Barium Enema (Diverticulosis) Case study 2016-1017 College of Health Sciences Medical Diagnostic Imaging Department Maryam Al-Morohen u00038946 Special Radiographic Technique Clinical Practice

Barium Enema ( Introduction): A 63 years old male patient was complaining of constipation , rectal bleeding and hemorrhoid . A 63 years old male patient was complaining of constipation , rectal bleeding and hemorrhoid . He was referred to ALQasimi hospital - radiology department for barium enema examination . The patient came walking at about 10:15 a.m in 19 feb 2017.

Anatomy: The large intestine start at the right iliac region of pelvis , where it joins to the end of the small intestine. It is 4 to 6 ft. ( 1.5 m ) long . It starts from the base of the appendix from cecum to rectum ( appendix attached to the inferior surface of the cecum ) . 1- cecum : it's peritoneal the beginning of the large intestine. 2- colon : it's part of the large intestine ( the final segment of the digestive system after distal to ilium and before proximal to anus ) . 3- appendix: inner organ and it can be inflamed, it is the last part of the GI tract and digestive system . Figure 1

Anatomy: Also it joined to the renal and it consists of many parts : Cecum Ascending colon ( cecum and appendix) Hepatic flexure Transverse colon Splenic flexure Descending colon Sigmoid colon ( s shape region ) Rectum . (Figure 1)

Large intestine has many functions in the body such as : 1. absorbs water, vitamin K , B12 , thiamine and riboflavin. 3 . It store fecal matter in the rectum until it can be discharge via anus and defection. 5 . It plays role in immunity ,

AP GI tract

RAO of the GI tract:

PATHOLOGY Diverticulosis : Chronic diverticulosis: it's a condition that develops when pouches form In the wall of the large intestine. These are out pocket of colonic mucosa and sub mucous through weakness of muscle layers in the colon wall . The pouches are usually small ( 5 - 10 ) mm but it can be larger . The most common part for diverticulosis is sigmoid colon where the pressure increases in this area . Diverticulosis may not be discover unless the symptoms occur such as chronic abdominal pain. Diverticular disease may occur if the pouches becomes inflamed .

I. Many people don't have symptoms but some people get infection in the pouches ( diverticulitis ). II. Irregular defecation . ( constipation ) III. Painless rectal bleeding ( bright red blood per rectum).

Diverticulosis is discovered only when tests such as barium enema or colonoscopy are done to see the problems .

Laxatives like polyethylene glycol ( miralax) or sennosides. Examples of diverticulosis treatment: Laxatives like polyethylene glycol ( miralax) or sennosides. Patient have to follow a diet ( high fibers diet 20 to 35 grams each day and supplements to prevent constipation . Food that contains high amounts of fibers such as brown rice, brown bread , vegetables, fruits ,eating in regular times and increasing fluids.

. A 63 year old man was referred from internal medicine department for barium enema examination. The patient was complaining of bloody stoles, constipation and hemorrhoid. The radiologist explained the preparations to the patient , and he explained to him the kinds of drinks and food that he can eat them and the number of hours that he have to fasten before the examination day.

Clinical assessment and diagnosis: Physical exam include : digital rectal exam , the doctor asked the patient to lays in his side while the patient flex his knee toward his chest , after putting gloves , the doctor inserts lubricated finger in the anus to examine the rectum . There was external hemorrhoid signs and the patient was in pain The doctor suspected that the patient has diverticulosis . the patient was transferred to the radiology department to do barium enema examination.

Investigation requested: No lab investigation was requested. Allergic reaction was not documented

Patient preparation: patient was instructed to do the following : 1. fast for about 8 hours accept water. 2. Take laxatives to empty the colon and enema (sterculia). 3. Avoid solid meals + Pepsi and food that causes gases. 4. patient have to take (disflatyl) to treat bloating and digestive disorders. 5. The patient signed the confirmation form.

Patient arrived to the department walking by himself The radiologist, radiographer and radiological nurse were in the fluoroscopy room. When the patient goes to change his clothes and wear the gown , the nurse prepares the barium and the tubes , also she wore a lead apron. The nurse explained the procedure to the patient and she let him to sign in the confirmation form, the radiographer asked him if he prepared well as the radiologist explained for him. Scout image was taken and the patient was not prepared well but because he is an old man and this is the second time that he didn’t prepare. The procedure was done for him and many projections were taken. It was double contrast procedure to visualize the mucosal lining of the stomach much clearly .

Should I put the main projections ? And CP , CR .. etc ? NO

AP scout image: Gases in the colon (patient not well prepared)

AP with barium: Diverticulosis

Left lateral: diverticulosis

Oblique image: Diverticulosis in sigmoid colon

Post evacuation image:

Radiologist opinion: Diverticulosis was documented.

The Dr recommended a diet to the patient and laxatives such as sterculia . Also some medications were recommended since the patient has hemorrhoid such as : Atorvastatin ( oral daily ) tab(s). Diosmin/hespirine. Fusidic acid 2% cream. Omeprazole. Perindopril. Tribenoside/hydrocortisone suppository. the patient have to follow up with the Physician to see the improvements .

Physical examination alone is not effective for diverticulosis ( because physical examination cannot give complete diagnosis. Barium enema ( Lower GI series) is an x-ray procedure used to define the anatomy of the large intestine and to see the Abnormalities within large intestine , Ex: diverticulosis , and to see if there is perforations when the barium is in the large intestine.

A 63 years old male patient was complaining of constipation , rectal bleeding and hemorrhoid . A barium enema examination was done for him. The patient was diagnosed and diverticulosis was found. Diverticulosis doesn't require a surgery, but the patient have to follow the doctor's instructions and he have to keep eating on time and following a diet and laxatives prescribed medications .

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