Barium enema procedure and patterns

BARIUM ENEMA
PROCEDURE AND PATTERNS

 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.

INDICATIONS
 Screening for colon cancer
 Inflammatory bowel disease
 Diverticular disease
 Inconclusive colonoscopy
 To check patency of distal loop

CONTRAINDICATIONS
- Toxic megacolon
- Recent biopsy
- Rigid endoscope within 5 days
- Flexible endoscope within 24 hrs
- Generalized peritonitis

METHODS
Double 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

Single contrast
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
 For SCBE- low density barium suspension -
12-25% w/v, and a kilo voltage of 100 -110 is
used.

 For DCBE- high density barium suspension –
60-120% w/v and a kilo voltage of about 90 is
used.

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 Bisacodyl
tablets for 2 days.
 A tap water cleansing enema of 1500 ml on the
morning of the barium enema examination.

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 )

Procedure
 A scout film is taken of the AP abdomen- 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.

 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.

 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.

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

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.

Aftercare
 Patients should be warned that their bowel
motions will be white for a few days after the
examination, and to eat and drink normally to
avoid barium impaction.
 The patient must not leave the department
until any blurring of vision produced by the
Buscopan has resolved.

Adverse reactions
 Constipation
 Hypersensitivity reactions – rare
 Perforation
 Intravasation in to veins

 Side-effects of the pharmacological agents
used
 Cardiac arrhythmia due to rectal distension

 Surface patterns
 Fold patterns
 Protruding lesions
 Depressed lesions
 Contour abnormalities

Surface patterns
 The normal mucosal
surface usually has a
smooth, featureless
appearance.

Surface patterns
 Reticular pattern
-This refers to a net
like appearance due to
barium in interstices of
normal columnar
mucosa.
- It is seen in any
condition causing
edema or
inflammation.

 Granularity
- punctate dot like
appearance due to
subtle elevation of the
mucosal surface seen
en face.
- can be due to
mucosal edema,
inflammatory exudate.
Surface patterns

 Nodularity
- relatively well
circumscribed
elevations seen en
face as round or
ovoid radiolucencies
Surface patterns

 Cobblestoning
- fissuring of
mucosal surface
with extension in to
sub mucosa and
muscularis propria.
- seen in chrons
disease
Surface patterns

 Innominate grooves or
areae colonicae:
- seen as collections of
barium within the crevices
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.
Surface patterns

Folds patterns
 Coil spring sign
- 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.

Folds patterns
 Serpentine Folds
- 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.

Folds patterns
 Pleating
- 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.

 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."

Protruding lesions - principle

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.

Protruding lesions
 Contour Defect
- A contour defect is
a disruption of the
expected luminal
contour by a sessile
lesion protruding
into the
gastrointestinal
lumen.

Protruding lesions
 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

Barium enema procedure and patterns

Protruding lesions
 Carpet Lesion
- Carpet lesions are
focal, flat, well-
circumscribed surface
elevations.
-When barium fills the
interstices of the
lesion, multiple small,
polygonal radiolucent
filling defects are seen
surrounded by barium.

Protruding lesions
 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

Protruding lesions
 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.

Protruding lesions
 Pliability
- Change or lack of
change in the size and
shape of a lesion is a
clue to its composition.
- Lesions that change in
size or shape depending
on the amount of
luminal distention or
manual compression are
often composed of fat,
fluid, or blood.

 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.

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, varioliform
erosions, and
amebiasis.

Depressed lesions
 Linear Ulcer
- Linear ulcers are not
infrequently 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.

Depressed lesions
 “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.

Depressed lesions
 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.

Depressed lesions
 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.

Contour abnormalities in enema

Contour abnormalities
 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.

 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.

 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.

 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.

 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.

 Angulation
- Gross angulation of
the bowel may occur
when an extrinsic
desmoplastic process
tethers the bowel
wall.

Barium enema procedure and patterns

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