1. Fluoroscopic Investigations Of The Gastrointestinal Tract
Small & Large Bowel

2. References Websites Radiographic procedures: By Stephen Chapman
Positioning in Radiography: By k.C.Clarke.
Text book of radiographic positioning and related
anatomy;bykenneth L.Bontrager.
Websites

3. With the end of these lectures the student will be able to:
Objectives
With the end of these lectures the student will be able to:
List common indications for ordering Ba F.th and Ba enema
Explain the contraindications for using barium sulphate in the examination of the small and large bowel
Describe the anatomy of the small and large bowel
Describe room preparation and identify supplies for small and large bowel barium studies
Describe how to perform the procedures
Explain patient care, after completing small and large bowel barium exams
Critique small and large bowel barium radiographs in term of positioning ,image quality, radiographic anatomy ,and pathology

4. Small Bowel
Barium follow through

5. Small intestine Continuous with stomach & large intestine
5 metres long
Responsible for chemical digestion of food
Three sections
Duodenum
Jejunum
Ileum (ileoceacal valve)

6. Barium follow through
Barium Follow Through demonstrates 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.

7. Barium follow through - Indications
Partial obstruction
Malabsorption
Abdominal masses
failed small bowel enema
Ulcer
Obstruction
Post-operative ileus
Crohn’s disease
SIGNS / SYMPTOMS
Pain
Hematemesis
Distention
Diarrhea

8. Barium follow through Contra-indications
Complete Obstruction
Perforation (especially after recent surgery)

9. Contrast agents & patient preparation
Barium sulphate
Gastrografin can be added to decrease transit time in small bowel ( increase flow)
Plain radiograph before is useful
(Maxalon to increases gastric peristalsis )
Physical & psychological preparation
Explanation of procedure

10. Barium follow through - Technique
Aim is to deliver a single column of barium into the small bowel
If this examination is performed in conjunction with a barium meal, then Glucagon is used
Prone abdomen taken every 20 minutes during the first hour of patient drinking solution.
Subsequent radiographs taken at 30 minutes until the colon is reached

11. Barium follow through - Technique
Spot films of the terminal ileum in supine position
( compression pad is used to separate any overlying loops of small bowel that are obscuring the terminal ileum
Additional films:
- Oblique's – to separate loops of small bowel
- Erect – To demonstrate Diverticula ( fluid level caused
by contrast media retained within the Diverticula

12. Example Barium F. Through

13. Small bowel enema
Indications & contra-indications same as for barium follow through
+ Rapid infusion of continuous column of contrast medium (avoids segmentation of barium column)
- Intubation may be unpleasant for patient

14. Small bowel enema Specific preparation includes
low residue diet for 2 days prior the exam
Stopping of any anti spasmodic drugs 1 day prior
anaesthetic spray immediately before the exam for pharynx anaesthesia
preliminary abdominal radiograph.

15. Contrast agent & specific equipment
Infusion takes place via intubation
Bilbao – Dotter tube / Silk tube
1500ml of barium introduced
< Viscosity gives better mucosal coating
Double contrast examination obtained by using a 100ml bolus of barium, followed by a continuous infusion of methyl cellulose

16. Small bowel enema Technique
Intubation achieved either orally or nasally.
Radiographs taken during infusion include
Spot films (possibly rapid sequence)
Supine & prone films taken at the end of the examination
In patient with Malabsorption the volume of barium should be increased to ml) with compression views of the loops

17. Small bowel enema After care
Reassurance for the patient (especially paediatrics)
Psychological reassurance (especially after tube is withdrawn)
Nothing to eat for five hours after the procedure
The patient should be warned that diarrhoea may occur as a result of large volume of fluid given.

18. Example of small bowel enema

19. Large Intestine
Barium Enema

20. Large Intestine 1.5 metres in length Consists of Caecum Appendix
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus

21. Large Intestine

22. Barium Enema examinations
Some Indications
Change in bowel habits
Mass (eg mass right iliac fossa)
Appendicitis / diverticulitis
Polyp / cancer
Volvulus
Signs / Symptoms
Right / left lower quadrant pain
Fever / elevated wbc’s
Distension / obstruction
Weight loss
Melena (Is darkening of the feces by blood pigments)

23. Barium Enema examinations contraindications
Absolute
recent biopsy
toxic mega colon
Pseudo membranous colitis
Relative:-
incomplete bowel preparation
recent Ba meal

24. Barium enema examinations
Double contrast – demonstrates mucosal pattern
Barium sulphate + air
Single contrast – Paediatrics, reduction of an intussusceptions (Intussusceptions occurs when part of the bowel or intestine is wrapped around itself producing a mass like object on the right side of the abdomen)

25. Patient Preparation Low residual diet ( 3 days before)
Laxative and fluids only (1day before )
Amoxicillin or Vancomycin prior and after the
procedures ( dose and type as instructed
Females – 10 day rule applies
Preliminary film taken in certain circumstances
full explanation of procedure
Catheter (miller) introduced
Muscle relaxant may be given
Drip stand, and hand pump for introducing air

26. Barium enema - Technique
Patient lies on one side & catheter is inserted gently into the rectum
Connections are made to the barium bag

27. Barium enema - Technique

28. Barium enema - Technique
Patient lies on one side & catheter is inserted gently into the rectum
Connections are made to the barium bag
i.v. injection of Buscopan / glucagon is given
The barium is infused slowly as far as the hepatic flexure under fluoroscopic control.
The column of barium within the sigmoid colon is run back out
Air is gently pumped into the bowel, forcing the column of barium round towards the caecum (double contrast effect)
The patient position is adjusted under fluoroscopic control as the complete colon is visualised as the barium travels round to the caecum
From a prone position, the patient rolls onto the left side and over into an RAO position

29. Barium enema - film series
Spot films of rectum and sigmoid colon:
- RAO, prone, LPO, left lateral of the rectum
Spot films of splenic flexure LAO
Spot films of hepatic flexure RAO
Spot film of caecum with compression
Over couch film supine abdomen
Over couch film prone abdomen
Right and left lateral decubitus films
Prone caudal angled sigmoid view
Post evacuation supine film

30. Patient aftercare & complications
Barium enema
Patient aftercare & complications
Encourage patient to drink plenty of fluids
Inform patients where & when to obtain results
Warning of the side effects against the muscle relaxant that may have been given during the examination
complications
barium impaction
reaction to the rubber of the cuff
Cardiac arrhythmias due to rectal distension
Perforation of the bowel

31. Barium Enema (1) caecum (2) ascending colon, (3) transverse colon
(4) descending colon
(5) rectum.
(6) right colic flexure (hepatic flexure)
(7) left colic flexure (splenic flexure)

32. Barium Enema
DIVERTICULOSIS

33. Barium Enema
Sigmoid Carcinoma

34. Barium Enema

35. GIT SUMMARY PLAIN X-RAY---bowel gas pattern BARIUM---outlines lumen
CT---problem solving NM
US special situations
ANGIO
MR--- little use

36. Thank you