Barium meal follow through

v. Siva prakashBsc.MIT 3nd year Saveetha medical collegeChennai.

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The study called because it is performed following barium meal.....

For evaluating patients with suspected small bowel abnormalities

Small bowel – ileocaecal junction

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SMALL INTESTINEIs the longest part of alimentary canal Extends from pylorus of stomachileocecal junction Length = 6 m Diameter = 4 – 2.5 cm.

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Site :it occupies all abdominal regions

except epigastic and

hypochondriac region normallyFixation :it is stabilized

by mesenteryMesentery = peritoneal

fold attaching small intestine to posterior body wall

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Anatomical subdivisions :

a) Duodenumb) Jejunumc) Ileum

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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 intestineThe widest & most fixed partCurves around the head ofpancreasBegins at pylorus on right

side & ends at duodenojejunal junction on left side

Partially retroperitoneal

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Duodenum is divided into four parts :

a) First (superior) partb) Second (descending)

partc) Third (horizontal) partd) Forth (ascending) part First part of duodenum It is 5 cm longLies antiero-lateral to

body of L1 vertebraeMost movable part

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DuodenumSecond part: It is 8 to 10 cm long Descends along right

sides of L1 through L3 vertebrae

Third part : It is 10 cm long Crosses L3 vertebraFourth part of

duodenum Ascending

It is 2.5 cm longBegins at left of L3 &

rises superiorly as far as superior border of L2 and continues with jejunum

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JEJUNUM & ILEUMJejunum 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 leftupper quadrant & most ileum lies in right lower quadrant

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Wall of small intestine is made of the following layers :a) Serosa coatb) Muscular coatc) Submucosa coatd) Mucosa coat Serosa: made of peritoneumMuscularis: made of smooth muscle fibers arranged in

outer longitudinal & inner circular layersSubmucosa : contains loose CT & large venous plexuses

(submucosa of duodenum contains duodenal or Brunner’s glands)

Mucosa composed of a layer of epithelium, lamina propria & muscularis mucosa (Plicae circulares numerous in jejunum, Peyer’spatches present in ileum)

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Barium TechniquesIndirectSmall bowel follow

through....Dedicated small

bowel follow through...

Peroral pneumocolon.....

Retrograde small bowel ....

DirectEnteroclysis...

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Indication Abdominal pain and diarrhoea Small bowel obstruction Crohn’s disease Nasogastric tube/failed intubationMalabsorptionAnaemia/gastrointestinal bleedingAbdominal mass

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ContraindicationsColonic obstruction Suspected perforation Paralytic ileus

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Contrast mediaMedium density barium suspension (50-

60%w/v) Suspending agent to prevent flocculation and

maintain stabilityHigh density barium(200-250%) may produce

an appearance of fold thickening and clumping of small bowel

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Acid Baso4 suspension may produce spasm, enlarged folds and dilatation of duodenum & jejunum

Alkaline Baso4 suspension improves coating of valvulae and improves diagnostic accuracy

It is usually mixture of any flavour

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Why barium used It is an insoluble materialIt is high atomic no:56It is high density, It provides a positive contrast in x-ray It is radiopaque material Is not absorbed or metabolized Is eliminated intact from the bodyAlkaline BaSO4 suspension improve coating

valvulae

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Why iodine is not usedIs water soluble Diminish blood volume

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PreparationPurgative- Dulcolax 2tab HS (not in

suspected obstruction, acute crohn’s exacerbation, ileostomy)

Low roughage high fluid intake diet 48hrs prior

No food/fluid should be taken for 12hrs before investigation

No antispasmodics, codeine, tranquilizers 24-48hrs prior

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Barium follow-through examinationThis is performed following a barium meal

examination of the esophagus, stomach and duodenum

150ml 250%w/v—200ml 20-25%--250ml40-45%

As the barium column progresses through the small intestine large radiographs of the abdomen are taken at intervals

First one is taken with the patient supine about 15 minutes after the barium meal and shows the proximal jejunum

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The remaining radiographs are normally taken at half hourly intervals with the patient prone.

When the barium column reaches the caecum spot views of the terminal ileum are taken

It takes from 2 to 6 hours for the head of the barium column to reach the caecum

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Dedicated small bowel follow throughSingle contrast techniqueBarium 50-60% 600-900ml Drink as rapidly as possibleTo right lateral position 15-20minsThen prone filming done every 15-20min until

ileocaecal junction opacification notedTo demonstrate ileocaecal junction supine right

is best as ileum enters caecum posteromediallyAlways empty the bladderprior to these spot

films

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Single contrast techniquePositioning Purpose

First Right side down dependent

To aid gastric emptying

Second Prone To separate bowel loops

Third Right side up To visualize IC junction

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Periodic fluoroscopic examination and compression spot films are recommended

4 spot films for ileocaecal junction should be taken with variable degree of compression

Compression over bowel loops to avoid overlap thereby prevents efffacemen of mucosa and small lesions may not be missed

The abnormality must be shown in 2 spot films taken at different times to confirm persistence of lesion

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Overlap of contrast filled bowel loops in pelvis Overcome byTable head down30 degree caudal angled view of pelvisEmptying urinary bladder prior to filming ileal loops

Peristalsis can be increased by Metoclopromide, Neostigmine , Cholecystokinin, glucagon20-40ml sodium/meglumine diatrizoate or gastrograffin to

barium increases transit timeCold water-barium more palatable ,speeds gastric emptying

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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 1.5-2mm bowel wall depth 1-1.5mm

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BA Meal follow through:

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The pattern of the mucosal lining of the first part of the duodenum is different from the other parts. longitudinal pattern of the mucosa of the first part of the duodenum forming what is known as the duodenal cap This pattern is very similar to that of thepylorus of the stomach  This pattern changes to a more flecked appearence in the distal duodenum 

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Reflux examinationBarium and air refluxed through the ileocaecal

valve during a barium enema examination give good views the terminal ileum. Replaced by enteroclysis

The radiographs should be studied carefully and spot views of the distal ileum is taken if necessary

All of the small intestine can be examined by refluxing barium from the colon into the terminal ileum – the complete reflux examination

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doublecontrast barium enema examination (with refluxinto terminal ileum) shows carcinoid tumor in terminal ileum

Doublecontrast barium enema examination (with refluxinto terminal ileum) shows lipoma as smooth, ovoid, submucosal mass in distal ileum

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Peroral Pneumocolon examinationExcellent view of the terminal ileum and

caecum can be obtained by giving barium orally and when the head of the barium column has reached the ascending colon introducing air per rectum and refluxed in to distal ileum

Glucagon can be used to relax ileocaecal valve

This procedure shows Crohn’s disease and carcinoma of the caecum particularly well

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Per oral pneumocolon examinationIndications contraindicatns Terminal ileum porly

visualized on routine compresion spot films .

Clinical suspicon of Crohn disease with normal apearance of terminal ileum

abnormal apearance of terminal ileum on routine compresion spot films

history ileocolic anastomosis.

Recent colonic or rectal biopsy

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Advantages DisadvantagesEasily performedNo catheterisationPhysiologic transit

time can be assessed

Overlapping of barium filled bowel loops in pelvis

Poor distensionPartial or

intermittent bowel obstruction

Operator dependantTime consuming

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ComplicaionsLeakage of barium form unsuspected

perforationAspirationImpacted barium converts partial obstruction

in to complete obstrctionBarium appendicitis impaction at appx

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