Midterm Barium Enema

Large Intestine It begins in right iliac region when it joins the ileum of the small intestine. The length is approximately 5 ft. (152cm) long and is greater in diameter than the small bowel (2.5 in diameter).

Large Intestine Anatomy CECUM  COLON  RECTUM ANAL                            

Colon subdivision Ascending Transverse Descending Sigmoid

*Rectum and Anal Canal* Rectal Ampulla Anal canal Anus RECTUM: the concluding part of the large intestine that terminates in the anus. The average length of the human rectum may range between 10 and 12 cm. Its caliber can be compared to that of the sigmoid colon at its onset. However, it gets dilated near the anus, where it forms the rectal ampulla. Its key role is to act as a temporary storehouse for feces. RECTAL AMPULLA: A dilated portion of the rectum just above the anal canal. Transverse folds of rectum is termed as valves of Houston ANAL CANAL: the terminal part of the rectum forming the passage to the anus. ANUS: the opening where the gastrointestinal tract ends and exits the body. 

Internal anal sphincter – smooth muscle External anal sphincter – skeletal muscle (can be consciously controlled)

Barium Enema (BE or Lower GI series) It is a Radiographic study of the large intestine. Purpose: to study radiographically the form and function of the large intestine, as well as to detect any abnormal conditions.

Clinical Indications

Colitis Diverticulum Neoplasm Volvulus caused by many factors including bacterial infection, diet, stress, and other environmental conditions. Diverticulum outpouching of the mucosal wall resulting from herniation of the inner wall of the colon. Neoplasm tumors in large intestine. Volvulus twisting of a portion of the intestine on its own mesentery.

Intussusceptions Polyps telescoping of one part of the bowel into another. Polyps A polyp is an abnormal growth of tissue projecting from a mucous membrane.

colitis

Volvulus - derived from the Latin word volvere (“to twist”).

polyps

Contraindications to Cathartics Gross bleeding Severe diarrhea Obstruction Inflammatory lesions (appendicitis) Pregnancy

Preparation of the Patient The final objective is that the section of alimentary canal to be examined must be empty. 2 – classes of Cathartics Irritant cathartic – castor oil Saline cathartic – magnesium citrate or sulfate Irritant cathartic or Stimulant cathartic act on the intestinal mucosa or nerve plexus resulting to stimulation of peristaltic action. They are the most severe among laxatives and should be used with care. Saline laxatives attract and retain water in the intestinal lumen resulting for a soft or watery stool.

Irritant Cathartic Saline Cathartic

Contrast media

Contrast Media High – density Barium Sulfate Air contrast It is excellent for use in double-contrast studies of the alimentary tract in which uniform coating of the lumen is required. Air contrast Carbon dioxide may also be used because it is more rapidly absorbed than nitrogen of air when evacuation.

Mixture of Barium suspensions Single contrast 12 % - 25% weight / volume Double contrast 75% - 95% weight / volume

Closed system type enema Open system type enema Barium Containers Closed system type enema Open system type enema

Closed system type Open system type

3 – common enema tips Plastic disposable Rectal retention Air contrast retention

“Prior to any special procedure a scout film should be taken first.”

Enema tips insertion  Sims position – relaxes the abdominal muscles and decreases pressure within the abdomen.

Sims Position

Summary of Enema tip insertion Describe the tip insertion to pt. Place pt. in sims position. (pt. should lie on the left side, with the right leg flexed at the knee and hip Shake and inspect the enema container to provide good mixture. Allow the barium to flow through the tubing and from tip to remove any air in the system

Continuation… Wearing gloves, coat enema tip with water-soluble lubricant.(KY jelly or any sterile lubricant) On expiration, direct enema tip toward the umbilicus proximally 1 to 1.5 inches After initial insertion, advance up superiorly and slightly anteriorly. Do not force enema tip.

Continuation… Tape tubing in place to prevent slippage. Do not inflate unless directed by radiologist Ensure IV pole/enema bag is no more than 24 inches (60cm) above the table. Ensure tubing stopcock is in the closed position and no barium flows into the pt.

3 – Types of Examinations of Colon Procedures 3 – Types of Examinations of Colon Single – contrast Ba. Enema Double – contrast Ba. Enema Defecogram

Single Contrast Ba. Enema

Double Contrast Ba. Enema

Cont… Single – contrast Double – contrast utilizes only a positive contrast medium. Double – contrast Difference is that in an examination there is both air and barium.

2 - Approaches of Double-contrast Administering

Two-stage procedure described “by Welin”  In which the entire colon is filled with a barium suspension. Patient evacuates the barium and immediately returns to the fluoroscopic table for injection of air or other gaseous contrast into the colon.

Single-stage double contrast examination The barium and the air are instilled in a single procedure as compared to the two-stage which reduces time and radiation to patient.

7 – pump method (by Miller) 7 pumps, left lateral position 7 pumps, LAO position(left PA-oblique) 7 pumps, prone position 7 pumps, RAO position 7 pumps, right lateral position 7 pumps, RPO position +7 pumps, supine position

10 – Miller’s Routine Sequence of Radiographs AP – to include flexures Left lateral rectum AP – 15 – 25 degs. Cephalic(CR) to include rectum. 15 – 25 degs.RPO – to include Left colic Right lateral – to include rectum

Cont… Prone PA – to include flexures Prone PA with 15 – 25 degs caudal angulation (Angle Prone)– to include rectum. 15 – 25 degs LPO- to include the right colic flexure. Supine – AP tightly collimated ileocecal region proj. taken in 2 – 3 degs obliquity. Using horizontal central ray, upright proj. of both flexures and lateral rectum.

Modification of Positions for Barium Enema Usually used in the hospital Modification of Positions for Barium Enema

Position and film used Structure Shown Central Ray AP (recto sigmoid area) Film: 10x12cm crosswise AP view of the Rectum & Sigmoid should be included 5-7 cm above the level of the pubic symphysis Left/Right position of the recto sigmoid area Film: 10x12cm lengthwise True lateral position of the Recto sigmoid 5-7 cm above the level of the pubic symphysis in the midaxillary plane AP (Single Contrast) Film: 14x17cm An Entire colon filled with contrast media should be demonstrated including the splenic flexure and the rectum. At the level of the L4 or at the level of the iliac crest Vertebral column should be centered so that the descending and ascending colon are completely included.

Position and film used Structure Shown Central Ray AP Double Contrast Film: 14x17cm lengthwise An Entire colon filled with positive and negative contrast media should be demonstrated including the splenic flexure and the rectum. At the level of the L4 or at the level of the iliac crest RAO Position (optional) Entire colon should be included Right colic (hepatic) flexure should be less superimposed or open when compared to the PA LPO Position (optional) Left colic (splenic) flexure should be less superimposed or open when compared to the PA

Right Lateral Decubitus Film: 14x17cm lengthwise Position and film used Structure Shown Central Ray Right Lateral Decubitus Film: 14x17cm lengthwise Best demonstrate the “up”, medial side of the ascending colon and the lateral side of the descending colon, when the colon is inflated with air. At the level of the L4 or at the level of the iliac crest Left Lateral Decubitus Best demonstrate the “up”, medial side of the descending colon and the lateral side of the ascending colon, when the colon is inflated with air.

Position and film used Structure Shown Central Ray Ventral Decubitus Film: 10x12cm lengthwise A cross table view of the recto sigmoid area Demonstrate the air-fluid level of the recto sigmoid area 5-7 cm above the level of the pubic symphysis in the midaxillary plane PA Axial position (Angle Prone) Film: 10x12cm or 11x14cm crosswise Rectosigmoid area must be less superimposition than in the PA projection because of the angulation of the CR Center it the midline of the body with an angulation of 30-400 caudad at approximate level of the anterior superior iliac spines.

Position and film used Structure Shown Central Ray Supine position Film: 14x17cm lengthwise A postevacuation radiograph view of the colon is taken after the procedure is done If inadequate satisfactory delineation of the mucus the patient may be given hot beverage (tea/coffee) to stimulate evacuation At the level of the L4 or at the level of the iliac crest After care Patient is advised to drink plenty of water, or laxative is taken to remove excess barium sulfate.

AP – Single Contrast

Double Contrast

Splenic Flexure

Left Lateral Decubitus

Right Lateral Decubitus

Lateral Cross table

Angle Prone 30-400 caudad

Postevacuation