BARIUM ENEMA

Group 5Dorado, AbbyGuallar, Feliz

Salvador, MaicoPatricio, Kim

Ancheta, SmartCaoile, Regine

Submitted to:Mr. Joel P. Majuk RRT, MGM (c)

Barium Enema/ BE/ Lower GI Series

The radiographic study of the large intestine. It requires the use of contrast media to demonstrate the large intestine and its components.

The purpose of the barium enema is to radiographically study the form and function of the large intestine to detect any abnormal conditions. Both the single-contrast and the double-contrast barium enema involve study of the entire large intestine.

Barium Enema IndicationsBarium enema is done for patients suspected of having large bowel problem.

Patients might present with blood in stool, alteration in bowel habits or recurrent abdominal pain.

Melena (blackish stool) Abdominal mass Diarrhea

Single Contrast Exam Double Contrast ExamWater-Soluble Contrast Exam

Polyps Colitis Suspected

Diverticulis Volvulus Fistula

Rectal Bleeding Polyps or

Carcinoma Inflammatory Bowel

Disease

Suspected perforation or high risk intestinal perforation.

Therapeutic Enema for Disimpaction

ContraindicationsThe two strict contraindications for the barium enema are similar to those

described for the small bowel series. These have been described as a possible perforated hollow viscus and a possible large bowel obstruction.

Anatomy

Begins in the lower right lower quadrant, just distal to the ileocecal valve.

• 1.5 m (5 ft)

Consists of:• Cecum • Colon • Rectum• Anal canal

The main functions of the large intestine are reabsorption of fluids and elimination of waste products.

Cecum• The pouchlike portion of the large intestine • Approximately 2 1/2 inches (6 cm) in length• 3 inches (7 . 6 cm) in diameter.

ColonSubdivided into:

• Ascending• Transverse• Descending• Sigmoid portions• The ascending colon joins the transverse portion at an angle called the right

colic flexure (hepatic flexure )• The transverse portion then makes a sharp curve, called the left colic flexure

(splenic flexure), and ends in the descending portion. • The descending colon passes

inferiorly and medially to its junction.• Sigmoid colon curves to form an S-shaped loop and ends in the rectum.

Rectum• Approximately 6 inches ( 15 cm) long. • Distal portion, about 1 inch (2.5 cm) in length, is constricted to form the anal

canal .

Pathologic Indications

ColitisColitis is an inflammatory condition of the

large intestine that may be caused by many factors, including bacterial infection, diet, stress, and other environmental conditions.

Ulcerative colitis describes a severe form of colitis that is most common among young adults. It is a chronic condition that often leads to development of coinlike ulcers within the mucosal wall.

DiverticulumDiverticulum is an outpouching of the

mucosal wall that may result from herniation of the inner wall of the colon. The condition of having numerous diverticula is termed diverticulosis. If these diverticula become infected, the condition then is referred to as diverticulitis. Inflamed diverticula may become a source of bleeding, in which case surgical removal may be necessary.

IntussusceptionIntussusception is a telescoping or

invagination of one part of the intestine into another. Radiographically, the barium column terminates into a “mushroom-shaped” dilation with very little barium/gas passing beyond it. This dilation marks the point of obstruction.

Neoplasms

Neoplasms are common in the large intestine. Although benign tumors do occur, carcinoma of the large intestine is a leading cause of death among both men and women. Most carcinomas of the large intestine occur in the rectum and sigmoid colon. These cancerous tumors often encircle the lumen of the colon, producing an irregular channel through it. The radiographic appearance of these tumors as demonstrated during a barium enema has led to the use of descriptive terms such as “apple-core” or “napkin-ring” lesions. Both benign and malignant tumors may begin as polyps.

PolypsPolyps are saclike projections similar to

diverticula except that they project inward into the lumen rather than outward, as do diverticula. Similar to diverticula, polyps can become inflamed and may be a source of bleeding, in which case they may have to be surgically removed. Barium enema, endoscopy, and computed tomography colonography (CTC) are the most effective modalities used to demonstrate neoplasms in the large intestine.

VolvulusVolvulus is a twisting of a portion of the

intestine on its own mesentery, leading to a mechanical type of obstruction. Blood supply to the twisted portion is compromised, leading to obstruction and necrosis, or localized death of tissue. A volvulus may be found in portions of the jejunum or ileum or in the cecum and sigmoid colon.. A volvulus will produce an air-fluid level, as is well demonstrated on an erect abdomen projection.

Barium Enema Procedure Light evening meal prior to the examination. NPO after midnight. 8 hrs fasting. Laxative or cleansing enema. No smoking to prevent gas formation.

After the fluoroscopic room and the contrast media have been completely prepared, the patient is escorted to the examination room. Before insertion of the enema tip, a pertinent history should be taken and the examination carefully explained. Because complete cooperation is essential and this examination can be somewhat embarrassing, every effort should be made to reassure the patient at every stage of the exam.

Previous radiographs should be made available to the radiologist. The patient is placed in Sims' position before the enema tip is inserted.

Barium Enema ContainersA closed-system enema container is used to administer barium sulfate or an

air and barium sulfate combination during the barium enema. Once mixed, the suspension travels down its own connective tubing, and flow is controlled by a plastic stopcock. An enema tip is placed on the end of the tubing and is inserted into the patient's rectum.

After the examination has been completed, much of the barium can be drained back into the bag by lowering the system to below tabletop level. The entire bag and tubing are disposed of after a single use.

Enema TipsVarious types and sizes of enema tips are available. The three most common

enema tips are (A) plastic disposable, (B) rectal retention and, (C) air-contrast retention enema tips.

Enema Tip Insertion

Step 1 Describe the tip insertion procedure to the patient. Answer any questions.

Step 2 Place the patient in Sims' position. Patient should lie on the left side, with the right leg flexed at the knee and hip.

Step 3 Shake enema bag once more to ensure proper mixing of barium-sulfate suspension. Allow barium to flow through the tubing and from the tip to remove any air in the system.

Step 4 Wearing gloves, coat enema tip well with water-soluble lubricant. Wrap proximal aspect of enema tip in paper towel. Step 5 On expiration, direct enema tip toward the umbilicus approximately 1 to 1½ inches (2.5 to 4 cm).

Step 6 After initial insertion, advance up superiorly and slightly anteriorly. The total insertion should not exceed 3 to 4 cm. Do NOT force enema tip.

Step 7 Tape tubing in place to prevent slippage. Do NOT inflate retention tip unless directed by radiologist.

Step 8 Ensure that IV pole/enema bag is no more than 24 inches (60 cm) above the table. Ensure that tubing stopcock is in the closed position, and that no barium flows into the patient.

Contast MediaBarium sulfate is the most common type of positive-contrast medium used

for the barium enema. The concentration of the barium sulfate suspension varies according to the study performed. A standard mixture used for single–contrast

media barium enemas ranges between 15% and 25% weight-to-volume (w/v). The thicker barium used for double-contrast barium enemas has a weight-to-volume concentration between 75% and 95% or higher.

Contrast Media PreparationThe mixing instructions as supplied by the manufacturer should be followed

precisely.

A debate has evolved over the temperature of the water used to prepare the barium sulfate suspension. Some experts recommend the use of cold water (40°F to 45°F) in the preparation of contrast media. Cold water is reported to have an anesthetic effect on the colon and to increase the retention of contrast media. Critics have stated that the use of cold water may lead to colonic spasm.

Room temperature water (85°F to 90°F) is recommended by most experts for completion of a more successful examination with maximal patient comfort.

The technologist should NEVER use hot water to prepare contrast media. Hot water may scald the mucosal lining of the colon.

Because barium sulfate produces a colloidal suspension, shaking the enema bag before tip insertion is important for preventing separation of barium sulfate from water.

Spasm during the barium enema is a common side effect. Patient anxiety, overexpansion of the intestinal wall, discomfort, and related disease processes all may lead to colonic spasm. To minimize the possibility of spasm, a topical anesthetic such as lidocaine may be added to the contrast media. If spasm does occur during the study, glucagon can be given intravenously and should be kept in the department for these situations.

Two basic radiologic methods of examining the large intestines: Single Contrast Method Double Contrast Method

Single Contrast MethodThe single-contrast barium enema is a procedure in which only a positive-

contrast media is used. In most cases, the contrast material is barium sulfate in a thin mixture. Occasionally, the contrast media must be a water-soluble contrast material. For example, if the patient is to be taken to surgery after undergoing the single-contrast enema procedure, then a water-soluble contrast media must be used.

Double Contrast MethodA second common type of barium enema procedure is the double-contrast

type. Double-contrast studies are more effective in demonstrating polyps and diverticula than is the single-contrast barium enema procedure. Radiographic and fluoroscopic procedures for a double-contrast barium enema are somewhat different in that both air and barium must be introduced into the large bowel. An absolutely

clean large bowel is essential to the double-contrast study, and a much thicker barium mixture is required. Although exact ratios depend on the commercial preparations used, the ratio approaches a one-to-one mix, so that the final product is like heavy cream.

Barium Enema Scout Left Lateral LPO RPO LPO Low Oblique/ Slight LPO KUB Decubitus

o R and L Lateralo X-table rectumo Post- evac

Scout Film

Radiograph exposed before contrast medium is given.

Preliminary film.

Patient Position:Patient is lying on his/her back.

Central Ray:Perpendicular to the IR.

Left Lateral

Patient Position:Patient is lying on his/her left side. Flex the knees slightly for stability.

Central Ray:Perpendicular to the IR entering the midcoronal plane at the level of the ASIS

Structures Shown: Rectum is barium-filled.

LPO/ RPO Position

Patient Position:Supine; Patient lying on his/her right/left side forming 35-45 degrees of

angulation.

Cental Ray:Perpendicular is at the level of the L4 or at the level of the iliac crest.

Structures Shown: LPO—The right colic (hepatic) flexure and the ascending and rectosigmoid

portions should appear “open” without significant superimposition.

RPO—The left colic (splenic) flexure and the descending portions should appear “open” without significant superimposition. Entire contrast-filled large intestine, including the rectal ampulla, should be included.

PA/ AP Projection

Pathology Demonstrated: Obstructions, including ileus, volvulus, and intussusception, are

demonstrated. Double-contrast media barium enema is ideal for demonstrating diverticulosis, polyps, and mucosal changes.

Structures Shown: The transverse colon should be primarily barium-filled on the PA and air-filled

on the AP with a double-contrast study. Entire large intestine, including the left colic flexure, should be visible.

Central Ray:Perpendicular at the level of the L4 or at the level of the iliac crest

Right Lateral Decubitus

Patient Position:Patient is lying in his/her right side.

Central Ray: Horizontally directed entering the midline of the body at the level of iliac crest.

Structures Shown: Entire large intestine is demonstrated to include air-filled left colic flexure and descending colon and barium-filled right colic flexure.

Left Lateral Decubitus

Patient Position:Patient is lying on his/her left

side

Central Ray:Horizontally directed entering the midline of the body at the level of iliac

crest.

Structures Shown: Entire large intestine is demonstrated, with air-filled right colic flexure,

ascending colon, and cecum.

Post-evacuationPA/ AP Projection

Postevacuation Phase To know the residual amount of contrast

media.

Structures Shown: Entire large intestine should be visualized with only a residual amount of contrast media.