Wednesday, 25 April 2012

GIT

Barium Enema

Basic Anatomy

Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London
Indications
Change in bowel habit
Abdominal pain
Abdominal Mass
Melaena
Contraindications
Toxic megacolon
Pseudomembranous colitis
Rectal biopsy with 7 days
Imminent abdominal bowel surgery
Contrast Media and drugs. (Typical Examples, See Contrast / Drugs Section for more information)
"
Polibar" Pre mixed Barium enema kit (500ml)
Buscopan / Glucagon injection.
Equipment
Fluoroscopy with rapid film capability 10 frames/second
Fluoroscopy table with 90/20 tilt.
Rectal canulation equipment,
Barium bag kit with barium / air introduction system.
Injection administration equipment.
Patient Preparation
Patient Identification, Check Pregnancy state, (Note 10 day rule not 28 day rule)
General psychological preparation and examination outline.
Check sensitivity to drugs used.
See sample Prep. sheets
Colonic clearance using, laxatives, enemas, washouts.
Low residue diet, * Note special preparation may be needed for diabetic patients.
Technique
A "control" film is taken to assess preparation, exposure and anatomy.
The patient lies on their left side and the rectum is catheterised, the catheter taped in position and connected to the barium / air introduction equipment.
An intravenous smooth muscle relaxant is administered.
The patient lies supine,
The barium is infused slowly as far as the splenic flexure under fluoroscopic control.
Air is then introduced to force the barium towards the caecum and producing the double contrast effect by coating the bowel wall and distending the bowel with air.
The patient position is adjusted under fluoroscopic control as the complete colon is visualised as the barium travels round to the caecum.
A series of films are taken then the barium and air are run back as much as possible, then the patient is sent to the toilet to complete the bowel evacuation.

Typical Film Series
Spot films of rectum and sigmoid region, RAO, prone, LPO, Lateral
Spot films of  splenic  flexure LAO
Spot films of hepatic flexure RAO
Spot film of caecum with compression

Overcouch film supine abdomen
Overcouch film prone abdomen
Right and left lateral decubitus films
Prone caudal angled sigmoid view

Post evacuation supine film

Typical Film from Image Series

Spot film of recto sigmoid region

Pre evac Overcouch decubitus film
Radiation Protection
Define strict referral criteria to exclude clinically unhelpful examinations
Minimise fluoroscopy time and current
Introduce QA programme to make regular checks on and to optimise staff and equipment performance
Collimate X-ray beam to minimise size
Shield sensitive organs when possible
Install modern image intensifiers with sensitive (e.g. CsI) photocathodes and digital image processing
Use video recorder instead of cine camera during fluoroscopy wherever possible
Use spot film photofluoroscopy with modern image intensifier and 100mm camera instead of radiography whenever appropriate
Use pulsed systems with image storage devices in fluoroscopy.
Aftercare
Record volumes and descriptions of contrast media and drugs administered.
General patient psychological aftercare
Ensure the patient understands the procedure for collecting the results.
Warn the patient of the possibilities of constipation and appropriate counter measures
Complications
Rectal perforation
Leakage of barium into the peritoneum with and unsuspected perforation
Barium impaction
Other Imaging Techniques
Colonoscopy
CT

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