Barium enema is a radiographic procedure used to examine the large bowel. It involves inserting barium sulfate into the rectum to coat the colon walls. There are two main techniques - double contrast uses both barium and air to better visualize the mucosal surface, while single contrast uses only barium. It is used to screen for and evaluate colon cancer, inflammatory bowel disease, and other conditions. Key steps in the procedure and patient preparation are outlined. Normal and abnormal findings seen on barium enema are described, including surface patterns, folds, protruding lesions like polyps, and depressed lesions like ulcers.

1. BARIUM ENEMA
PROCEDURE AND PATTERNS
DR. J K PATIL
Prof. department of Radio-diagnosis,
DY Patil medical college, hospital & research institute
Kolhapur

2. • It is the radiographic study of the large bowel by administration of
barium through the rectum.
• The major advantage of barium enema is its ability to examine the
entire colon.
• It is reasonably accurate, minimally invasive and requires no sedation
on routine basis.

3. • INDICATIONS:
Screening for colon cancer
Inflammatory bowel disease
Diverticular disease
Inconclusive colonoscopy
Assessing integrity of rectal anastomosis is prior to take down of diverting colostomy
or ileostomy
• CONTRAINDICATIONS
Toxic megacolon
Recent biopsy
Rigid endoscope within 5 days
Flexible endoscope within 24 hrs
Generalized peritonitis

4. METHODS
DOUBLE CONTRAST SINGLE CONTRAST
• The method of choice to demonstrate
mucosal pattern.
• The primary aim in a double contrast
study is to achieve good mucosal
coating.
• Preferred in high risk patients- rectal
bleeding, anemia, weight loss, family
history of carcinoma / polyp,
suspected IBD.
• Contrast medium - high density barium
suspension – 60-120% w/v and a kilo
voltage of about 90 is used.
• simpler, shorter and does not require
rigorous maneuvers.
• Preferred in very young, very old, sick
and disabled patients.
• In suspected obstruction and in
evaluation of distal colon after
colostomy
• Contrast medium - low density barium
suspension - 12-25% w/v, and a kilo
voltage of 100 -110 is used.

5. Patient preparation:
For 3 days prior to examination
Low residue diet.
On the day prior to examination
Fluids only
Drink plenty of water to prevent dehydration.
Magnesium citrate solution or Dulcolax tablets for 2 days.
A tap water cleansing enema of 1500 ml on the morning of the barium
enema examination.

6. Procedure of double-contrast enema
The quality of the images depends on
- mucosal coating which in turn depends on the barium suspension.
- distension ( should just efface the normal mucosal folds )
- projection ( ideally without any overlapping loops and with lesions
in profile )

7. Procedure
• A scout film is taken of the AP- if retained stool is present consider
rescheduling.
• The patient lies on their left side with right leg flexed in Sims position,
and the catheter tip is lubricated and is inserted gently into the
rectum. The insertion should not exceed 3 to 4 cm. It is taped firmly
in position.
• Inflate the rectal balloon only if necessary.

8. • Connections are made to the barium reservoir and the hand pump for
injecting air.
• An intravenous injection of Buscopan (20 mg) or glucagon (1mg) may
be given.
• The infusion of barium is commenced. Intermittent screening is
required to check the progress of the barium.
• The infusion is terminated when the barium reaches the hepatic
flexure.

9. • The column of barium within the sigmoid colon is run back out by
either lowering the infusion bag to the floor or tilting the table to the
erect position.
• Air is gently pumped into the bowel, forcing the column of barium
round towards the caecum, and producing the double contrast effect.
• CO2 can be used as an alternative to air.

10. Spot films of all areas of the large bowel are taken including oblique
views.
• Rectum: PA and left lateral view
• Sigmoid: LPO and right lateral
• Splenic flexure: RPO view
• Hepatic flexure: LPO view
• Caecum: AP and LPO view

11. Single contrast barium enema
• The aim is to achieve a homogeneous barium particle suspension
throughout the bowel lumen.
• Basic principle is that all segments of colon should be clearly seen
without overlapping loops.
• Each segment should be seen on at least 2 films so that any suspected
lesion can be verified.
• This is done by a combination of fluoroscopy and compression spot
films of the entire colon.

13. Adverse reactions
• Constipation
• Hypersensitivity reactions – rare
• Perforation
• Intravasation into veins

14. PATTERNS IN BARIUM ENEMA
• Surface patterns
• Fold patterns
• Protruding lesions
• Depressed lesions
• Contour abnormalities

15. Surface patterns in enema
• Surface patterns The normal
mucosal surface usually has a
smooth, featureless
appearance.

16. Reticular pattern Granularity Nodularity Cobblestoning Innominate grooves
This refers to a net like
appearance due to
barium in intervening
spaces of normal
columnar mucosa. - It is
seen in any condition
causing edema or
inflammation.
punctate dot like
appearance due to subtle
elevation of the mucosal
surface. - can be due to
mucosal edema,
inflammatory exudate
relatively well
circumscribed elevations
are seen as round or
ovoid radiolucencies
fissuring of mucosal
surface with extension in
to sub mucosa and
muscularis propria. -
seen in chrons disease
seen as collections of
barium within the fissure
of the normally collapsed
colon. It should not be
mistaken for superficial
ulceration. Ulcers will
persist with distension of
colon and innominate
grooves will disappear.

17. Folds patterns in enema
Coil spring sign Serpentine Folds Pleating
If barium is forced between one loop
of bowel intussuscepting into
another loop, the barium may coat
the mucosal folds of the outer loop. -
The resulting radiographic
appearance of concentric rings of
barium is said to resemble a coil
spring.
Serpentine folds are sinuous or wavy
and are often aligned parallel to the
longitudinal axis of the bowel. -
Serpentine folds are seen in mucosal
and submucosal inflammatory or
vascular processes.
If an extrinsic desmoplastic process
extends into the bowel wall, the
overlying mucosa may be thrown
into thin folds, termed pleating . - In
the colon, this finding suggests
endometriosis or intraperitoneal
metastases involving the serosal
surface.

18. Protruding lesions in enema
• Protrusions into the lumen of a hollow viscus can be either normal
structures such as mucosal folds or pathologic lesions such as tumors.
• A protrusion on the dependent surface displaces barium from the
barium pool and is seen as a filling defect.
• A protrusion on the nondependent surface is coated with barium and
the X ray beam catches the edges of the protrusions, which are then
"etched in white."

19. Protruding lesions
• Filling Defect - A filling defect
is a radiolucency in the
barium pool caused by
displacement of the barium
by a protruding lesion in a
single contrast study.
• Contour Defect - A contour
defect is a disruption of the
expected luminal contour by
a sessile lesion protruding
into the lumen.

20. • Polyp - A polyp is a
protrusion from a
mucous membrane. -
Polyps may be seen as
radiolucent filling
defects on the
dependent surface or
may be etched in white
on the nondependent
surface

21. • Carpet Lesion - focal, flat, well-
circumscribed surface elevations. -
When barium fills the intervening
spaces of the lesion, multiple small,
polygonal radiolucent filling defects are
seen surrounded by barium.

22. • Saddle Lesion - A focal mass that
is just beginning to encircle but is
still predominantly on one wall
may resemble a saddle and is
described as a saddle or semi
annular lesion

23. • Annular Lesion - Lesions that
extend circumferentially around
the bowel lumen are termed
annular. - Annular
configurations are seen in
benign strictures caused by
ischemia, radiation therapy, or
diverticulitis or in malignancies
such as primary tumors or
metastases.

24. Depressed lesions in enema
• Depressed lesions are lesions that extend beyond the normal contour
of the bowel, such as ulcers or diverticula.
• When located on the dependent surface, they trap the barium and
therefore are seen as a focal barium collections.
• When located on the nondependent surface, they empty of barium. If
there is adequate coating of the sides of the depressed lesion, it is
seen as a ring shadow.

25. Depressed lesions
• Aphthoid Ulcer - An aphthoid ulcer is
a small ulcer occurring on a mucous
membrane. -The most common
causes of aphthoid ulcers are Crohn’s
disease & viral infections.

26. • Linear Ulcer - Linear ulcers
are frequently seen and
have a variety of causes,
especially Crohn’s disease
or the toxic effects of
drugs such as aspirin and
other nonsteroidal anti-
inflammatory agents.

27. • “Collar Button” Ulcer -
Collar button ulcers are
ulcers with a narrow neck
and a broad base. -These
ulcers are formed when
the inflammatory process
spreads in the soft fat of
the lamina propria and
submucosa, parallel to
the mucosal surface.

28. • Exoenteric Mass - Exoenteric
masses are masses of
gastrointestinal origin that extend
predominantly outside the bowel
rather than into the lumen of the
bowel. -The most common
neoplastic exoenteric masses
include lymphoma, metastatic
melanoma, and gastrointestinal
stromal tumors.

29. • Tracking - Linear collections of
contrast medium within the bowel
wall are termed intramural tracks.
Linear collections of contrast
medium outside the expected
confines of the bowel are referred
to as extramural tracks. -Tracks
associated with radiation damage,
trauma, Crohn’s disease, or
iatrogenic perforation may spread
in any direction.

30. Contour abnormalities in enema
• Tapering - A shallow, smooth-
surfaced, gradual narrowing of
the contour of the bowel
reflects a desmoplastic disease
in the mucosa and sub mucosa
that tapers the lumen. -
Tapering is usually due to
benign scarring from chronic
inflammatory disease.

31. • String Sign -The term string sign
is used when severe narrowing
of a bowel loop causes the
lumen to resemble a string. -
This term is especially applied
in Crohn’s disease when severe
narrowing is caused by edema,
spasm, inflammation, or
fibrosis.

32. • Thumb printing - Submucosal
hemorrhage or severe edema
occurs to a greater degree
along the mesenteric border of
the small bowel and is
manifested radiographically by
thumb printing.

33. • Sacculation - Sacculation refers to
broad-based out poaching of the
bowel wall. Relatively normal bowel
wall may appear sacculated between
folds radiating toward a neoplastic or a
desmoplastic process. -This form of
sacculation occurs on the bowel wall
opposite the mesenteric changes of
Crohn’s disease, ischemia, or
diverticulitis.

34. • Spiculation - A desmoplastic
process extrinsic to the bowel,
resulting from either
inflammatory or neoplastic
disease, may extend into the
serosa or muscularis propria and
pull the luminal contour into
spike like points, termed
spiculation.

35. •Thankyou.