1. Midterm
Barium Enema

2. 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).

3. Large Intestine Anatomy
CECUM 
COLON 
RECTUM
ANAL
                           

4. Colon subdivision
Ascending
Transverse
Descending
Sigmoid

6. *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. 

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

8. 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.

10. Clinical Indications

11. 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.

12. 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.

13. colitis

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

16. polyps

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

18. 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.

19. Irritant Cathartic
Saline Cathartic

20. Contrast media

21. 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.

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

23. Closed system type enema Open system type enema
Barium Containers
Closed system type enema
Open system type enema

24. Closed system type
Open system type

25. 3 – common enema tips Plastic disposable Rectal retention
Air contrast retention

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

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

28. Sims Position

29. 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

30. 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.

31. 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.

32. 3 – Types of Examinations of Colon
Procedures
3 – Types of Examinations of Colon
Single – contrast Ba. Enema
Double – contrast Ba. Enema
Defecogram

33. Single Contrast Ba. Enema

34. Double Contrast Ba. Enema

35. 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.

36. 2 - Approaches of Double-contrast Administering

37. 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.

38. 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.

39. 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

40. 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

41. 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.

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

43. 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.

44. 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

45. 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.

46. 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 caudad at approximate level of the anterior superior iliac spines.

47. 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.

48. AP – Single Contrast

49. Double Contrast

50. Splenic Flexure

51. Left Lateral Decubitus

52. Right Lateral Decubitus

53. Lateral Cross table

54. Angle Prone caudad

55. Postevacuation