IT IS USEFULL FOR ALL RADIOGRAPHY STUDENT

1. BARIUM FOLLOW THROUGH
& SMALL BOWEL ENEMA
PRESENTED BY:
RABIN PAUDEL
B.Sc. MIT 2ND YEAR
ROLL NO:49
IOM, MAHARAJGUNJ MEDICAL CAMPUS

2. Introduction
• Because the thin walled alimentary canal doesn't have
sufficient density to be demonstrated through surrounding
structures, its radiographic demonstration requires the use of
artificial contrast medium (barium).
• Barium examinations require use of high KVp technique to
penetrate barium (not <90).
• Barium follow through & small bowel enema are two basic
types of small bowel examination to examine small bowel in
its entirety i.e. to evaluate functional capabilities as well as
morphological abnormalities.
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3. Anatomy of the small intestine
• Extends from pyloric sphincter of stomach to ileoceacal valve,
where it joins large intestine at right angle.
• Lies in abdominal cavity surrounded by large intestine
• About 6.5 m long & diameter gradually decreases from about
3.8 cm in proximal part to approximately 2.5 cm in distal part.
• Wall contains 4 layers- serosa, muscle layer, submucosa &
mucosa. Mucosa contains finger- like projections called villi.
• Divided into 3 portions:
a) Duodenum,
b) Jejunum &
c) Ileum
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4. Duodenum
• About 25 cm long & widest part.
• Begin at pylorus & curves around the head of pancreas as “C”.
• Constitute 4 portions:
1. First (superior): duodenal bulb
2. Second (descending): common bile duct & pancreatic duct
usually unites to form hepatopancreatic ampulla, which opens
on greater duodenal papilla.
3. Third (horizontal or inferior)
4. Fourth (ascending): joins jejunum at a sharp curve called
duodenojejunal flexure & is supported by suspensory muscle
of duodenum (ligament of Treitz)
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5. Jejunum & Ileum
• Jejunum is the middle section of small intestine & is about 2.5
m long.
• Ileum is the terminal section about 4 m long, leads into large
intestine at ileoceacal valve.
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6. BARIUM
FOLLOW
THROUGH
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7. Introduction
• Barium Follow Through is designed to demonstrate 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 by oral administration of contrast media
(Barium)
• may be performed as a continuation of an upper
gastrointestinal (UGI) series or as a separate ,dedicated study
of the small bowel.
• Also known as barium meal follow through (BMFT) & small
bowel follow through (SBFT)
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8. Methods
• Single Contrast
• Double Contrast (with addition of an effervescent agent)
• Peroral Pneumocolon.
Note: Double contrast technique is normally adopted.
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9. Indications
• Crohn’s disease (most common)
• Pain
• Diarrhoea
• Loss of weight
• Anaemia (Gastro-intestinal Bleeding)
• Partial Obstruction
• Mal-absorption (Dyspepsia)
• Abdominal Mass
• Suspected Tubercular Lesion
• Lesions such as strictures, neoplasms, Mekels diverticulum
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10. Contraindications
• Complete Bowel Obstruction
• Suspected Perforation
• Paralytic ileus
• Very ill Patient
• Recently Operated Patient
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11. Contrast medium
• Barium sulphate solution 100% w/v 300 ml (150 ml if
performed immediately after barium meal)
• Usually given in 10-15 min increments or full at once
• Transit time through small bowel has been shown to be
reduced by the addition of 10 ml of gastrograffin to barium.
• In children,3-4 ml/kg is suitable volume of contrast.
• In situations where barium is contraindicated, non-ionic water
soluble solutions are used.
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12. Equipment
• High power x-ray generator
• Spot film device
• Fluoroscopic unit with II TV system
• Tilting type of x-ray table
• Over- couch x-ray tube.
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13. Patient preparation
• Accurate & clear history must be obtained from pt. for e.g., in the
case of insulin- dependent diabetes, the best time for stopping eating
can be arranged.
• A low residue- diet for 2 days prior to the examination.
• A laxative should be taken on the evening prior to the examination.
• NPO for 6 hrs prior to examination
• Metoclopramide 20 mg orally given 20 min before or during the
examination to enhance gastric emptying.
• Pt’s bladder must be empty before & during procedure to avoid
displacing or compressing ileum.
• Pt must be informed that the barium may taste chalky.
• Pt must remove all the clothing & jewelry & wear a hospital gown.
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14. Preliminary Film
Plain radiograph of the abdomen.
• To see bowel preparation.
• To rule out contraindication.
• helps in assessing any abnormalities of gas filled bowel loops.
• If residual fecal matter presence-examination should be
cancelled.
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15. Single Contrast Technique
• Patient is asked to drink Barium Suspension as rapidly as
possible and then put the patient on right side.
• Give dry food if transit time is slow.
• If follow through is combined with barium meal, glucagon is
used instead of buscopan for duodenal cap view.
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16. Filming
• Prone PA films of the abdomen are taken.
 The first radiograph is taken 10 min following the drink,
with the second image at 30 min stage. Then the
radiographs are taken at 30 min intervals until the barium
has reached terminal ileum.
 Pressure on the abdomen helps to compress abdominal
contents so that the loops of small bowel are separated.
Thus for better radiographic quality, prone position is used.
• Spot films of the terminal ileum are taken supine.
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17. 15 min post
contrast film
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18. 30 min post
contrast
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19. 1 hour post
contrast film
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20. Supine films
• Compression pad is used in right iliac fossa to displace any
overlying loops of small bowel that are obscuring terminal
ileum.
• Supine position is used for
 Superior & lateral shift of barium filled stomach
 For visualizations of retrogastric portions of duodenum &
jejunum
 To prevent possible compression overlapping loops of
intestine.
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21. The leading edge of
barium normally takes
1/2 to 4-hours to reach
ileoceacal junctions.
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22. Additional Films
To separate loops of small bowel
-compression with fluoroscopy
-Oblique view
-x-ray tube Angled into the pelvis.
-Patient tilted head down.
To demonstrate Diverticula
-Erect (Reveals fluid level within the diverticulum
by CM).
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23. Double contrast Technique
• Same as single contrast study.
• Gas producing agent is given when head of Barium column
reaches the caecum. This should generate about 750-1000 ml
of gas.
• Pt is placed on the left side slightly head down (Tredelenberg
position) to allow the gas to leave the stomach & enter the
small bowel.
• Compression radiographs with patient in supine or oblique
positions are taken.
Modifications: Lacquer- coated effervescent tablets to provide a
select release of gas in small bowel.
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24. Advantages of DC
• Better distension.
• Separation of loops.
• Improved mucosal detail.
• Effective for young patients & those who are in able to
swallow the enema tube.
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25. Peroral pneumocolon
• The peroral pneumocolon examination is a method for
obtaining a double-contrast image of the terminal ileum and
right colon by insufflating air in conjunction with a
conventional barium follow-through examination.
• The indications for the peroral pneumocolon examination are
(1) a poorly seen terminal ileum,
(2) clinically suspected inflammatory bowel disease with an
apparently normal terminal ileum, and
(3) an abnormal terminal ileum with equivocal fistulae
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26. Technique
• When orally ingested barium reaches the right colon, air is
advanced through a small catheter inserted into the rectum.
Spot views of the different areas of small bowel especially the
terminal ileum are taken. Compression may be used.
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27. A, Terminal ileum was poorly demonstrated on conventional spot
films. B, It was seen well on Peroral pneumocolon, which shows
deformed, irregular caecum, ileoceacal valve, and distal terminal
ileum.
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28. Disadvantages
• Requires colon cleaning for an adequate study.
• Uncomfortable procedure for the patient.
• Reflux sometimes not possible in~10% cases.
• Long procedure time.
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29. Barium Meal + Follow-Through
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30. After-Care
• Inform the pt that his bowel motions will be white for few
days after the examination & may be difficult to flush away.
• Advise to drink adequate volume of water to avoid Barium
impaction. (Laxative may be taken if required)
• Pt should not leave the department till any blurring of vision
produced has resolved.
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31. Complication
• Leakage of Barium suspension from unsuspected perforation.
• Aspiration of Barium.
• Conversion of partials obstruction into complete obstruction
by impaction of Barium.
• Barium Appendicitis (if Barium impacts in Appendix)
• Side effect of pharmacological agents used.
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32. Advantage of BMFT
• Easily performed.
• No discomfort/intubation to the patient like Enteroclysis.
• It is a physiological process. Hence transit time can be
assessed.
Disadvantage of BMFT
• Overlapping of Barium filled bowel loops in the pelvis.
• Poor distension of bowel loops.
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33. Ileo-vesical Fistula
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34. Meckel’s diverticulum
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35. Early Crohn's disease
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36. SMALL
BOWEL
ENEMA
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37. Introduction
• Small bowel is demonstrated following duodenal intubation
rather than by oral administration of contrast as in BMFT.
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38. Indications & Contraindications
• Same as barium follow through
– Crohn’s disease (most common)
– Pain
– Diarrhoea
– Loss of weight
– Anaemia (Gastro-intestinal Bleeding)
– Partial Obstruction
– Mal-absorption (Dyspepsia)
– Abdominal Mass
– Suspected Tubercular Lesion
– Lesions such as strictures, neoplasms, Mekels diverticulum
• Usually in case of equivocal follow through
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39. Methods
• Single contrast- Enteroclysis
• Double contrast
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40. Contrast medium
• Enteroclysis: Barium sulphate solution 70 % w/v is diluted to
give 1500 ml of 20 % solution.
• Double contrast: 600 ml of 0.5 % methylcellulose after 500 ml
of 70 % w/v barium sulphate solution.
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41. Equipment
• Same as barium follow through.
• For contrast administration, two types of tubes are available:
 Bilbao- dotter tube with guide wire
 Silk tube with tungsten filled guide-tip.
It is made up of polyurethane & the
stylet & internal lumen of the tube are
coated with water- activated
lubricant to facilitate the smooth
removal of the stylet after insertion.
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Silk tube

42. Patient preparation
• A low residue- diet for 2 days before the examination.
• A laxative should be taken on the evening prior to the
examination.
• NPO for 6 hrs prior to examination
• If the patient is taking any antispasmodicdrugs, they must be
stopped 1 day prior to examination.
• Amethocaine lozenge 30 mg, 30 min before the examination.
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43. Preliminary film
• Plain abdominal film if a small bowel obstruction is suspected.
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44. Intubation technique
• The patient sits on the edge of x-ray table. The pharynx is
anaesthetized with lignocaine spray.
• The tube is then passed through nose or mouth with brief lateral
screening. If per nasal approach is planned the patency of the
nasal passage is checked by asking the patient to sniff with one
nostril occluded.
 The Silk tube should be passed with the guide wire pre-
lubricated & fully within the tube.
 For Bilbao- dotter tube, the guide wire is usually introduced
after the tube tip is in stomach.
• The patient is asked to swallow with neck flexed as the tube is
passed through the pharynx. The tube is then advanced into the
gastric antrum.
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45. Intubation technique
• The pt then lies down & the tube is passed into duodenum.
 Lie the pt on the left side so that the gastric air bubble rises to
the antrum, thus straightening out the stomach.
 Advance the tube whilst applying clockwise rotational motion
(as viewed from the head of the pt looking towards feet).
 In the case of the Bilbao-Dotter tube, introduce the guide wire.
 In the case of the silk tube, lie the pt on right side, as the tube
has a tungsten-weighted guide tip which will then tend to fall
towards antrum.
 Get the pt to sit up to overcome the tendency of the tube to coil
in the fundus of stomach.
 Metoclopramide (20 mg i.v.) can be used.
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46. Intubation technique
When the tip of the tube has
been passed through pylorus, the
guide wire tip is maintained at
the pylorus & the tube is passed
over it along the duodenum to
the level of ligament of Treitz.
The tube is passed as far as the
duodenojejunal flexure to
diminish the risk of aspiration
due to reflux of barium into
stomach.
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47. Single contrast technique
•Barium is then run in
quickly at the rate about 75
ml/min & spot films are
taken of the barium column
& its leading edge at the
regions of interest until the
colon is reached.
•Fluoroscopy is performed
during infusion & images are
recorded using digital
acquisition, 100/105 mm film
or full size radiographs as
required.
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48. Double contrast:
•Methylcellulose is infused
continuously(100 ml/min) after
initial bolus of barium
(100ml/min), until the barium
has reached the colon.
•The tube is then withdrawn,
aspirating any residual fluid in
the stomach.
•Finally, prone & supine
abdominal films are taken.
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49. Following single contrast
method, air may be
introduced via catheter
once barium has reached
caecum to provide double
contrast effect.
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50. Modification of technique
• In patients with malabsorption, especially if an excess of fluid
has been shown on the preliminary film,
 The volume of barium should be increased (240-260 ml).
 Compression views of bowel loops should be obtained
before obtaining double contrast.
 It is important to obtain the images of duodenum & the
catheter tip should be sited proximal to the ligament of
Treitz.
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51. Aftercare
• Nil orally for 5 hrs after the procedure
• The patient should be warned that diarrhoea may occur as a
result of large volume of fluid given.
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52. Complications
• Aspiration
• Perforation of the bowel owing to manipulation of the guide
wire.
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53. Advantages
• Gives better visualization of the small bowel unobstructed by
overlying barium filled stomach & duodenum.
• Rapid infusion of large, continuous column of contrast directly
into jejunum avoids segmentation of barium column & does
not allow time for flocculation to occur.
• Hypotonia caused by fluid overload makes demonstration of
lesions easier because abnormalities are more clearly visible
when the intestine is distended rather than contracted.
• As a result of the dilatation, minimal strictures, small sinus
tracts and fistulas, and minimal extrinsic compressions can be
visualized.
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54. Disadvantages
• Intubation may be invasive & unpleasant for the patient & may
occasionally prove difficult.
• It is more time-consuming for the radiologist.
• There is higher radiation dose to the patient (screening the tube
into position).
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55. References
• A guide to radiological procedures- Chapman & Nakielny
• Clark’s special procedures in diagnostic imaging
• Merrill's atlas of radiographic positioning & procedures
• Encyclopedia of radiographic positioning, vol.2
• Various internet sources
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56. Questions???
• What are the contrast medium for barium follow through &
small bowel enema?
• What are the indications for barium follow through & small
bowel enema?
• What are the contraindications for barium follow through &
small bowel enema?
• What are the main differences between barium follow through
& small bowel enema?
• What are the complications of barium follow through & small
bowel enema?
• Describe the film sequence for BMFT.
• What is the role of compression pad in BMFT?
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