Barium meal. How to perform and interpret
- 2. BARIUM MEAL • Barium is used as a contrast medium to image stomach and duodenum
- 3. Anatomic segments: • Cardia • Fundus • Body • Antrum • Pylorus • Other Features: • Rugae are mucosal folds in nondistended stomach • Areae gastricae : normal reticular mucosal pattern of stomach, most prominent in body & antrum • Lesser curvature forms right gastric border & extends from cardia to pylorus. • Greater curvature forms left gastric border & extends from cardia, over dome of fundus, & to pylorus Stomach : Anatomy
- 4. Cardia • 1st anatomical segment of stomach, where abdominal part of esophagus enters stomach
- 5. Fundus • dome-shaped & directly adjacent to cardia, projecting superiorly. • typically air-filled & is the portion of stomach where gastric bubble is commonly appreciated on upright plain films
- 6. Body • inferior to fundus & extends from cardia to the level of incisura angularis, a notch in lower part of lesser curvature • largest gastric segment • shape & size is quite variable due to parastalsis
- 7. Antrum • from incisura angularis to pyloric opening
- 8. Pylorus • most distal segment of stomach • consists of thickened band of circular muscle that forms sphincter functioning to control rate of gastric emptying into duodenum • length of pyloric canal is about 1cm in adults • characterized histologically by pyloric glands & lack of parietal cells
- 11. Introduction : Barium • Barium (Ba) • Atomic number : 56 • Barium suspension is made up from pure barium sulphate (Barium carbonate is poisonous) • Non-ionic suspension medium is used, otherwise Ba particles would aggregate into clumps • Ba solution has a pH of 5.3, which makes it stable in gastric acid
- 12. Brand name Density (w/v) Baritop 100 100% – all parts gastrointestinal tract E-Z HD 250% – oesophagus, stomach and duodenum Micropaque DC 100% – oesophagus, stomach and duodenum Barium suspensions & dilutions with water to give a lower density
- 13. Pros n Cons of using Ba over water soluble contrast Advantages • Excellent mucosal coating, allowing demonstration of normal & abnormal mucosal patterns • Cost Disadvantages • Subsequent abdominal CT & US are rendered difficult to interpret (Patients may be asked to wait for up to 2 weeks to allow satisfactory clearance of the barium) • High morbidity associated with barium in peritoneal cavity (if barium leaks into peritoneum)
- 14. Barium Meal Methods a. Double contrast – method of choice to demonstrate mucosal pattern small volume of barium (for mucosal coating) + Carbex granules / Eno (for distension) b. Single contrast – uses: a. In children – usually not necessary to demonstrate mucosal pattern b. to demonstrate contour abnormalities, strictures, and large polypoid defects large volume of barium
- 15. Indications 1.Failed upper gastrointestinal endoscopy 2.Dyspepsia 3.Weight loss 4.Upper abdominal mass 5.Gastrointestinal haemorrhage (or unexplained iron-deficiency anaemia) 6.Partial obstruction 7.Assessment of site of perforation – it is essential that a water-soluble contrast medium is used, e.g. Gastrografin
- 16. Contraindications • Complete large-bowel obstruction
- 17. Contrast Media • 1. E-Z HD 250% w/v 135 ml 2. Carbex granules / Eno (double contrast technique)
- 18. Patient preparation 1. Nil orally for 6 to 8 hrs prior to examination 2. No contraindications to pharmacological agents used
- 20. Technique Double contrast method: 1.Gas-producing agent (Eno) is swallowed 2.Patient then drinks barium while lying on left side supported by elbow (This position prevents barium from reaching duodenum too quickly) 3.Patient then lies supine & slightly on right side, to bring barium up against gastro- oesophageal junction This will check for GE-reflux (ask patient to cough or to swallow water while in this position). If reflux is observed, spot films are taken to record the level to which it ascends 4. i.v. injection of a smooth muscle relaxant (Buscopan 20 mg or glucagon 0.3 mg) is given 5.Patient is asked to roll onto right side & then quickly over in complete circle, to finish in RAO position. This roll is performed to coat the gastric mucosa with barium. (Good coating has been achieved if areae gastricae in the antrum are visible)
- 21. Films • great variation in views recommended • 1. Spot films of the stomach (lying): a. RAO – to demonstrate antrum & greater curvature b. Supine – antrum & body c. LAO – lesser curvature in en-face d. Left lateral tilted, head up 45 degree or erect AP veiw– fundus • From left lateral position, patient returns to supine position & then rolls onto left side & over into a prone position. This sequence of movements is required to avoid barium flooding into duodenal loop
- 22. 2. Spot films of duodenal loop & cap (lying): b. Prone c. RAO –patient attains this position from prone position by rolling first onto left side d. Supine e. LAO
- 26. Modification of technique for young children • Main indication will be to identify a cause for vomiting • Examination is modified to identify three major causes of vomiting – i. Gastro-oesophageal reflux ii. Pyloric obstruction & iii. Malrotation It is essential that position of duodeno-jejunal flexure is demonstrated: 1. Single contrast technique using 30% w/v barium sulphate & no paralytic agent 2. Relatively small volume of barium – enough to just fill fundus – is given to infant in supine position. A film of distended oesophagus is exposed
- 27. 3. Child is turned semi-prone into a LPO or RAO position. Film is exposed as barium passes through pylorus 4. Once barium enters duodenum, child is returned to supine position, second film is exposed as barium passes around duodenojejunal flexure. (DJ-flexure normally crosses midline, lies left to the left pedicle of vertebral body & lies inferior to the duodenal bulb if not, that’s malrotation) Once malrotation has been diagnosed or excluded, a further volume of barium is administered until stomach is reasonably full & barium lies against gastro- oesophageal junction. Child is gently rotated through 180 in an attempt to elicit gastro-oesophageal reflux
- 28. In newborn infants with upper intestinal obstruction • E.g. duodenal atresia, diagnosis may be confirmed if 20 ml of air is injected down the nasogastric tube • If diagnosis remains in doubt, it can be replaced by a positive contrast agent (dilute barium or LOCM if the risk of aspiration is high)
- 29. Aftercare 1.Patient should be warned that his bowel motions will be white for few days after the examination & may be difficult to flush away 2.Patient should be advised to eat & drink normally to avoid barium impaction. Laxatives may be taken if required 3.Patient must not leave department until any blurring of vision produced by Buscopan has resolved
- 30. Complications 1.Leakage of barium from an unsuspected perforation 2.Aspiration of stomach contents due to the Buscopan 3.Conversion of a partial large bowel obstruction into a complete obstruction by the impaction of barium 4.Barium appendicitis, if barium impacts in the appendix (exceedingly rare) 5.Side-effects of the pharmacological agents used
- 31. Radiological Anatomy Double-contrast barium meal, (a) and (b) with the patient supine
- 32. Radiological Anatomy Double-contrast barium meal (c) with patient erect, (d) with patient in a supine oblique position
- 33. Terminology in barium meal studies • Mucosal lesions • Wall lesions (i.e., submucosal, intramural) • Extrinsic lesions
- 34. Mucosal pattern / lesions terminology
- 35. Reticular pattern • Netlike • In general, columnar mucosa in GIT is divided into islands of tissue surrounded by shallow grooves • This pattern is best exemplified in the areae gastricae of the stomach • Areae gastricae are seen as well- circumscribed, polygonal radiolucencies surrounded by barium-filled grooves
- 36. • Gastric rugae (arrow) • reticular pattern to the gastric antrum (areae gastricae ) , which are a normal finding
- 37. Fold Patterns • Folds in GIT are composed of: • mucosa—epithelium, • lamina propria, & muscularis mucosae and • submucosa • In Barium meal: the enlarged or nodular folds implies the process involves mucosal or submucosal layers, or both
- 38. RADIATING FOLDS • Folds that radiate to a focal site • Radiographic analysis of radiating folds aids in differential diagnosis • Smooth folds radiating to mucosal lesion : active inflammatory process or scarring Benign gastric ulcer Smooth straight folds (short arrows) radiate toward the barium- etched rim of the ulcer (long arrow).
- 39. • Lobulated, pointed, or clubbed radiating folds : malignant or severe inflammatory process Adenocarcinoma of the stomach Abnormal folds radiate toward the center of the lesion. The folds are club-shaped (c) and nodular (n). Note the nodular mucosa in the center of the ulcer crater
- 40. Protruding Lesions FILLING DEFECT • is a radiolucency in barium pool caused by displacement of barium by a protruding lesion Hyperplastic polyp in the gastric antrum Filling defect (arrow) seen in the barium pool
- 42. POLYP • is a protrusion from mucous membrane • seen as radiolucent filling defects on the dependent surface or • may be etched in white on the nondependent surface A. Hyperplastic polyp in the gastric antrum. A filling defect (arrow) is seen in the single contrast study B. Same polyp is seen in double contrast as round, increased radiodensity etched in white (arrow). In B, the polyp is not described as a filling defect
- 43. ULCERATED MASS • Lesions that have both depressed & elevated components are typically ulcerated masses of mucosal or submucosal origin Single-contrast compression view of lesser curvature performed with patient in a prone position shows an ulcerated mass as an ovoid barium collection (white arrow) within a radiolucent mass protruding into the gastric lumen. The mass has a coarsely nodular rim of tissue (black arrows).
- 44. Depressed Lesions EROSION • = is a defect in mucosa that does not extend beneath muscularis mucosae • Erosions are characterized by a small central barium collection & a surrounding radio- lucent mound of edema Erosions. Numerous linear & ovoid collections of barium (arrows) are surrounded by radiolucent halos of edema. Case of erosive
- 45. ULCER NICHE (CRATER) • niche or crater refers to the defect or hole in mucosal surface, representing an ulcer. • niche may be visualized in profile as a projection of barium extending beyond luminal contour • Or may be seen en-face as a barium collection, or the edges of the crater may be etched in white Ulcer niche (crater): benign gastric ulcer. Ulcer niche (crater) is seen as focal barium collection (arrow). The benign nature of the lesion is indicated by smooth folds that radiate to ulcer’s margin & lack of surrounding mass effect or mucosal nodularity
- 46. SUBMUCOSAL MASS • refers to lesions arising in the sub-mucosa & muscularis propria • also referred to as intramural or extramucosal • typically are benign or malignant tumors of smooth muscle, fat, or neural origin • overlying mucosa is stretched & may be ulcerated
- 47. SUBMUCOSAL MASS • In profile: smooth-surfaced mass is seen forming right angles to the luminal contour • En face: barium trapped in the abrupt margins results in well-defined tumor smooth, rounded submucosal mass (arrow) that proved to be a benign GIST
- 48. TARGET LESION or BULL’S-EYE LESION • is a mass with a central ulcer crater • typically ulcerated submucosal masses caused by primary tumors such as GIST or malignant tumors, especially metastatic melanoma, Kaposi’s sarcoma, & disseminated lymphoma • Ectopic pancreatic tissue in gastric wall Gastric ectopic pancreas Double-contrast barium meal mage shows intramural mass (arrow) along greater curvature of gastric antrum. Central barium- filled pit, or umbilication (arrowhead). The location & central umbilication in this lesion are characteristic of ectopic pancreas
- 49. Contour Abnormality LINITIS PLASTICA • refers to diffuse narrowing & loss of pliability (not changing size or shape) of stomach • usually seen in scirrhous carcinoma of the stomach • Also seen in caustic ingestion or metastatic breast carcinoma Linitis plastica: adenocarcinoma of the stomach. The fundus and body of the stomach are diffusely narrowed. The luminal contour is altered by nodular, broad-based indentations (arrows), but the mucosa is relatively smooth. These findings indicate the submucosal location of the bulk of the
- 50. Pathologies on barium meal • Congenital • Inflammatory • Ulcers • Neoplastic • Pseudotumors • Iatrogenic • Others
- 51. Pyloric stenosis • Primarily diagnosed by USG Barium meal: • Elongation & narrowing of pyloric canal (2-4 cm in length) • String Sign: Passage of small contrast through narrowed pyloric channel • Crowding of mucosal folds in pyloric channel producing a double or triple track sign • Kirklin or “Mushroom” Sign: Indentation of duodenal bulb base around hypertrophied pylorus; also referred to as "shouldering" spot film of the pylorus
- 53. Gastritis • inflammation of the gastric mucosa • Erosions: typical finding in acute gastritis • Represent destruction of gastric mucosal surface not extending beyond muscularis mucosa • In contrast to ulcers, erosions do not heal by scar formation, but are replaced by new epithelium • Radiographic Findings: • Thickened gastric rugae (> 5mm) secondary to edema • Mucosal nodularity • Erosions
- 54. Diffuse gastritis with thick nodular folds
- 55. Atrophic gastritis. Diffuse atrophy of the muscosal folds in a narrowed featureless stomach
- 56. Gastric ulcer on barium meal 1. Location • Part of stomach: Most benign ulcers – in Antrum (90%) & lesser curvature(75%) Elsewhere in stomach – strong suspicion of malignant ulcer 2. Position on mound • Benign ulcer: inflammatory reaction surrounding a ulcer tends to be uniform & ulcer tends to be centrally placed • Malignant masses: often eccentrically placed within the mass 3. Ulcer shape: • Benign ulcers: uniform & round • Malignant: Most have irregular ulcer margins
- 57. 4. Ulcer collar: area of edema around the ulcer • Benign ulcer: uniform (Hampton’s line, radiolucent line across neck of an ulcer (i.e., it separates barium in ulcer from gastric lumen)) • Malignant ulcer: collars may not be present but when they are, they are usually thick & irregular benign lesser curvature gastric ulcer with a Hampton line (arrow)
- 58. 5. Ulcer fold convergence: • Benign: almost always converge right up to the ulcer margin • Malignant : folds, often irregular, fail to meet the ulcer margin large benign lesser curvature ulcer (large arrow) with uniform fold convergence on the ulcer (small arrow)
- 59. 6. Mucosal fold shape: • Benign folds : smooth and uniform • Malignant folds : irregular, amputated, clubbed, or fused
- 60. 7. Visualization of an ulcer within or outside gastric wall: • Benign: project outside gastric wall as they erode through mucosa • Malignant ulcers: tend to erode less outside of stomach wall, but rather, into the gastric lumen as an intraluminal mass Benign lesser curvature ulcer large greater curvature malignant ulcer (large arrow) with a surrounding irregular mound (small arrows) due to infiltrated adenocarcinoma
- 61. 8. Carman- Meniscus sign: • large, flat ulcer with heaped-up edges • radiolucent halo on compression views, which represents heaped-up edges, with a convex outer shape to trapped barium in the ulcer crater radiolucent halo (large arrow) due to a Carman meniscus sign that surrounds central Malignant ulcer crater (small arrow)
- 62. 9. Crescent sign: • represents benignity • seen in ulcers along greater curvature of the stomach (usually antrum) • barium pool protruding outside mucosa has a concavity away from gastric lumen & gives appearance of a crescent Double-contrast spot image of gastric body with patient in supine position shows incompletely filled ulcer on dependent or posterior wall as hemispheric ring shadow with two crescent-shaped barium-coated lines (arrows) coating various portions of inferior rim of ulcer
- 63. 9. Concurrent duodenal ulcer disease • its presence strongly suggests benign gastric ulceration • Unusual with malignant gastric disease
- 65. Neoplastic
- 67. • Malignant ulcerative lesion, Linitis plastica, gastric outlet obstruction, No trans-pyloric infiltration into duodenum • Malignant ulcerative lesion, Linitis plastica, NO gastric outlet obstruction, Trans-pyloric spread into duodenum Submucosal ulcerated lesion with exophytic large mass Bull’s-eye like lesion
- 68. Pseudoneoplasm Gastric diverticulum • Luminal outpouching with a broad neck • Normal mucosal pattern may be appreciated within the pouch • Location: 75% near GE junction on posterior wall; 20% on greater curvature at the gastric antrum • Defect changes size and shape during imaging (vs. an ulcer which is rigid) A. upright view: large outpouching from the gastric fundus near GE junction. Air/fluid level within the diverticulum B. supine view from same patient. Note the broad neck
- 69. Others • Gastric Bezoars • concretions of accumulated undigested material found in the stomach • Intraluminal filling defect not attached to bowel wall • Upright view may show a mass at air/fluid level interface (representing a bezoar floating on liquid within stomach) • Partial or complete obstruction
- 70. A2. Spot film shows contrast outlining filling defect, suggesting it is not attached to gastric wall. Upper endoscopy confirmed the diagnosis of a phytobezoar. A1. Filling defect in gastric body. Evidence of prior vagotomy, as indicated by surgical clips (arrowheads), which would contribute to delayed gastric emptying
- 71. Menetrier's Disease • idiopathic condition characterized by excessive mucus production, giant mucosal hypertrophy, hypoproteinemia, & hypochlorhydria (due to the loss of parietal cells) • gastric rugae are typically wider than 25mm (normal fold diameter does not exceed 5mm) • gastric body is most commonly affected, with frequent involvement of fundus antrum is typically spared • Barium meal findings: • Enlarged & serpiginous rugal folds in body & fundus secondary to glandular hyperplasia & hypertrophy • Folds may be poorly visualized secondary to poor adherence & dilution of oral contrast agent by excess mucus • Antral sparing (vs. lymphoma which preferentially occurs in antrum)
- 72. Menetrier's Disease enlarged rugae in body without abnormality in antrum
- 73. Gastric volvulus • stomach twists on its mesentery • It should be at least 180° & cause bowel obstruction to be called gastric volvulus • May occur in children due to congenital diaphragmatic defects • In adults, rarely occurs before age 50 o Most common cause in adults are diaphragmatic defects
- 74. 2 types •commonly occurs in trauma or para-esophageal hernia
- 75. Organo-axial volvulus • mirror image of normal anatomy can occur with reversal of the greater and lesser curves frontal radiograph from an upper GI examination shows stomach located in the lower chest in a large hiatal hernia. Greater curvature of the stomach lies superior to the lesser curvature organoaxial gastric volvulus. Note that the stomach is not obstructed
- 76. Mesentero-axial volvulus • displacement of antrum above GE-junction • stomach appears upside-down with antrum & pylorus superior to the fundus and proximal body close approximation of the pylorus ( short arrow ) & the gastroesophageal junction ( long arrow ), the relative positions of which are the inverse of normal lesser curvature ( L ) & greater curvature ( G ) maintain their normal relationship
- 77. Reference
Editor's Notes
- #12: %w/v = weight per volume, used when solid chemical is dissolved in a liquid (Ex. 250% w/v means 250gram of barium in 100ml of water)