Fluoroscopic InvestigationsFluoroscopic Investigations Of The Gastrointestinal TractOf The Gastrointestinal Tract

Small & Large BowelSmall & Large Bowel

References

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

Websites

• http://www.e-radiography.net/

ObjectivObjectiveses

With the end of these lectures the With the end of these lectures the student will be able to:student will be able to: List common indications for ordering Ba F.th List common indications for ordering Ba F.th

and Ba enemaand Ba enema Explain the contraindications for using barium Explain the contraindications for using barium

sulphate in the examination of the small and large sulphate in the examination of the small and large bowelbowel

Describe the anatomy of the small and large bowelDescribe the anatomy of the small and large bowel Describe room preparation and identify supplies Describe room preparation and identify supplies

for small and large bowel barium studiesfor small and large bowel barium studies Describe how to perform the procedures Describe how to perform the procedures Explain patient care, after completing small and Explain patient care, after completing small and

large bowel barium examslarge bowel barium exams Critique small and large bowel barium Critique small and large bowel barium

radiographs radiographs in term of positioning ,image quality, in term of positioning ,image quality, radiographic anatomy ,and pathologyradiographic anatomy ,and pathology

Small BowelSmall BowelBarium follow throughBarium follow through

Continuous with Continuous with stomach & large stomach & large intestine intestine

5 metres long 5 metres long Responsible for Responsible for

chemical digestion chemical digestion of food of food

Three sections Three sections Duodenum Duodenum Jejunum Jejunum Ileum (ileoceacal Ileum (ileoceacal

valve)valve)

Small intestineSmall intestine

Barium follow throughBarium follow through

Barium Follow Through demonstrates Barium Follow Through demonstrates the small bowel from the duodenum to the small bowel from the duodenum to the ileoceacal region encompassing the the ileoceacal region encompassing the duodenum, jejunum and ileum duodenum, jejunum and ileum including the junctions superiorly with including the junctions superiorly with the stomach and inferiorly with the the stomach and inferiorly with the ascending colon. ascending colon.

Barium follow through - Barium follow through -

IndicationsIndications Partial obstruction Partial obstruction MalabsorptionMalabsorption Abdominal massesAbdominal masses failed small bowel enemafailed small bowel enema

Ulcer Obstruction Post-operative ileus Crohn’s disease

Pain Hematemesis Distention Diarrhea

SIGNS / SYMPTOMS

Barium follow through Barium follow through

Contra-indicationsContra-indications

• Complete Obstruction

• Perforation (especially after recent surgery)

Contrast agents & patient Contrast agents & patient

preparationpreparation Barium sulphateBarium sulphate Gastrografin can be added to Gastrografin can be added to

decrease transit time in small bowel decrease transit time in small bowel ( increase flow)( increase flow)

Plain radiograph before is useful Plain radiograph before is useful (Maxalon to (Maxalon to increases gastric peristalsis increases gastric peristalsis

) ) Physical & psychological preparation Physical & psychological preparation Explanation of procedure Explanation of procedure

Barium follow through - Barium follow through -

TechniqueTechnique Aim is to deliver a single column of Aim is to deliver a single column of

barium into the small bowelbarium into the small bowel If this examination is performed in If this examination is performed in

conjunction with a barium meal, then conjunction with a barium meal, then Glucagon is used Glucagon is used

Prone abdomen taken every 20 minutes Prone abdomen taken every 20 minutes during the first hour of patient drinking during the first hour of patient drinking solution. solution.

Subsequent radiographs taken at 30 Subsequent radiographs taken at 30 minutes until the colon is reachedminutes until the colon is reached

Spot films of the terminal ileum in supine Spot films of the terminal ileum in supine positionposition

( compression pad is used to separate any ( compression pad is used to separate any overlying loops of small bowel that are overlying loops of small bowel that are obscuring the terminal ileumobscuring the terminal ileum

Additional films:Additional films:

- Oblique's – to separate loops of small - Oblique's – to separate loops of small bowelbowel

- Erect – To demonstrate Diverticula - Erect – To demonstrate Diverticula ( ( fluid level caused fluid level caused

by contrast media retained within the by contrast media retained within the DiverticulaDiverticula

Barium follow through - Barium follow through -

TechniqueTechnique

Example Barium F. ThroughExample Barium F. Through

Small bowel enemaSmall bowel enema

Indications & contra-indications same Indications & contra-indications same as for barium follow throughas for barium follow through

+ + Rapid infusion of continuous column of Rapid infusion of continuous column of contrast medium (avoids segmentation of contrast medium (avoids segmentation of barium column) barium column)

- - Intubation may be unpleasant for Intubation may be unpleasant for patient patient

Small bowel enemaSmall bowel enema

Specific preparation includes Specific preparation includes

low residue diet for 2 days prior the low residue diet for 2 days prior the

examexam

Stopping of any anti spasmodic Stopping of any anti spasmodic

drugs 1 day prior drugs 1 day prior

anaesthetic spray immediately before anaesthetic spray immediately before

the exam for pharynx anaesthesia the exam for pharynx anaesthesia

preliminary abdominal radiographpreliminary abdominal radiograph..

Contrast agent & specific Contrast agent & specific

equipmentequipment Infusion takes place via intubation Infusion takes place via intubation

Bilbao – Dotter tube / Silk tube Bilbao – Dotter tube / Silk tube 1500ml of barium introduced1500ml of barium introduced < Viscosity gives better mucosal coating< Viscosity gives better mucosal coating Double contrast examination obtained by Double contrast examination obtained by

using a 100ml bolus of barium, followed using a 100ml bolus of barium, followed by a continuous infusion of methyl by a continuous infusion of methyl cellulose cellulose

Small bowel enemaSmall bowel enemaTechniqueTechnique

Intubation achieved either orally or Intubation achieved either orally or nasally. nasally.

Radiographs taken during infusion Radiographs taken during infusion includeinclude

Spot films (possibly rapid sequence) Spot films (possibly rapid sequence) Supine & prone films taken at the Supine & prone films taken at the

end of the examinationend of the examination

In patient with Malabsorption the In patient with Malabsorption the volume of barium should be increased to volume of barium should be increased to 240-260 ml) with compression views of 240-260 ml) with compression views of the loops the loops

Small bowel enemaSmall bowel enema

After careAfter care Reassurance for the patient (especially Reassurance for the patient (especially

paediatrics) paediatrics) Psychological reassurance (especially Psychological reassurance (especially

after tube is withdrawn) after tube is withdrawn) Nothing to eat for five hours after the Nothing to eat for five hours after the

procedureprocedure The patient should be warned that The patient should be warned that

diarrhoea may occur as a result of large diarrhoea may occur as a result of large volume of fluid given.volume of fluid given.

Example of small bowel Example of small bowel

enemaenema

Large IntestineLarge IntestineBarium EnemaBarium Enema

1.5 metres in 1.5 metres in length length

Consists of Consists of Caecum Caecum AppendixAppendix Ascending Ascending colon colon

Transverse Transverse colon colon

Descending Descending colon colon

Sigmoid colon Sigmoid colon Rectum Rectum AnusAnus

Large IntestineLarge Intestine

Large IntestineLarge Intestine

Barium Enema examinations Barium Enema examinations Some IndicationsSome Indications

Change in bowel habits Change in bowel habits

Mass (eg mass right iliac fossa) Mass (eg mass right iliac fossa)

Appendicitis / diverticulitis

Polyp / cancer

VolvulusSigns / Symptoms

Right / left lower quadrant pain Fever / elevated wbc’s Distension / obstruction Weight loss Melena (Is (Is darkening of the feces by blood

pigments)

AbsoluteAbsolute recent biopsyrecent biopsy toxic mega colontoxic mega colon Pseudo membranous colitisPseudo membranous colitis

Relative:-Relative:- incomplete bowel preparationincomplete bowel preparation recent Ba mealrecent Ba meal

Barium Enema examinations Barium Enema examinations

contraindicationscontraindications

Barium enema Barium enema examinationsexaminations

Double contrast – demonstrates mucosal Double contrast – demonstrates mucosal pattern pattern Barium sulphate + air Barium sulphate + air

Single contrast – Paediatrics, reduction of Single contrast – Paediatrics, reduction of an intussusceptions (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)

Patient PreparationPatient Preparation Low residual diet ( 3 days before)Low residual diet ( 3 days before) Laxative and fluids only (1day before )Laxative and fluids only (1day before ) Amoxicillin or Vancomycin prior and after the Amoxicillin or Vancomycin prior and after the

procedures ( dose and type as instructed procedures ( dose and type as instructed Females – 10 day rule applies Females – 10 day rule applies Preliminary film taken in certain Preliminary film taken in certain

circumstances circumstances full explanation of procedure full explanation of procedure Catheter (miller) introduced Catheter (miller) introduced Muscle relaxant may be given Muscle relaxant may be given Drip stand, and hand pump for introducing airDrip stand, and hand pump for introducing air

Barium enema - TechniqueBarium enema - Technique Patient lies on one side & catheter is inserted Patient lies on one side & catheter is inserted

gently into the rectum gently into the rectum Connections are made to the barium bag Connections are made to the barium bag

Barium enema - TechniqueBarium enema - Technique

Barium enema - TechniqueBarium enema - Technique Patient lies on one side & catheter is inserted gently into Patient lies on one side & catheter is inserted gently into

the rectum the rectum

Connections are made to the barium bag Connections are made to the barium bag

i.v. injection of Buscopan / glucagon is given i.v. injection of Buscopan / glucagon is given

The barium is infused slowly as far as the hepatic flexure The barium is infused slowly as far as the hepatic flexure under fluoroscopic control. under fluoroscopic control.

The column of barium within the sigmoid colon is run The column of barium within the sigmoid colon is run back out back out

Air is gently pumped into the bowel, forcing the column Air is gently pumped into the bowel, forcing the column of barium round towards the caecum (double contrast of barium round towards the caecum (double contrast effect) effect)

The patient position is adjusted under fluoroscopic The patient position is adjusted under fluoroscopic control as the complete colon is visualised as the barium control as the complete colon is visualised as the barium travels round to the caecum travels round to the caecum

From a prone position, the patient rolls onto the left side From a prone position, the patient rolls onto the left side and over into an RAO positionand over into an RAO position

Barium enema - film seriesBarium enema - film series • Spot films of rectum and sigmoid colon: Spot films of rectum and sigmoid colon:

- - RAO, prone, LPO, left lateral of the rectumRAO, prone, LPO, left lateral of the rectum

• Spot films of splenic flexure LAOSpot films of splenic flexure LAO

• Spot films of hepatic flexure RAOSpot films of hepatic flexure RAO

• Spot film of caecum with compressionSpot film of caecum with compression

• Over couch film supine abdomenOver couch film supine abdomen

• Over couch film prone abdomenOver couch film prone abdomen

• Right and left lateral decubitus filmsRight and left lateral decubitus films

• Prone caudal angled sigmoid viewProne caudal angled sigmoid view

• Post evacuation supine film Post evacuation supine film

Barium enema Barium enema Patient aftercare & Patient aftercare &

complications complications Encourage patient to drink plenty of fluids Encourage patient to drink plenty of fluids Inform patients where & when to obtain Inform patients where & when to obtain

results results Warning of the side effects against the muscle Warning of the side effects against the muscle

relaxant that may have been given during the relaxant that may have been given during the examination examination complicationscomplications barium impaction barium impaction reaction to the rubber of the cuff reaction to the rubber of the cuff Cardiac arrhythmias due to rectal Cardiac arrhythmias due to rectal

distension distension Perforation of the bowel Perforation of the bowel

Barium EnemaBarium 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)

Barium EnemaBarium Enema

DIVERTICULOSIS

Sigmoid Carcinoma

Barium EnemaBarium Enema

Barium EnemaBarium Enema

PLAIN X-RAY---bowel gas pattern

BARIUM---outlines lumen

CT---problem solving

NM

US special

situations

ANGIO

MR--- little use

GIT SUMMARYGIT SUMMARY

Thank you