Barium Enema Flashcards
Why are lower GI studies performed
to diagnose pathological conditions of the large intestine
contrast of Lower GI
- Single contrast using barium only
- Double contrast using barium and room air/carbon dioxide - carbon dioxide is more rapidly absorbed compared to the nitrogen in room air (produces less cramping!)
indications
- Change in bowel habits
- Abdominal pain
- Palpable Mass
- Ulcerative Colitis / Crohn’s Disease
- Intussusception
- Volvulus
- Polyps
- Diverticulitis vs. Diverticulosis
- Fistulas
- R/O Ca
- Hirschsprung’s/ Congenital Aganglionic Megacolon
slide 6
“apple core” lesions
- radiographic appearance of cancer
slide 7
diverticulosis - out pouching of the bowel walls
- radiographic appearance of low fiber/low residue diet - due to constipation
contraindications to barium
- Suspected perforation
- Known bowel obstruction
- Immediately prior to surgery
- Bowel biopsy in past 24hrs
- Recent pelvic irradiation
- Poor bowel preparations
equipment
- Fluoroscope
- Over table tube
- Enema tube and bag
- O2 or CO2
- IV Pole, towels, rags
Bowel preparation
- It is essential that the bowel be completely cleansed of stool - retained “stool” can resemble polyps or obstruct visualization of anatomy or pathology (prevents the barium from sticking to the bowel wall)
- Scout radiograph - check for stool and assess gross anatomy
slide 12
residual stool mimicking pathology
patient prep
- Low residue diet 3 days prior
- Fluids only 24 hrs prior
- Laxative day before – this will be hospital specific
- Possible suppository or cleansing enema the morning of the exam
- Remove all clothing - hospital gown
- Infants – No Prep
condraindication to prep
- Gross bleeding
- Severe diarrhea
- Known obstruction
- Inflammatory conditions (appendicitis)
Patient care
- Uncomfortable
- Pain (in some cases)
- High anxiety
- Embarrassed- keep them covered at ALL TIMES!!
- Fear
- Abdominal cramping
- Inform the patient of the various positions throughout the exam
- The patient will feel the urge to defecate
- Give breathing instructions
Anticholinergic drugs
Administered intravenously before enema
Buscopan or glucagon
- Reduce motility
- Relieve spasm, allow bowel to expand
contraindications to anticholinergic drugs?
- cardiac disease and glaucoma
glucagon
- Hormone found in the pancreas - used to raise blood sugar an antispasmodic medication for imaging
- Used if patient has contraindication to buscopan
- 1mg IV
Contraindicated for diabetics
double air contrast study
- patient will experience much more discomfort
- reassure the patient
- Assist the patient with any difficult movements
- Remember to deflate the cuff prior to removing the enema tip
- Assist the patient to the bathroom
- Give the patient clean towels and extra gown
cold barium
- 41F or 5C
- Produces less irritation
- Has a mild anesthetic effect – relaxes colon
- Stimulates tonic contraction of the anal sphincter making it easier to retain
warm barium
- 85-90F or 29-30C
- Maximum patient comfort
- Warm in a sink of warm water
common enema tubes
- disposable rectal retention tip
- double lumen tube
- inflatable balloon - inflater – 90 mL of air (1 full squeeze)
abnormal anus considerations
Use a Foley catheter
- Severe hemorrhoids
- Fissures
- Stricture
slide 23
know which tip is for barium only versus double contrast
slide 24
what is squeezed for what
slide 26 device
used for CO2 versus room air
enema tip insertion procedure
Step 1 - check that the retention balloon works
Step 2- Describe the tip insertion procedure to the patient. Answer any questions.
Step 3- Place patient in Sim’s position - expose only anus, keep patient covered – modesty
Step 4- Shake enema bag to ensure proper mixing of suspension. Allow barium to flow through the tubing to remove any air in the system – clamp the tube
Step 5- Wearing gloves, coat enema tip well with water-soluble lubricant.
Step 6- On expiration, direct enema tip anteriorly toward the umbilicus approximately 1 to 1 ½ “
Step 7- Advance tip superiorly. The total insertion should not exceed 4” or 10 cm. Do NOT force enema tip – any resistance, call the Radiologist
Step 8- May tape tubing in place to prevent slippage. Inflate retention tip when directed by radiologist.
Step 9- Ensure IV pole/enema bag is no more than 24 inches (60 cm) above the table and tubing stopcock/clamp is in the closed position - no barium flows into the patient at this time.
sims position
reduces abdominal pressure and relaxes abdominal muscles
safety concerns
- Never force enema tip into rectum
- The height of the bag does should not exceed 24” (60cm) above the level of the anus
- Verify water temperature - never hot
- Escort patient to washroom after study
more common complications
Rectal PERFORATION
- in infants and elderly
- if obstructing neoplasm present
- if bowel wall ulcerated
- patients on steroids
hypersensitivity for barium enemas
latex sensitivity
single contrast method
- Demonstrates general anatomy of colon and tonus
- Thinner barium is used
Air contrast
- Double contrast (thicker barium is required)
- Air distends the colon
- Optimum visualization of the barium-coated mucosa - best demonstrates polypoid lesions
** areas best demonstrated are air-filled and barium coated**
Air-contrast barium single stage procedure
- Barium and air are introduced together
- Reduces the time for the exam and radiation exposure
Air-contrast barium two stage procedure
- Barium is instilled until it fills the intestine to the splenic flexure
- Air is instilled to push the barium through to the right side
- The enema bag is lowered to the ground and as much barium is drained as possible
- Second stage consists of filling the entire colon with air that pushes any barium forward leaving behind only the barium coating the wall
if there is ever a Ba enema and upper GI in the same day what goes first?
Ba enema
order of procedures
- non-contrast
- IV contrast
- Ba enema
- upper GI exam
overhead images
- PA or AP
- PA Axial or AP Axial
- RAO & LAO or RPO & LPO
- Lateral rectum
- Rt. and Lt. Lateral Decubitus views
- Erect - obliques for flexures (spot imaging or fluoro) - post evacuation (full length)
PA or AP
- CP - iliac crests
** trendelenberg - separates redundant and overlapping loops of bowel**
redundant mean?
extra bowel
- massive loops cause constipation
PA oblique (RAO)/ AP oblique (LPO)
- obliquity 45 to table
- CR - 1-2” lateral to midline on elevated side
- CP - level of iliac crests
best demonstrates the hepatic flexure, ascending colon and sigmoid colon
PA oblique (LAO)/ AP oblique (RPO)
- obliquity 35-45 to table
- CR - 1-2” lateral to midline on the elevated side
- CP - level of iliac crests (or a bit above the crests)
best demonstrates the splenic flexure, descending colon and cecum
how do we rotate patient to get gravity to move the barium through the entire large bowel
- stomach
- left side
- stomach
- right side
- back
- left side
Lateral rectum
- right or left side down
- CR - posterior to mid coronal plane
- CP - similar to lat sacrum/coccyx
- remove enema tip
- often done prone with horizontal CR ventral decubitus position
intussusception meaning
telescoping of the bowel into itself
- inner bowel risk of dying because of pinching off blood supply
- can cause obstruction
Right lateral decubitus view
- may be done AP or PA
- pt. lies on right side - arms above head
- elevated on radiolucent sponge
- use a portable grid
- CR - horizontal beam
- CP - 2” above iliac crests and along MSP
best demonstrates lateral wall of descending colon and medial wall of ascending colon
Left lateral decubitus view
- lying on left side AP or PA
- elevated on radiolucent sponge
- use a portable grid
- CR - horizontal beam
- CP - iliac crests along MSP
best demonstrates lateral wall of ascending colon and medial wall of descending colon
why is the rt. lateral decubitus CP higher?
because splenic flexure is more superior
AP Axial or PA Axial
- “butterfly”
- AP 30-40 cephalad - CP - 2” below ASIS in the MSP
- PA 30-40 caudad - CP - PSIS in the MSP
best demonstrated the recto-sigmoid area
Post examination
- Place bag on the floor and drain as much barium as possible
- Escort patient to the washroom to evacuate more barium and as much of the gas (air) as possible
- May perform final image(s) labeled: post evac
- Patient will be given post care instructions and sent to the changeroom
Post evacuation views
- PA or AP - erect or supine
- CP - at iliac crest for recumbent view
- CP - slightly lower for erect view
Colostomy imaging methods
- S/C or D/C enema
ostomy named by?
area of surgery
- If the opening is from the colon = colostomy; if it is from the ileum = ileostomy.
colostomy imaging
- The stoma (loop of bowel brought to the surface) could be temporary or permanent.
- Be sensitive to the patient and be professional at all times.
- Never use the prone position
colostomy imaging equipment
- As per Ba Enema
- Stomal disks to prevent leakage
- LAIRD irrigation tips
- Foley catheter - inflate balloon and use as a seal
- Stoma fragile and high risk of perforation
- BE CAREFUL
what does cathartic mean?
laxative
Patient prep for colostomy imaging?
- Irrigation of the stoma the night prior and in a.m.
- NPO after 10pm evening before
- Patient to supply clean pouch or seal for after enema - May reuse existing one
technique for colostomy imaging
- Patient supine – depends on site of colostomy
- Remove and discard dressing and/or bag
clean skin around stoma and place gauze over stoma until ready - Lubricate tube, insert (patient may assist)
- Fluoro, spot images, over table images
Post care of colostomy enema
- possible irrigation of colostomy by radiologist
- patient can resume normal diet
- encouraged to drink lots of fluids
