Fluoroscopic Investigations Of The Gastrointestinal Tract Small & Large Bowel

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 http://www.e-radiography.net/

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

Small Bowel Barium follow through

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

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.

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

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

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

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

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

Example Barium F. Through

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

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.

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

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 240-260 ml) with compression views of the loops

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.

Example of small bowel enema

Large Intestine Barium Enema

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

Large Intestine

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)

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

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)

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

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

Barium enema - Technique

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

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

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

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)

Barium Enema DIVERTICULOSIS

Barium Enema Sigmoid Carcinoma

Barium Enema

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

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