Radiological aspect

1. BARIUM ENEMA
DR ATHUL D
JR MDRD
KMC

2. PREPARATIONS OF BARIUM

3. WEIGHT BY WEIGHT SYSTEM:
Specified weight of barium is used & enough water
added to obtain certain total weight.
Eg:
30% w/w suspension =
30 gm of barium + 70 gm of water = 100gm.

4. WEIGHT BY VOLUME SYSTEM
• A specified weight of barium sulphate is
determined and enough water added to obtain a
certain total volume.
• Eg:
80% w/v suspension =
80gm barium sulphate + enough water = 100ml

5. Using percentage by weight (w/v)
Formula
The formula for weight percent (w/v) is: [Mass of solute (g) /
Volume of solution (ml)] x 100
Example
A 10% NaCl solution has ten grams of sodium chloride dissolved in
100 ml of solution.
Procedure
Weigh 10g of sodium chloride. Pour it into a graduated cylinder or
volumetric flask containing about 80ml of water. Once the sodium
chloride has dissolved completely (swirl the flask gently if
necessary), add water to bring the volume up to the final 100 ml.

6. • Not recommended
• A unit volume of dry barium can vary,
depending on the degree of packing.

7. • IT IS THE RADIOGRAPHIC STUDY OF THE LARGE BOWEL BY ADMINISTRATION
OF THE CONTRAST MEDIUM THROUGH THE RECTUM.
CONTRAST
Barium sulphate .
Particle size - 0.6-1.4 to 4-50 microns
Particles are coated with various agents to -achieve rapid flow ,
-good mucosal adhesion ,
-adequate radiographic density

8. DIET
• A low fiber diet for 2 days prior
• should not have any fatty fried foods.
• should not have vegetables and fruits.
• can have egg, meat, dal and soups.
• Iron containing medication should be stopped 2 days
before the examination because they make stools adhere
to mucosa

9. BOWEL WASH
• Previous night.
• In the morning, 2 hours prior to the procedure.
• Pass the tube beyond the rectosigmoid junction and infuse about
1.5-2 liters of fluid allowing evacuation. Repeat this till efflux clear of
any fecal matter. This is done for removal of smaller particles.
• Patient lies: Left lateral position-receiving first 500 ml.
Prone position-receiving second 500 ml.
Right lateral position-receiving third 500 ml.

10. PREPARATION OF THE PATIENT SHOULD NOT BE DONE IN
• 1. Diarrhoea.
• 2. Total obstruction.
• 3. Paralytic ileus.
• 4. Children less than 8 yrs. of age

11. POSITION

12. DOUBLE CONTRAST BARIUM ENEMA (DCBE)
Preliminary Films
Plain radiograph of the abdomen is essential and helps in
assessing any abnormalities of gas filled bowel loops. In the
presence of residual fecal matter, double contrast
examination should be cancelled.

13. INDICATIONS
1. Preferred method for routine examination.
2. High risk patients - rectal bleeding, previous H/ o carcinoma or
polyp, family H/ o colorectal cancer or polyposis.
3. Demonstration of sinuses or fistulas.
4. Patient with severe diverticulosis, polyposis or diarrhoea.
5. Presence of obstruction.
6. Reduction of an intussusception

14. CONTRAINDICATION
1. Allergy to barium suspension.
2. Peritonitis.
3. Acute or fulminating inflammatory colon disease.
4. Debilitated, unconscious, inability to cooperate.
5. History of recent rectal/ colonic biopsy.

15. Barium High density (slower flowing, better coating) 75%to 95% w/v.
•
position with left side down oblique - splenic flexure.
patient prone –air inflated - frontal view of rectum & left lateral taken.
Then oblique right side down view for rectosigmoid junction is taken.
barium comes into transverse colon turn the patient left side up - barium
enters right sided colon and reaches the ileocaecal junction
the right side up, more air is pumped till air outlines the ileocaecal junction.
Take spot films for flexures and ileo caecal junction.

16. Disadvantages of Double
Contrast Over Single Contrast
• Difficult in uncooperative
patients.
• Fistulae/sinuses can be
missed.
• Effacement of submucosal
detail of the colon and
overlooking of
annular /polypoid lesion is
possible.
Advantages of Double
Contrast Over Single
Contrast
• Better surface details.
• Surface lesions can
be demonstrated to the
best effect.
• Easy unraveling of
the colon as it is
possible to look
through loops.

17. SINGLE CONTRAST BARIUM ENEMA (SCBE)
Indications
1. Uncooperative, very debilitated or immobile
patient.
2. Evaluation of acute obstruction/volvulus.
3. Reduction of intussusception.
4. Show configuration of colon.
5. Where only gross pathology is to be excluded.
Contraindications
1. Allergy to barium suspension.
2. Risk of perforation.
3. Peritonitis.
4. Suspicion of acute/fulminating
ulcerative colitis.
5. Following a recent deep
biopsy.

18. Barium suspension : Low density15% to 20% w /v
In the prone position, pelvis tilts forward, sacrum lies parallel to the film and
foreshortening of rectum is prevented.
Tube is placed in the rectum with the patient in left lateral position.
When rectum is full, a lateral view is taken.
patient is put prone with the infusion running, the frontal film of the
rectum is taken
The patient is kept prone with right side down oblique position for
rectosigmoid junctions

19. Now the patient is kept prone oblique with left side down.
Splenic flexure opens out and spot view of splenic flexure is taken.
patient is turned right side down oblique and spot films of hepatic
flexure taken
as the reflux across ileo-caecal junction takes place, the tube is clamped and
ileo-caecal spot films are exposed

20. ABSOLUTE CONTRAINDICATIONS FOR BOTH DCBE AND SCBE
• Toxic megacolon.
• Pseudomembranous colitis.
• If rectal biopsy has been done in the previous 5 days, it is preferable
to wait for 7 days.
• Paralytic ileus.
• Difficulty to pass tube in rectum. For example, inflammed piles,
growth etc.

21. SPECIAL BARIUM ENEMA STUDIES
Sigmoid Flush
In severe diverticular disease to improve visualization of affected bowel.
500-700 ml of dilute barium suspension is run in at the end of standard DCBE
and spot radiographs are taken of the filled sigmoid and descending colon.

22. COLOSTOMY ENEMA
• A non-wash out bowel preparation is strongly advised in
patients with a colostomy. Standard barium suspension
may be used. Catheter is advanced for about 15 cm
through the nipple and is then inserted into the stoma.
The suspension is run through the main tube and gas is
introduced through the sidearm.

23. INSTANT BARIUM ENEMA
shows the extent and severity of known colitis. (U.C and Chrons)
No bowel preparation is required as residue does not accumulate in
a segment of active colitis
Colon should be filled, rectum is drained and gas is very gently
insufflated

24. WATER-SOLUBLE CONTRAST ENEMA
Gastrografffin (meglumine diatrizoate) or similar products are used as enema contrast media for
certain conditions.
Indications
1. Intestinal perforation due to diverticulosis, perforated carcinoma, leaking anastomosis and
abdominal stab wounds communicating with colon.
2. Fistulas (vesicocolonic, vaginocolonic)
3. Softening of meconium in newborns and to relieve faecal impaction in adults.
Hyperosmolar nature of gastrograffin may produce severe dehydration, shock and death in:
• hypovolemic infants.
• sick children.
• very old and very ill

25. Barium Enema
Double contrast barium enema of
the colon
Adenoma
Sigmoid
Rectum
Carcinoma
Barium filled colon revealing a
carcinoma

26. • Colonic carcinoma on single-
contrast barium enema.
• This oblique compression spot
image of the splenic flexure shows a
• polypoid, ulcerated carcinoma of
the distal transverse colon.
• Careful patient positioning and the
use of compression are critical
components of this examination

27. • Small colonic polyp on compression
spot image
• from a single-contrast barium enema.
Oblique compression spot
• image of the splenic flexure shows an
8-mm colonic polyp (arrow).
• This small polyp was not seen on other
images of the same area when
compression was not applied.

28. With the patient in the supine position, there is a
lobulated filling defect in the distal rectum. The
plaque like carcinoma is therefore on the
dependent (posterior) wall
With the patient turned into the prone position,
the carcinoma is now etched in white because it
is on the nondependent (anterior) surface

29. • The stalactite phenomenon.
Radiograph of the colon with the
patient in the upright position shows
a long droplet of barium (arrow)
hanging from a haustral fold

30. • A. When the dome of
the hat (arrow) points
away from the long axis
of the bowel, it is a
diverticulum.

31. • When the dome of
the hat points
toward the lumen of
the bowel, it is a
polyp

32. • Mexican hat sign. Typical
appearance of a pedunculated polyp
seen end-on. The outer ring
represents the head of the polyp,
and the inner ring represents the
stalk

33. • Depressed lesions on the dependent
and nondependent surfaces. In a
segment of colonic diverticulosis,
diverticula on the dependent
surface are filled with barium,
whereas diverticula on the
nondependent surface are etched in
white.

34. Barium pool obscures polyp in splenic flexure. (a) Spot radiograph
obtained with the patient in a right posterior oblique position shows
the splenic flexure. The barium pool obscures the en face mucosal
detail (b) Spot radiograph obtained with the patient in an erect right
posterior oblique position shows a 7-mm polyp in splenic flexure.

35. Spot radiograph of the splenic
flexure with the patient in an
erect right posterior oblique
position. Diverticula are filled
with barium (short arrows)
and coated with barium (long
arrow).

36. Spot radiograph of the splenic flexure with the
patient in a horizontal right posterior oblique
position. The contour of the descending limb is
sacculated. Subtle mucosal ulceration is
manifested as shallow barium-filled ulcers
surrounded by radiolucent halos (arrows).

37. sigmoid colon shows a 1.9-cm
polypoid adenocarcinoma The mass
is manifested as a barium-etched
hemispheric line (solid arrows)
surrounding tiny radiolucent tumor
nodules outlined by barium in the
interstices of the tumor;
representative nodules are
identified by the open arrow. The
normal mucosal surface is
featureless and gray.

38. patient in a left-side-down position
(left lateral view) shows the rectum
early in the examination. At the
edge of the barium pool, there is a
7-mm lobulated radiolucent filling
defect (arrow). The enema tube tip
obscures the distal rectum

39. U.C VS CROHN’S DS
Mucosal changes-
• Symmetrical lesions
• Granularity seen
• Psuedopolypoidal &
postinflammatory polyps seen
Mucosal changes-
• Aphthoid ulceration- linear, transverse,
serpigenous or rounded
• Asymmetrical skip lesions
• Discrete superficial ulceration with
normal background mucosa
• Fissuring ulceration

40. Configuration of bowel
wall
• Blunted /obliterated
haustra
• Generalized narrowing
& shortening
• Widened presacral
space
• Stricture formation ‘coz
of smooth muscle
hypertrophy
Configuration of bowel
wall
• Localized deformity
pseudodiverticula
formation
• Stricture formation-
asymmetrical with
sacculation & secondary
to ulceration at
antimesentric border

41. DISTRIBUTION OF LESION
• Rectum involved
• Continuity in lesions
noted Left side of colon
predominantly
• Reflux ileitis – 10-15cm
of ileum is featureless
,dilated & with granular
mucosa & ulceration .I-c
valve is rigid patulous
• Rectal sparing
• Discontinous lesions –
mouth  anus , right
sided colon terminal
ileum MC involved
• Multiple anal fistulas
noted

42. The
granular
mucosa
typical of
UC. Note the
intact
mucosal line.

43. it an acute
attack of UC
with collar stud
ulcers (arrow)
protruding
through the
mucosal line
(arrowhead).

44. Aphthoid ulcers
(arrows)

45. Filiform
postinflammatory
polyposis (arrow)
following an acute
attack of UC. The
mucosal surface and
haustration are normal
as the colitis was
inactive.

46. Patulous, rigid
ileocaecal valve
with associated
terminal ileal
granularity ('back-
wash ileitis') in a
patient with
ulcerative colitis

47. Innumerable aphthoid ulcers in Crohn's disease

48. Barium enema
showing the
typical
pseudodivertic
ula found in
crohn’s
disease

49. Instant enema in Crohn's
disease demonstrates
extensive 'cobblestoning' due
to linear ulceration and
mucosal oedema. Note the
rectum is relatively spared but
contains aphthoid ulcers

50. Long stricture in
Crohn's disease. A
long segment of
narrowing is seen in
the ileum just proximal
to the site of an
ileocolic anastomosis
in a patient who had
undergone a previous
resection for Crohn's
disease.

51. Instant enema in a patient
with ulcerative colitis
reveals fine,
continuous, symmetrical,
left-sided ulceration.

52. Classical splenic
flexure 'thumb-
printing'
diagnosing
ischaemic colitis.

53. Splenic flexure sacculation
and stricturing as sequelae to
ischaemic colitis.

54. Radiation-induced colitis. A large, discrete
penetrating ulcer is visible (arrow).

55. HIRSCHPRUNG’S DISEASE
• .
Hirschsprung's disease -- segmental areas of contraction
in the long aganglionic bowel segment.
Plain radiograph –extensive fecal build up outlining the
dilated recto sigmoid
Water sol contrast enema—a short , narrow ,
abnormally contracted segment leading into the funnel
of the transition zone & dilated normal proximal bowel

57. •Thank you