2015 pm lecture 4 barium enema
DESCRIPTION
Barium EnemaTRANSCRIPT
Patient ManagementLecture 4
Barium enema study1. Definition2. Anatomy of the large intestine3. Indications and contraindications4. Patient preparation for barium
enema studies5. The barium enema procedure6. Special circumstances in barium
enema studies
Objectives
At the end of the session, students should be able to:
• Define the term “Barium enema”• Outline the anatomy of the large intestine• Discuss the indications and contraindications of
barium enema studies• Give details of the patient preparation for barium
enema studies• Outline patient care procedures for barium
enema studies
Objectives
• Outline procedures for rectal catheterization for barium enema studies
• Define terminology associated with bowel pathology
• Outline the care of patients with colostomy• Outline special procedures to be followed
for diabetics, infants, ward, and elderly patients
Barium Enema
Definition
• A suspension of barium sulphate introduced via the rectum as a contrast agent for radiologic examination of the large intestine
– Can be single or double-contrast study
Anatomy of the large intestines
Single and double contrast studies
Single contrast study Double contrast study
Barium Enema
Indications:
• Diverticulosis - • Polyps• Malignancies• Tumours • Ulcerative colitis• Recurrent / chronic constipation• Hirschsprung’s disease• Recurrent diarrhoea
Barium Enema
Contraindications:
• Pregnancy• Intestinal obstruction• Perforation / fistula• Allergy to Barium Sulphate
Barium enema – Patient preparation
Includes:
• General abdominal preparation • Psychological preparation • Local preparation
Barium enema – Patient preparation
General abdominal preparation
• Low residue diet for 4 - 7 days prior to examination (gives the least possible fecal residue e.g. gelatin, fish, chicken, broth, fruit, meat, hard-boiled eggs)
• Diet restricted to fluids only 24 hours prior to the procedure)
• Liquid intake encouraged• Suitable aperient on each of two nights
preceding the examination
Barium enema – Patient preparation
Abdominal preparation cont’d
• Patient to remain as ambulant as possible to assist in the prevention of accumulated gas
• NPO for 8-10 hrs. (or NPO after 10pm on night prior to examination: alternatively, take light breakfast just before examination)
• No smoking 4-6 hrs. prior to examination• High colonic cleansing enema administered
on morning of examination just prior to Barium enema procedure
Barium Enema cont’d
Contraindications to washout
• Babies and toddlers• Ulcerative colitis• Diarrhoea• Dehydration• Congenital megacolon• Gross bleeding from GI tract
Barium enema – Patient preparation
Psychological and local preparation• Explain the procedure/answer questions the
patient may ask about the procedure• Make enquiries of the patient’s bowel
preparation• Patient to completely undress in privacy• Patient is given clean gown to be placed with
its opening to back• Patient to use bathroom before examination
Barium enema – trolley setting
Trolley setting
• Enema bag and tubing • Foley catheter (16-30)• Forceps / clamp for catheter• Air bulb for introducing air contrast into
intestines for double contrast studies• Lubricant
Barium enema – trolley setting
Trolley setting cont’d
• Drip stand• 30 ml syringe for catheter balloon• Incontinence pad• Large kidney dish• Bedpan• Gloves
Barium enema - Catheterizing the patient
Rectal catheters
• Are of two main designs:– without retainer balloon– with retainer balloon
• Are made of firm but fairly flexible plastic• The olive-shaped tip has end and side holes
and is designed for easy insertion– Care to be taken to avoid perforation of rectal
walls during insertion of this type
Barium enema - Catheterizing the patient
• Rectal catheter with retainer balloon
• Rectal catheter without retainer balloon
Barium enema - Catheterizing the patient
The Foley catheter
Barium enema - Catheterizing the patient
Barium enema - Catheterizing the patient
• Foley catheter is commonly used in local
practice, having the advantages of flexibility and self-retention
• Steps are to be taken to ensure that the foley catheter is secure and that patient is able to retain catheter before introducing barium suspension
• The foley catheter is secured by:– Advancing catheter to appropriate distance– Inflating the balloon– Tightening the sphincter around the catheter– Use of adhesive tape to secure catheter to patient’s skin
Barium enema - Catheterizing the patient
• Explain the procedure to the patient • Ensure good lighting• Patient instructed to lie on left side• Knees and hips flexed• Don gloves• The catheter is clamped and its tip is
lubricated• Buttocks parted at natal cleft to reveal
anal orifice
Barium enema - Catheterizing the patient
• Inspect the anus for haemorroids and other abnormalities
• If no abnormalities are evident, advance the catheter until 3- 4 inches of catheter is inserted
• Inflate the retainer balloon• Tug slightly on catheter to check its security
in the rectum and further secure with adhesive tape to the patient’s skin.
Barium Enema - The procedure
• After catheterization, the radiologist releases the clamp on the catheter and tubing and allows a quantity of barium suspension to run in to partially fill the large intestine
• The barium flow is then suspended (by clamping the catheter) and air is introduced via a hand pump or bulb.
Barium Enema - The procedure
• As the air advances the barium suspension along the tract, the patient is manipulated into various positions and spot radiographs are taken
• Attention is to be paid to the patients level of cooperation, any deterioration in his health status, and any complaints of discomfort resulting from the procedure
• The barium and air are allowed to flow to the ileo-caecal junction
Barium Enema - The procedure
Fluoroscopy spot films are done to include the following projections:
• Left lateral rectum • Sigmoid (RAO)• Descending colon (LAO)• Splenic flexure (LAO)• Transverse colon• Hepatic flexure (RAO)• Ascending colon (RAO)• Caecum
Barium Enema - The procedure
• Overcouch exposures
1. Supine Abdomen2. Prone Abdomen3. Right and Left Lateral Decubitus4. Post- evacuation abdomen
Left lateral rectum
Left lateral rectum
LAO colon
LAO Colon
Supine Colon
Supine colon
Right Lateral Decubitus
Right Lateral Decubitus
Left Lateral Decubitus
Left Lateral Decubitus
Barium enema - Aftercare
• Excess barium and air are to be released through catheter into bedpan or suitable container on completion of the study before the patient is directed to the bathroom
• The catheter is deflated and withdrawn from rectum
• The patient is directed/ assisted to bathroom for further evacuation and clean-up
Barium enema - Aftercare
The patient is informed of
– White stools for a few days post - study– Possibility of constipation– Diet to follow to assist in clearing the bowel of the
barium suspension (fruits, fruit juices, water)– Return to normal diet & medication regime– Return to referring physician in the event of adverse
effects of the study
Barium Enema - special circumstances
1. Post-operative patientsWater-soluble contrast agent is used in place of Barium Sulphate suspension e.g. Gastrograffin, Urografin, Ultravist
– The use of barium sulphate increases the risk of peritonitis if the barium seeps into the peritoneum via surgically- created connection
Barium Enema - special circumstances
2. The colostomy patient
Definition of colostomy– A surgical procedure in which the colon is
opened onto the surface of the abdomen to provide an artificial outlet for faecal contents
– Surgically formed fistulas from the large or small bowel through the abdominal wall that terminate in an external opening called a stoma.
Barium Enema - special circumstances
• The patient with a colostomy
Barium Enema - special circumstances
Types of colostomya) Temporary
– Performed to rest the bowel and allow it to heal after surgery, massive trauma, infection, or chronic disease. After the bowel is healed, the healthy portions are re-connected, and the temporary opening is closed
Barium Enema - special circumstances
Types of colostomyb) Permanent
– When the diseased portion of bowel is removed and a permanent artificial opening is created
– Performed on patients with imperforate anus which is the result of developmental error, the rectum does not open normally into the anal canal
Barium Enema - special circumstances
Location of the temporary colostomy
• involves a loop of the transverse colon and the colostomy bag is usually sited to the right of the midline in the upper abdomen between the umbilicus and lower costal margin
• Often has a double-barreled construction (two entrance points at the colostomy opening)
Location of the temporary colostomy
•Openings separated by a spur of tissue organized to prevent bowel contents passing from one opening to the other. Usually, the opening to the right is the active end. The left opening will fill the distal colon.
– Distal loop may also be examined via the rectum and the barium exits the colostomy site
Barium Enema - special circumstances
Barium Enema - special circumstances
Location of the permanent colostomy
– Where the rectum was surgically removed the sigmoid is brought out as a colostomy opening sited in the left iliac fossa
– Any examination of the remaining bowel must be carried out via the colostomy opening
Barium enema - special circumstances
The colostomy bag
Barium enema - special circumstances
The Colostomy Patient for Barium enema study– Barium Enema is administered via colostomy
opening or via rectum– Because of lack of control of evacuation the
radiographer must prepare for mopping up procedures
– the radiographer should know how to attach /remove /operate the colostomy apparatus
Barium enema - special circumstances
The Colostomy Patient for Barium enema studyThe patient may be sensitive about wearing the
colostomy bag because:– The bag collects faeces– The accompanying alteration in body image
difficult to accept– Any expression of revulsion by the
radiographer may be perceived as disgust or rejection
Barium enema - special circumstances
The Colostomy Patient for Barium enema study• When booking procedures which will require the
removal of the colostomy bag, remind the patient to bring their own supplies
• Provide private facility for the patient to empty the colostomy bag
• provide facilities for cleaning reusable bags• Provide assistance in replacing bag where
necessary
Barium enema - special circumstances
The Colostomy Patient for Barium enema study• When booking procedures which will require the
removal of the colostomy bag, remind the patient to bring their own supplies
• Provide private facility for the patient to empty the colostomy bag
• provide facilities for cleaning reusable bags• Provide assistance in replacing bag where
necessary
Barium enema - special circumstances
The Colostomy Patient for Barium enema study• Bowel preparation as instructed by the
radiologist in consultation with referring doctor• Patient to follow low residue diet• Enema to be delivered at low pressure
(keep enema bag at reasonable height above patient)
• Consider patient’s sensitivity to his condition; allow him to operate the bag on his own if he can
Barium enema - special circumstances
The Colostomy Patient for Barium enema study• Have spare colostomy bags available in the
department• Careful catheterization of the stoma is
required• Study requires more dilute suspension than
regular barium enema• Do not force catheter if resistance is
encountered• Do not overfill the bowel
Barium enema - special circumstances
The Colostomy Patient for Barium enema study• Make facilities available for patient to wash
his hands• Clean site with warm water and soap• Thoroughly clean and dry the skin
Barium enema - special circumstances
3. Patients with enlarged colon– May require the use of water-soluble contrast
medium to prevent impaction of barium suspension in the large intestines.
Hirschsprung's disease / congenital megacolon – neurological deficiency in distal portion of
intestines hence peristalsis is impaired– Enlarged colon leads to greater opportunity for
water absorption of water from the bowel (larger surface area) leading to impaction
Barium enema - special circumstances
Patients with enlarged colon cont’d
– Where barium sulphate is used, the suspension should be prepared with saline solution instead of water. This reduces the loss of water from the colon during the study
Barium enema - special circumstances
4. The diabetic patient– Starvation period to be kept minimal– There should be little disturbance to their
diet and medication regime 5. The infant patient
– special bowel preparation and starvation instructions
Conditionsof the colon
• Diverticulosis • Intussusception
Conditions of the colon• Volvulus
Tutorial questions1. Outline the after-care you would provide a patient following a
Barium Enema study.2. With reference to a colostomy:
– Define the term.– Give ONE indication each for a:
• Temporary colostomy• Permanent colostomy
– What psychological considerations are to be given for barium enema patients with colostomy apparatus attached?
Tutorial questions3. Under what situations should consideration be given to the use of water-soluble contrast medium for enema study?4. Define the following terms:
– Volvulus– Diverticulosis– Diverticulitis– Intussusception– Imperforate anus– Hirschsprung’s disease
References• Culmer, P. (7th edition) Chesney’s Care of the Patient
in Diagnostic Radiography. Blackwell Science. Chapter 6, p73 – 95
• Ehrlich, R., Daly, J. (7th edition) Patient Care in Radiography Mosby. Chapter 6, p 194 – 195