2. Source & Chemical nature
Barium Sulphate (BaSo4) is used.
Naturally occurring BaSo4 is toxic.
Medically used BaSo4 is precipitated from other
compounds.
An inert substance.
Atomic number-56
Specific gravity - 4.5
3. DENSITY & VISCOCITY :
Density depends on the particle size
Thick and Thin barium depending on the viscosity of
the suspension not on the density.
4. ADVANTAGES: DISADVANTAGES
• EXCELLENT COATING
allowing good
demonstration of
anatomical details .
• Cost effective.
• High morbidity if barium
enters peritoneal cavity
• Subsequent CTand
ultrasound exams are
rendered difficult as it
may take a few days for
the barium to clear up
6. GLUCAGON
• Polypeptide hormone produced by alpha cells of islets
• Causes smooth muscle relaxation and hyperglycemia
• Dose 0.3 mg i.v for barium meal and1.0 mg i.v for enema
• Advantages : more potent vs buscopan, short duration
: does not affect small bowel transit time
• Disadvantages : hypersensitivity reactions
: long onset of action [1 min] ,costly
• Contraindications :insulinoma and glucagonoma
: phaeochromacytoma {causes release of
catecholamines}
7. Metaclopramide
Dopamine agonist ,stimulates gastric
emptying and small intestinal transit
Dose: 20 mg oral or i.v
Advantages : enhanced transit during during bmft
: antiemetic
Disadvantages : extrapyramidal side effects at dose
> .5mg/kg
8. Double Vs single contrast studies
In a double contrast study a negative contrast agent
like air is used in addition to BaSo4 to distend and
help in coating the mucosa.
A very high density and low viscosity BaSo4
suspension used.
Gives a better mucosal detail.
Technically demanding.
9. Single contrast studies
Rapid
Economic
In elderly, infirm, uncooperative patients
PRINCIPLE :
Fluoroscopy equipment
Films are to be taken with sufficient compression so as
not to miss the lesion due to the barium pools.
10. Suspensions used are:
Oesophagus- 50 to 100% w/v
Upper GI series – 50 t 100% w/v
Enteroclysis – 15 to 20 % w/v
Enema – 15 to 20%
11. Quality control:
Operated at 90 to 120 kvp.
Skeletal shadows should be visible through the barium
column .
The bowel loops should be visible through the
overlapped loops.
12. BARIUM MEAL
To evaluate stomach and the duodenum
PRINCIPLES
Fluoroscopy
Careful compression
Controlled filling of each portion
13. INDICATIONS
• Epigastric pain , anorexia, weight loss , vomiting , anemia ,
heart burn , dyspepsia
• Upper abdominal mass
• GI haemorrhage
• Gastric or duodenal obstruction
• Malignancies of OG junction , stomach or duodenum
• Motility disorders of GIT
• In children to identify causes of vomiting
- reflux
- pyloric obstruction
- malrotation
• Systemic disease like TB of GIT
14. CONTRAINDICATIONS
• Suspected gastro duodenal perforation
• History or suspicion of aspiration
• Large bowel obstruction {barium inspissation may
occur in these cases }
• Fistulous communication with any other organ
other than GIT
• Recent biopsy from GIT { barium granuloma may
form at biopsy site}
15. PREPARATION
1. NPO for at least 6 hours before examinations . For
routine studies keep the patient fasting overnight .
2. Patient should restrain from smoking as it
interfers with mucosal coating
3. In patients with gastric outlet obstruction ,
prolonged fasting , IV metaclopramide
CONTRAST MEDIA
• Single contrast – lower density contrast (80 -100%w/v) is used. 30%
w/v suspension in used for high kv technique
• Double contrast – high density (250% w/v ) low viscosity barium is
best for mucosal coating
16. METHOD
Patient drinks barium lying on the left side with elbow
support
Patient then lies supine and slightly to the right to check
the GO junction for reflux. Take a spot film if any reflux is
noted
Give iv muscle relaxant
Roll patient in a complete circle clockwise to finish in RAO
Spot films ahould be taken in both distended and empty
states
17. Basic views for stomach
1. Prone - mucosa of the anterior wall
2. Supine –body and proximal antrum
3. Supine RAO -body and whole antrum
4. Supine LAO –fundus and upper body
Basic views for duodenum
1. RAO – duodenal cap
2. Prone with left side up – ‘c’ loop of the duodenum.
18.
19. AFTER CARE :
Patient should be warned that his bowel motion
will be white for a few days
Patient should be told to drink adequate ammount
of water to prevent impaction
Patient must not leave till the side effects of
buscopan have subsided
20. Complications
Leakage from unsuspected perforation
Aspiration due to buscopan
Impaction leading to large bowel obstruction or
appendicitis
21. Few added points-
Single contrast high kV technique– 120-130kV,low
density barium 30 % w/v
Retrogastric space – evaluated with additional 200 ml
barium , supine position with translateral film
Erect RAO- for incisura angularis, c loop of duodenum
22. DOUBLE CONTRAST BARIUM
STUDY
INDICATIONS- for small muscosal lesions –
polyps,ulcers,erosions,recurrent tumors, post
operative study
CONTRAST MEDIA- HIGH density (200-250% w/v)
LOW viscosity
GAS FORMING AGENTS- sod.bicarb,citric acid PO
MUSCLE RELAXANTS- Buscopan ( 1 ml i.v., given just
before giving barium )
Patient is supine,rotated towards right lateral,to prone,to
left lateral and back to supine
23. Angular Notch
Incisura Angularis
Barium Meal, Double Contrast
(Supine Position)
Body
Antrum
Supine Position:
Note Barium Distribution
in the Fundus due to
gravity
36. Antral folds >5mm----abnormal
All neoplastic processes will show thickened
IRREGULAR rugae
Gastric varices- multiple filling defects which are
variable in size and shape ( df from neoplastic
processes) ; also may show extrinsic compression from
enlarged spleen
37.
38. GASTRIC OUTLET OBSTRUCTION
KEY FEATURES ON BARIUM:
• Over-distended stomach
outline with air fluid levels (can
be visualized on plain too)
• Lower level if stomach towards
pelvis
• Mottled density of gastric
residue
• Delayed gastric emptying
• Persistent barium in stomach
• Benign malignant
Smooth irregular
contour contour
42. INDICATIONS
Low suspicion of small bowel disease-
Pain,Diarrhoea,Anemia
Partial obstruction
Malabsorption
Abdominal mass
CONTRAINDICATIONS
1. Complete obstruction
2. Suspected perforation
3. Paralytic ileus
43. CONTRAST USED : Medium density barium
suspension ( 50-60% w/v)
PATIENT PREPARATION : purgative should be
administered (except in cases of obstruction or illiostomy
or acute chron’s)
Low roughage diet and high fluid intake is maintained
Patient is kept NPO since 12 hours
metaclopramide {20 mg orally 20 min before the procedure
} may be given
44. TECHNIQUE :
Initally 150 ml taken for upper gi study
Then , 200ml (20-25%) for decreasing the high
density effect of upper gi study and then 250 ml
(40-45%) is given.
patient lies on his right after ingesting barium to
hasten gastric emptying . Then patient is put in
prone position and finally supine
45. FILMS TAKEN :
keep the patient supine—proximal jejunum
Then keep the patient prone and a film is taken to
demonstrate ileum
• Take spot films every 15 to 20 min till ileocaecal junction is
opacified
• To visualise IC junction take a film in supine right side up
Use compression and also empty the bladder prior to these
spots to displace the loops and to check for motility
• Any abnormality should be shown in two different spots at
different times to demonstrate persistence of lesions
• Usual time without drugs---2-6 hours
46. Advantages of prone position
Better separation of bowel loops
Compression of abdomen ensuring uniformity of
abdomen
Ileal loops migrate cephalad
47. DISADVANTAGES:
Overlap may decrease information that can be
btained
Poor distension of bowel loops
Operator dependence
Time consuming
Intermittent obstruction may be missed
ADVANTAGES:
-Easy to perform
-No intubation is necessary
-Transit time can be determined
48. Barium Meal + Follow-Through
(Erect Position)
Barium Meal
Barium
Follow-Through
Duodenal Cap
Pyloric Canal
2nd Part of
Duodenum
3rd Part of
Duodenum
Body
Antrum
DJJ:
Normal Position= Left side
Angular Notch
Incisura Angularis
Jejunum:
Plica Circularis on the
outer border
Ileum
49. Barium Follow-Through to Cecum
(Erect Position)
2nd Part of
Duodenum
3rd Part of
Duodenum
DJJ:
Normal Position= Left side
50. ENTEROCLYSIS
Indications :
Unexplained pain
Unexplained diarrhoea
Unexplained weight loss
To evaluate morphology in
a. Crohn’s disease
b. Intestinal tuberculosis
c. Neoplasms
d. Radiation damage
51. TECHNIQUE:
800 ml of 15 to 20 % w/v suspension used for single
contrast technique at 75-120ml/min.
Naso jejunal [Bilbao- Dotter tube] tube is placed in the
proximal jejunum to prevent gastric reflux and
vomiting.
Spot and prone over head films are taken , high kV
technique
For double contrast views 80% w/v of BaSo4 &
aqueous solution of methylcellulose is used.
52. Problems
Prolonged examination
Incomplete distension of small bowel
Prolapse of small bowel into the pelvis
Faecal material in the terminal ileum
Reflux into duodenum and stomach
53.
54. CT ENTEROCLYSIS
8F NJ tube is inserted
Distilled water infused with a pressure controlled
pump
i.v. antispasmodic given
Helical scanning started 70 s after i.v. contrast
ADVANTAGES- intraluminal/extraluminal
/intramural pathologies
5-35mm pathologies detected
Bowel wall thickness can be measured
55. MR ENTEROCLYSIS
Basic procedure is same
Iron based and posititve gado contrast agents
ADVANTAGES-
Bowel wall enhancement – assessment of IBD Activity
like in UC,CD
No radiation- pediatric / pregnant patients
76. Single contrast BE needs low density preparations
(12 – 20%w/v)to achieve a see through effect
Double contrast BE needs higher density barium
(60 – 110%w/v) so that there will be high
radiographic density in the thin coating
Features of an ideal suspension for DCBE:
1- should flow easily
2- should not flocculate
3- should remain plastic when it dries out
4- foaming should be minimal
{Anti foaming agents like dimethyl polysiloxane are added
to destablise bubbles}
77. BOWEL PREPARATION
DIET:
Low fiber diet for three days before examination
Patient should not have fatty foods
Patient is instructed to increase water intake
Iron containing medications to be stopped 2 days before
the procedure as iron causes adherence of the stool to the
mucosa
LAXATIVES:
Castor oil : cheap unpleasant irritant cathartic
Bisacodyl : irritant cathartic , has direct effect on the bowel
78. MAGNISIUM CITRATE :
• saline laxative which is more pleasant
• Causes osmotic retention of fluid and increased peristalsis
SUMMARY
• Tab dulcolax 2 HS
• Tap water enema to be done the previous night
and 2 hours prior to the procedure
• Patient to come on empty stomach on the day of
examination
79. Antibiotic prophylaxis is to be given to
patients with
Prosthetic heart valves
Previous h/o endocarditis
Surgically constructed pulmonary shunt
Regimens
Amoxycillin 1 g + gentamycin 120 mg i.v 15 minutes
prior to procedure + amoxycillin 500 mg 6 hours later
Vancomycin 1 g slow i.v over 100 min +gentamycin 120
mg i.v prior to start of procedure for penecillin
sensitive patients
80. Preliminary film only if:
Severe constipation renders bowel preparation ineffective
Toxic megacolon is suspected
TECHNIQUE
Patient lies on one side on an incontinence sheet and the
rectal catheter is inserted gently
A muscle relaxant may be given i.v
Infusion of barium is commenced . Intermittent screening
is needed to check progress of barium .
81. Films are taken to demonstrate each segment clearly
Left lateral position for rectum
Supine or prone film for the colon
Spot films for flexures and caecum
Post evacuation films are taken for ulcerative colitis or
crohn’s disease.
Spot films to be taken of any abnormality seen
82.
83. COMPLICATIONS
Perforation of bowel this risk increases in
• Infants and elderly
• Obstructing neoplasm
• Ulceration of the bowel wall
• Inflation of foleys catheter balloon in a colostomy or
rectum
• Patient on steroid therapy
• hypothyroidism
84. • Transient bacteremia
• Cardiac arrhythmias due to rectal distension
• Intramural barium
• Venous intravasation
97. COLONIC POLYPS
1.adenomatous
2.hyperplastic
1.sessile
2.pedunculates
On DCBE---
Polyps may be confused with other filling defects like-
air bubbles,oil droplets,fecal matter and intraluminal
appearing diverticula ( air fluid level, Different
projections)
112. 1 corrosive poisoning
2 bull eye – melanoma mets
3 gall stone ileus
4 gall stone ileus
5 picket fence appearance- small bowel h’age
6 solitary rectal ulcer syndrome
113. INTERESTING QUESTIONS-
1. “WATERMELON STOMACH”
2. ONE LOCATION WHERE THE GASTRIC ULCERS
ARE DEFINITELY MALIGNANT
Rams horn appearance ??
114. 1. CHRONIC GI BLEED
2. FUNDUS , ABOVE THE LEVEL OF THE CARDIA
3. appearance of stomach in crohns disease
115. IT IS PRUDENT TO MENTION HERE, THAT, BARIUM
EXAMINATIONS CANNOT BE MADE OBSOLETE!
There are areas where endoscopy, axial imaging, and physiologic monitoring are
inadequate; they are invasive, time consuming, expensive, and not without their
shortfallings, ambiguity, and complications.[2,3] It is primarily the financially
driven initiatives that have propagated the use of other complementary
modalities as a primary modality(s) of choice over the conventional barium
examination.
Barium studies, till date, remains the safest, fastest, and cheapest diagnostic
investigation to evaluate vague abdominal symptoms and the art has to be
revived.[4,5] Motility disorders of the gastrointestinal tract from pharynx
to anus and submucosal lesions are best and quickly evaluated by barium
studies. No other modality can be as faster, safer, and more accurate than this
age-old barium evaluation.[4,5]
The role of barium evaluation of the bowel in patients with malabsorption is
irrefutable. It is useful for both, diagnostic as well as for follow-up to evaluate
response to therapy.[5,6]
116. REFERENCES
EISENBERG-GIT RADIOLOGY 4TH ED
Status of barium studies in the present era of
oncology: Are they a history?
Abhishek Mahajan, Subash Desai, Nilesh Pandurang
Sable, and Meenakshi Haresh Thakur
White textbook of procedures
Radiology procedures- Lakhar
Editor's Notes
Hyperplastic --- epilthelial sessile proliferation less than 5mm
Adenomatous – true neoplastic lesions with dysplastic potential ----size,shape,number
