Small bowel follow through

1. Small Bowel Follow Through
Colonogram

2. • Small bowel follow-through is a fluoroscopic technique
designed to obtain high-resolution images of the small
bowel. The motility of the small bowel can also be grossly
evaluated.

3. The small bowel follow-through can be useful for the
evaluation of:
• Strictures
• Obstruction
• Diverticula
• Masses
• Extraluminal tethering
• Abnormal motility

4. • Procedure
Small bowel follow through is a single contrast study (oral contrast, either barium or
water-soluble contrast). It is often performed after an upper GI fluoroscopic study, as
the contrast column moves from the stomach and duodenum into the small bowel.

5. • Barium specially prepared for the small bowel (e.g. low
density 30-50% weight/volume)
• if concerned about a small bowel leak, water-soluble contrast
should be used.
• high-density barium used for double-contrast upper GI studies is
suboptimal for evaluation of distal small bowel loops

6. TECHNIQUE
The following technique is one conventional approach.
• patient starts fasting at midnight. Study is scheduled for the next morning
• first, a single contrast upper GI study is performed
• after this, the patient drinks an additional 1-2 cups and waits outside the
fluoroscopy suite
• after 15-30 minutes, a spot radiograph of the abdomen is obtained, and the
patient is re-evaluated with fluoroscopy
• spot radiograph with fluoroscopic re-evaluation is continued every 15-45
minutes until the enteric contrast reaches the terminal ileum/IC junction
and enters the ascending colon
• patient is usually positioned during interval fluoroscopy for better
evaluation of small bowel loops and paddle palpation is used to spread
out bowel loops.
• normal small bowel transit ranges between 30-120 minutes

12. • A barium enema is an X-ray exam that can detect changes
or abnormalities in the large intestine (colon). The
procedure is also called a colon X-ray.

13. An enema is the injection of a liquid into your rectum through
a small tube. In this case, the liquid contains a metallic
substance (barium) that coats the lining of the colon.
Normally, an X-ray produces a poor image of soft tissues, but
the barium coating results in a relatively clear silhouette of
the colon.

14. During a barium enema exam, air may be pumped into the
colon. The air expands the colon and improves the quality of
images. This is called an air-contrast (double-contrast) barium
enema.
Before a barium enema, your doctor will instruct you to
completely empty your colon.

15. • Abdominal pain
• Rectal bleeding
• Changes in bowel habits
• Unexplained weight loss
• Chronic diarrhea
• Persistent constipation

16. Similarly, a barium enema X-ray previously may have been
ordered by your doctor to detect such conditions as:
• Abnormal growths (polyps) as part of colorectal cancer
screening
• Inflammatory bowel disease

17. Risks
A barium enema exam poses few risks. Rarely, complications
of a barium enema exam may include:
• Inflammation in tissues surrounding the colon
• Obstruction in the gastrointestinal tract
• Tear in the colon wall
• Allergic reaction to barium

18. How you prepare
Before a barium enema exam, you'll be instructed to empty your colon. Any residue in your
colon may obscure the X-ray images or be mistaken for an abnormality.
To empty your colon, you may be asked to:
• Follow a special diet the day before the exam. You may be asked not to eat and to drink
only clear liquids — such as water, tea or coffee without milk or cream, broth, and clear
carbonated beverages.
• Fast after midnight. Usually, you'll be asked not to drink or eat anything after midnight
before the exam.
• Take a laxative the night before the exam. A laxative, in a pill or liquid form, will help
empty your colon.
• Use an enema kit. In some cases, you may need to use an over-the-counter enema kit —
either the night before the exam or a few hours before the exam — that provides a cleansing
solution to remove any residue in your colon.
• Ask your doctor about your medications. At least a week before your exam, talk with your
doctor about the medications you normally take. He or she may ask you to stop taking them
days or hours before the exam.

19. Double contrast barium enema (DCBE) technique is a method
of imaging the colon with fluoroscopy. "Double contrast" refers
to imaging with the positive contrast of barium sulfate contrast
medium (rarely water-soluble iodinated contrast) as well as with
the negative contrast of gas (CO2preferable). An exam with only a
positive contrast agent is considered a
single contrast barium enema.

20. Contraindications:
There are few contraindications:
• Suspected colonic perforation.
• Toxic megacolon
• Psuedomembranous colitis
• Imminent rectal biopsy within 7 days of procedure or within
7-10 days after the rectal biopsy 1
• documented history of anaphylaxis to barium

21. EQUIPMENT
• Rectal tube (e.g. Miller) for administration of contrast
• the Miller tube has three components
• a (wide bore) tube for administration of barium
• a (usually blue) tube for administration of gas (usually through manual
insufflation)
• a smaller tube for inflating the balloon at the tip
• Adhesive tape is often useful to tape the tube to the patient and prevent it
from backing out
• Enema bag and IV pole

22. • Why isn’t water soluble contrast used for Barium enema ?

23. • Some radiologists may premedicate the patient with an anti-
peristaltic agent before the exam to relax the colon , but this
is not mandatory.
• Main agents employed are hyoscine, butylbromide or
glucagon. IV / IM.

24. • Scout (if indicated) views are shown below:
• AP abdomen
• AP pelvis
• left lateral pelvis
1.With the patient in the prone position, barium is slowly administered until it reaches the mid-
transverse colon.
2.After it reaches this point, drain the barium from the distal rectosigmoid and rectum.
3.Begin manual gas insufflation
• sigmoid colon (important to get these first before contrast potentially reaches the right colon)
• LPO, RPO, prone
• rectum
• Prone, lateral
• hepatic flexure, erect LPO, distal ascending colon, erect LPO, mid transverse colon, erect
or supine, splenic flexure, erect RPO, proximal descending colon, erect RPO
• cecum
• LPO, prone
• rectum, tip out
• Supine, right lateral
• terminal ileum, LPO, if there is a question of inflammatory bowel disease

25. • Sigmoid colon (important to get these first before contrast potentially reaches
the right colon)
• LPO, RPO, prone
• Rectum
• Prone, lateral
• Hepatic flexure---- erect LPO,
• Distal ascending colon----erect LPO,
• Mid transverse colon----erect or supine,
• Splenic flexure----erect RPO,
• Proximal descending colon----erect RPO
• Cecum
• LPO, prone
• Rectum, tip out
• Supine, right lateral
• Terminal ileum, LPO, if there is a question of inflammatory bowel disease