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Update on barium x-ray

examinations of thegastro-intestinal tractFel icit y Goodyear- Smith MB ChB MGP FRNZCGP, Senior Lecturer, Goodfell ow Unit , Divi sion of

General Practi ce & Primary Health Care, Facul ty of Medical & Health Sciences, Universit y of Auck-

land; Stephen Wood BSc MB ChB, Radiology Registrar, Auckland Healthcare, Auckland; Dennis

Keri ns MA DipPH, Development M anager IT, Goodfell ow Uni t, Di vision of General Practi ce & Pri -

mary Health Care, Faculty of Medical & Health Sciences, Uni versit y of Auckland

This summary has been adapted

from a sect ion in t he Goodfellow

Unit Int ernet CME Club. Furt her in-

format ion, including Patient Infor-

mat ion Sheets that can be print ed

off as pdf f iles, can be found on t he

Club site. Access to the Club sit e is

free to all GPs. To join, visit the sit e

at http://cmeclub.auckland.ac.nz,

click on the icon join the club andthen fill out the registrat ion form

and submit it (please make a note

of your user name and password).

As well as providing updates on

various investigat ive procedures,

the site contains int eracti ve self -

marking quizzes based on guide-

lines, PreMeC Bullet ins and other

resources. Most courses quali fy

Barium studiesBarium studies (x-rays) of the bowelare used to diagnose abnormalitiesof the gastrointestinal tract, such astumours, ulcers and other inflamma-tory conditions, polyps, hernias, andobstructions (strictures). Studies con-sist of either upper gastrointestinaltract examinations (barium swallowor meal) or lower gastrointestinaltract examinations (barium enema).Barium studies involve x-rays of the

doct ors f or t wo RNZCGP MOPS

(Maint enance of Professional

Standards) point s, and GPs print

off their cert ifi cate on completion

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tains virtual courses which link to

medical resources and other int er-

est ing sit es on t he Internet. Other

features include case studies insports medicine, a sect ion on in-

vest igat ive procedures, a toolbox

of useful medical resources on the

Internet, t ips from Goodfellow CME

courses, and the Journal Review

Service with elect ronic ordering of

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t ribut ed by post from the Philson

Library.

GI tract taken in conjunction withthe use of a diluted barium sulphatesolution lining the area of the bowelunder examination. Barium sulphateis a radio-opaque metallic contrastmedium. Often the studies are termeddouble contrast by virtue of use ofgas as a second contrast medium.

Barium swallow/meal

A barium swallow involves partiallyfilling the oesophagus and stomach

with barium liquid while x-ray im-ages are taken. It is usually performedon an outpatient basis.

The patient is positioned on anx-ray fluoroscopy table and imagesare obtained during and after the in-gestion of barium sulphate. Depend-ing on the indication the examina-tion will include images of the oro-pharynx, oesophagus, stomach andsmall bowel, particularly the duo-denum. The patient will be exam-ined in erect and supine/prone po-sitions and may be given a gas form-ing mixture for a double contrastexamination.

Indications for barium swallowinclude assessment of dysphagia orpain on swallowing, assessment oftracheo-oesophageal fistula in chil-dren and assessment of the site of aperforation.

Indications for barium meal in-clude investigation for dyspepsia, re-flux, weight loss, an upper abdomi-nal mass, a gastrointestinal haemor-rhage or unexplained iron deficiencyanaemia, partial obstruction or a sus-pected hiatus hernia.

There are a number of advan-tages to performing a barium swal-low/meal. In comparison to gastros-copy, barium swallow is safer. Theexamination is useful for functional

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assessment as it allows the assess-ment of motility, reflux and disten-sion. It is difficult to compare costsbetween barium studies and gastros-

copy and they may be of compara-ble cost. However, in some centresbarium studies are much more ac-cessible to GPs and may be arrangedwith much less delay for the patientthan gastroscopy.

There are also a number of dis-advantages in performing the pro-cedure. It is not as comprehensiveor accurate a method for diagnosisof some conditions as gastroscopy.Furthermore, it is not possible to

Above: Corkscrew oesophagus

Top right : Erosive gastr it is

Right : Gastr ic ulcer

take samples or provide treatmentas part of the procedure. There arealso considerations with respect toradiation exposure. The dose re-

ceived from a barium swallow is 2-3 millisieverts compared with a chestfilm 0.06 millisieverts and back-ground radiation of 2 millisievertsper year. Users of ionising radiationare required to inform all women ofchildbearing age about the risks ofradiation in pregnancy. Pregnancyis a relative contraindication to theuse of radiation unless the urgencyis such that an alternative investi-gation is not available.

There are several potential diffi-culties that may arise out of a bariumswallow/meal referral. Air insufflationcan cause discomfort for patients. Poortolerance of swallowed gas mixture

can make for poor stomach andoesophageal distension. Wherebuscopan injection is used to relaxbowel for better pictures, patients mayexperience some blurring of vision.There is also a tendency of barium tocause constipation in the days follow-ing the procedure. Patient co-opera-tion is important and there is there-fore a need for an interpreter in non-English speaking patients.

Less commonly performed upper

gastro-intestinal barium studies in-clude the modified barium swallowwhich involves the patient eatingvarious barium-coated foods and re-quires specialist input from a speechlanguage therapist. The barium mealfollow-through is time-consumingand is now a relatively uncommonprocedure.

Barium enema

A barium enema involves filling thelarge intestine with barium liquidwhile x-ray images are taken. Thismay involve either single or doublecontrast images. For single contrastprocedures, the colon is filled withbarium liquid and x-ray images re-veal any significant abnormalities inthe large intestine, although this pro-cedure is largely used to detect ob-structing lesions in the acute setting.With double contrast, which is usu-ally the barium study of choice, asmaller quantity of thicker barium

liquid is introduced to the large in-testine, followed by air. This allowsthe barium to form a film on the in-ner surface, allowing smaller surfaceabnormalities of the large intestineto be detected and assessment of thestate of the bowel mucosa.

A barium enema is usually per-formed on an outpatient basis. Toprevent obscuring of the image, it isnecessary for the large bowel to beemptied of faeces prior to the exami-

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nation. This is vital as faecal residuecan mimic the appearance of a polyp.Bowel preparation involves the pa-tient drinking clear fluids during thepreceding day, using a laxative and

having nil by mouth for some hoursprior to the procedure. The patientideally needs to be passing clearstools prior to the commencement ofthe study.

The patient is positioned on anx-ray table and the barium liquid in-troduced per rectum via an enematube. During double contrastimaging, the colon is also inflatedwith air through the same rectal tubewith a small hand pump.

Indications for barium enemainclude the investigation of ab-dominal pain, bleeding from therectum or melena, change in bowelhabit, chronic diarrhoea or consti-pation, unexplained weight loss oranaemia, palpable mass (with sus-picion that it arises from the bowel)or unusual bloating.

In comparison to colonoscopy,barium enema is safer. The perfora-tion rate for barium enema is

1:25000, compared with 1:1700 forcolonoscopy. Again, it is difficult tocompare costs between barium stud-ies and endoscopy and they may beof comparable costs. However in

some centres barium studies aremuch more accessible to GPs andmay be arranged with much less de-lay for the patient than colonoscopy.

The disadvantages of barium en-ema are similar to those of bariumswallow/meal. It is not possible to takesamples or provide treatment as partof the procedure. The radiation expo-sure dose is 510 millisieverts com-pared with chest film 0.06 millisievertsand background radiation of 2

millisieverts per year. Users of ionis-ing radiation are required to informall women of childbearing age aboutthe risks of radiation in pregnancy.Pregnancy is a relative contraindica-tion to the use of radiation but gen-erally in the context of the bariumenema the urgency may be such thatit is not acceptable to delay or choosean alternative investigation.

Barium enema is not as compre-hensive or as accurate a method for

Above: Stomach cancer

Right : Normal enema

diagnosis of some conditions in com-parison to colonoscopy. For exam-ple, one study found that bariumenema x- ray missed 60% ofadenomatous polyps detected usinga colonoscope. It can be a danger-ous examination to perform in thepresence of toxic megacolon but thiscondition would in all likelihood besuspected by clinical presentation,

Above: Chrohns disease

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Above: Colon polyp

Right : Colon carcinoma

plain x-ray or preliminary film, orduring filling with barium and priorto pumping in air.

There are a number of potentialdifficulties that may arise out of abarium enema referral. The bowelpreparation is reasonably arduousand can make frail, elderly people feelquite unwell. People who are proneto constipation are occasionally notcleared adequately on the usualpreparation and need an extra day.

Rolling around/lying on the ta-ble is hard and uncomfortable (pa-tients need to be able to roll through360 degrees and lie prone and su-pine). A good indication is that aperson who can climb on to an ex-amination couch without too muchassistance can generally tolerate adouble contrast study.

As with barium swallow, the dis-comfort of air insufflation can trou-

ble some patients, and wherebuscopam injection is used to relaxbowel for better pictures, patientsmay experience some blurring of vi-sion. As patients need to be able tofollow instructions, there is a needfor an interpreter in non-Englishspeaking patients. There is also a ten-dency for barium to cause constipa-tion in the days following the proce-dure.

References

1. Salena B J , Hunt R H. Upper and lower gastrointestinal endoscopy: lower gastrointestinal endoscopy. Ch 56B, 11451151.

2. Winawer S J , Stewart E T, Zauber A G, Bond J H, Ansel H, Waye J D et al. A comparison of colonoscopy and double-contrast bariumenema for surveillance after polypectomy. National Polyp Study Work Group New England Journal of Medicine 2000;342:176672.

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