arrows)extending below it

Additional view of the fundusSpot films of the oesophagus

Modification technique for young children

Indication• Vomiting

Technique• Single contrast• 30 % barium sulphate• No paralytic agent

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

Barium follow- through

examination

Anatomy of small intestine

length = 6-7 m (approx)

Extent- From Pylorus to ileo-caecal valve

Proximal 2/5th constitute the jejunum and distal 3/5th constitute the ileum

The Valvulae conniventes -2 mm thick in jejunum and 1 mm thick in ileum.

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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)

• 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

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Wall of small intestine is made of the following layers :

a) Serosa coat

b) Muscular coat

c) Submucosa coat

d) Mucosa coat

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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)

Indications

ContraindicationsComplete obstructionSuspected perforation

PainDiarrhoeaAnemiaGastrointestinal bleedingMalabsorptionAbdominal mass

Methods

Single contrast With addition of effervescent agent

Contrast medium 300 ml of 100% w/v

Barium suspension

Patient preparation

NPO overnightA prokinetic agent metoclopramide(20 mg ) is

given orally,atleast 30 mins before the study starts.

Plain abdominal radiograph if perforation is suspected

Preliminary film

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

ingestedFilms

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

Compression is mandatory

To separate the bowel loops Assess mobility Define mucosal pattern

• Done by prone inflatable paddle

Additional films

To separate loops of small bowelOblique viewWith X-ray tube angled into the pelvisWith patient tilted head down

To demonstrate diverticula Erect-will reveal any fluid level

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

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Interpretation Jejunum Ileum Constitutes proximal 2/5th of small intestine

3/5th

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

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

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