learn barium meal & follow through
TRANSCRIPT
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Dr. Santosh Atreya Resident (Phase- A) Radiology & ImagingBSMMU,Dhaka from Nepal
BARIUM MEAL &
FOLLOW THROUGH
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BARIUM MEAL
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• The study is called so because it is performed following barium meal
INTRODUCTION
• The thin walled alimentary canal does not have sufficient density to be demonstrated through surrounding structures, so its radiographic demonstration requires the use of artificial contrast medium (Barium)
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Contd…• Barium sulphate is the
radiopaque contrast media used for the gastrointestinal system.
• Barium examinations require use of high KVp technique to penetrate barium (not <90).
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Taste• Chalky Taste (Real
Taste )
• Different flavour these days – Banana
Vanilla
Pineapple
lemon etc
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Excellent coating of mucosaCost effectiveHigh density Provides a positive contrast in x-ray
Advantages of barium sulphate
Radiopaque material Insoluble materialNot absorbed or metabolized Eliminated from the body
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Disadvantages
High morbidity associated with barium in the peritoneal cavity
Subsequent CT and US are rendered difficult
Complication
PerforationAspirationIntravasation
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Why iodine is not used ?
Water soluble Diminish blood volume
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Gas agents
Carbondioxide CO₂ is administered orally , in the form of effervescent
granules
• Production of adequate volume of gas• Non interference with barium coating• No bubble production• Rapid dissolution• Easily swallowed• Low cost• Carbon dioxide -cause less abdominal pain
Properties of this agent
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Other pharmacological agents
Hyoscine-N-butyl bromide ( Buscopan)• antimuscarinic agent • inhibits both intestinal motility and gastric secretion
Glucagon• smooth muscle relaxation
Metoclopramide• stimulates gastric emptying and small intestinal
transit
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Anatomy of the stomach
Divided into two parts: -Cardiac and pyloric part
Cardiac -Fundus and body Pyloric -Pyloric antrum and pyloric canal
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Duodenum:• C-shaped tube • 25 cm long & width 3.75-4 cm• Joins stomach to jejunum• The first & shortest part of small
intestine
•The widest & most fixed part Curves around the head ofPancreas . •Begins at pylorus on right side & ends at duodenojejunal junction on left side . Partially retroperitoneal
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BARIUM MEAL Methods : 1. Double contrast – the method of choice to
demonstrate mucosal pattern. 2. Single Contrast – uses : a) Children -since it
usually is not necessary to demonstrate mucosal pattern b) Very ill adults – to demonstrate gross pathology only Indications 1.Dyspepsia 2.Weight loss 3.Upper abdominal mass 4.Gastrointestinal haemorrhage or unexplained iron
deficiency anaemia
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Contd… 5. Partial obstruction 6. Assessment of site of perforation – it is essential that
water soluble contrast medium e.g. Gastrografin or Dionosil aqueous is used.
CONTRAINDICATIONS :• Complete large bowel obstruction.
CONTRAST MEDIUM : •120 ml of high density barium 250 % W/V (Double contrast)•Sufficient 100 % W/V ( Single Contrast )
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Patient Preparation
Patients fast for 6 hrs prior to the examination Should abstain from smoking Should ensure that no contraindications to the pharmacological agents used H/O previous surgery
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Procedure - The double contrast method
Patient swallows effervescent agent (tablet form known from gastro)
High density barium(250% w/v) is swallowed while lying on the left side
Then to the supine position. If reflux is observed spot films are taken
A hypotonic agent –Buscopan(20 mg I.V )or glucagon (0.1-0.2 mg) is administered
Patient rolled from side to side so barium coats mucosal surfaces by washing mucus from the gastric mucosa
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Sequences of films for barium meal examination
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Patient supine position-AP viewinferior portion of the body
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Normal barium meal anatomy of stomach
Area gastricae-2-4 mm polygonal islands ,varies from fine reticular pattern to coarse nodularity
Longitudinal folds or rugae
Transient fine transverse folds
Gastric cardia –shows a rosette of short folds radiating from esophageal orifice
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Supine –body and antrum
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Right lateral position - fundus
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Spot films for duodenal loop
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Spot film of the abdomen with the patient in prone position
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DUODENAL CAPSymmetric and triangularShows fine velvety pattern when coated with
barium - when distendedA fold pattern is seen in the inferior bend between
the 1st and 2nd parts of the duodenum.When the duodenal cap is undistended ,a fold pattern is seen.
• The major papillae of vater
• minor papilla (of Santorini)
Barium meal appearance of the duodenum
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The normal duodenal cap seen by double contrastsurface coating almost homogenous
Fine velvety reticular pattern
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Transient fine transverse mucosal folds
A: AntrumC:duodenal cap
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Double contrast barium mealsupine right anterior oblique view
The papilla of Vater (white arrow) has a longitudinal (arrowhead) and two oblique folds (black arrows)extending below it
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Additional view of the fundusSpot films of the oesophagus
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Modification technique for young children
Indication• Vomiting
Technique• Single contrast• 30 % barium sulphate• No paralytic agent
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Aftercare Patient should be told that the
bowel will be white for few days
Patient should be advised to drink adequate water
Patient should not leave the department until blurring of vision has resolved
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Barium follow- through
examination
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Anatomy of small intestine
length = 6-7 m (approx)
Extent- From Pylorus to ileo-caecal valve
Proximal 2/5th constitute the jejunum and distal 3/5th constitute the ileum
The Valvulae conniventes -2 mm thick in jejunum and 1 mm thick in ileum.
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JEJUNUM & ILEUM• Jejunum begins at
duodenojejunal flexure (L2) & ileum ends at ileocecalJunction.
• Jejunum & ileum = 6 to 7 m long (jejunum 2/5, ileum 3/5)
• Coils of jejunum & ileum are suspended by mesentery from posterior abdominal wall & freely movable.Most jejunum lies in left upper quadrant & most ileum lies in right lower quadrant
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Wall of small intestine is made of the following layers :
a) Serosa coat
b) Muscular coat
c) Submucosa coat
d) Mucosa coat
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Introduction – Barium Follow Through
• Barium Follow Through is designed to demonstrate 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.
• Also known as barium meal follow through (BMFT) & small bowel follow through (SBFT)
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Indications
ContraindicationsComplete obstructionSuspected perforation
PainDiarrhoeaAnemiaGastrointestinal bleedingMalabsorptionAbdominal mass
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Methods
Single contrast With addition of effervescent agent
Contrast medium 300 ml of 100% w/v
Barium suspension
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Patient preparation
NPO overnightA prokinetic agent metoclopramide(20 mg ) is
given orally,atleast 30 mins before the study starts.
Plain abdominal radiograph if perforation is suspected
Preliminary film
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Procedure A lower density barium suspension (50-100% w/v is
ideal) 300 ml of 100% w/v barium suspension diluted with
equal volume of water Patient lies on the right side after barium has been
ingestedFilms
Prone PA films of the abdomen are taken every 20 mins during the first hour
Then every 30 mins until the colon is reached Spot films of the terminal ileum are taken supine
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Compression is mandatory
To separate the bowel loops Assess mobility Define mucosal pattern
• Done by prone inflatable paddle
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Additional films
To separate loops of small bowelOblique viewWith X-ray tube angled into the pelvisWith patient tilted head down
To demonstrate diverticula Erect-will reveal any fluid level
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Appearance of small bowel
• No reliable radiological demarcation between jejunum and ileum
• Luminal diameter decreases along the length of the small bowel
• Jejunal diameter should not exceed 3.5 cm on barium follow-through and 4.5 cm on enteroclysis
• Small bowel wall should not measure more than 1-2 mm thick when distended
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Interpretation Jejunum Ileum Constitutes proximal 2/5th of small intestine
3/5th
Position Upper left and periumblical region
Lower right hypogastric and pelvic region
Max. diameter 4 cm 3 cm
Number of folds 4-7 per cm 3-5 per cm
Pattern Feathery mucosa Less feathery or maybe absent
Fold thickness 1-2mm
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Mucosal pattern of small intestine The appearance of the mucosal
folds depends upon the diameter of the bowel
• When distended the folds are seen as lines traversing the barium column known as Valvulae conniventes
• When relaxed folds appear feathery
Mucosal folds are largest and most numerous in the jejunum and tend to disappear in the lower part of the ileum
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Normal enteroclysis (small bowel enema). This technique gives good mucosal detail
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