Small Intestine

Radiologic examinations of the small intestine are performed by administering a barium

sulfate preparation ( l ) by mouth, (2) by complete reflux filling with a large volume barium
enema, or (3) by direct injection into the bowel through an intestinal tube, a technique that is
called enteroclysis, or small intestine enema. The latter two methods are usually used only
when the oral method fails to provide conclusive information. Enteroclysis is the technically
difficult,

PREPARATION FOR EXAMINATION

preferably, the patient has a soft or low-residue diet for 2 days before the small intestine
study. Because of economics, however, it often is impossible to delay the examination for 2
days. food and fluid are usually withheld after the evening meal of the day before the
examination, and breakfast is withheld on the day of the study. A cleansing enema may be
administered to clear the colon; however, an enema is not always recommended for
enteroclysis because enema fluid may be retruned in the small intestine. The barium formula
varies depending on the method of examination. The patient's bladder should be empty before
and during the procedure to avoid displacing or compressing the ileum.

ORAL METHOD OF EXAMINATION

The radiographic examination of the small intestine is usually termed a small bowel series
because several identical radiographs are done at timed intervals. The oral examination, or
ingestion of barium through the mouth, is usually preceded by a preliminary radiograph of the
abdomen. Each radiograph of the small intestine is identified with a time marker indicating
the interval between its exposure and the ingestion of barium. studies are made with the
patient in the supine or prone position. The supine position is used (1) to take advantage of the
superior and lateral shift of the barium-filled stomach for visualization of the retrogastric
portions of the duodenum and jejunum and (2) to prevent possible compression overlapping
of loops of the intestine. The prone position is used to compress the abdominal contents, this
enhances radiographic image quality. For the final radiographs in thin patients, it may be
necessary to angle the table into the Trendelenburg position to "unfold" low-lying and
superimposed loops of the ileum.

The first exposure of the small intestine is usually taken 15 minutes after the patient drinks the
barium. The interval to the next exposure varies from 15 to 30 minutes depending on the
average transit time of the barium sulfate preparation used. Regardless of the barium
preparation used, the radiologist inspects the radiographs as they are processed and varies the
procedure according to requirements for the individual patient. Fluoroscopic and radiographic
studies (spot or conventional) may be made of any segment of the bowel as the loops become
opacified.

Some radiologists request that a glass of ice water (or other routinely used food stimulant) be
given to the patient with hypomotility after 3 or 4 hours of administrating barium sulfate to
accelerate peristalsis. Others give patients a water soluble gastrointestinal contrast medium,
tea, or coffee to stimulate peristalsis. others radiologists administer peristaltic stimulants every
15 minutes through the transit time. With these methods, the transit of the medium is shown
fluoroscopically, spot and conventional radiographs are exposed as indicated, and the
examination is usually completed in 30 to 60 minutes.

COMPLETE REFLUX EXAMINATION

For a complete reflux examination of the small intestine, the patient's colon and small
intestine are filled by a BE administered to show the colon and small bowel . Before the
examination, glucagon may be administered to relax the intestine. Diazepam (Valium) may
also be given to diminish patient discomfort during the initial filling of the bowel. A 15% ±
5% weight/volume barium suspension is often used, and a large amount of the suspension
(about 4500 ml) is required to fill the colon and small intestine.

A retention enema tip is used, and the patient is placed in the supine position for the
examination. The barium suspension is allowed to flow until it is observed in the duodenal
bulb. The enema bag is lowered to the floor to drain the colon before radiographs of the small
intestine are obtained (Fig. 1 7-67 ) .

ENTEROCLYSIS PROCEDURE
Enteroclysis (the injection of nutrient or medicinal liquid into the bowel ) is a radiographic
procedure in which contrast medium is injected into the duodenum under fluoroscopic control
for examination of the small intestine. Contrast medium is injected through a specially
designed enteroclysis catheter, historically a Bilbao or Sellink tube.

Before the procedure is begun, the patient's colon must be thoroughly cleansed. Enemas are
not recommended as preparation for enteroclysis because some enema fluid may be retained
in the small intestine. Under fluoroscopic control, the enteroclysis catheter with a stiff
guidewire is advanced to the end of the duodenum at the duodenojejunal flexure , near the
ligament of Treitz. The retetntion ballon, if present, is filled with sterile water or saline.
Barium is instilled through the tube at a rate of approximately 100 ml/minute ( Fig. 1 7-68) .
Spot radiographs, with and without compression, are taken as required. In some patients, air is
injected into the small intestine after the contrast fluid has reached the cecum (Fig. 1 7-69).

After fluoroscopic examination of the patient's small intestine, radiographs of the small
intestine image. The projections most often requested include the AP, PA, obliques, and
lateral . Both recumbent and upright images may be requested. (positioning descriptions
involving the abdomen are presented in Chapter 1 6. )

INTUBATION EXAMINATION
PROCEDURES
Gastrointestinal intubation is the procedure in which a long, specifically designed tube is
inserted through the nose and passed into the stomach. From there the tube is carried
inferiorly by peristaltic action. Gastrointestinal intubation is used for both therapeutic and
diagnostic purposes.

When gastrointestinal intubation is used therapeutically, the tube is connected to a suction

system for continuous siphoning of the gas and fluid contents of the gastrointestinal tract. The
purpose of the maneuver is to prevent or relieve postoperative distention or to deflate or
decompress an obstructed small intestine.

Although used much less frequently than in the past, a Miller-Abbott (M-A ) double-lumen,
single balloon tube (or other similar tubing) can be used to intubate the small intestine. Just
above the tip of the M-A tube is a small, thin rubber balloon. Marks on the tube, beginning at
the distal end, indicate the extent of the tube's passage and are read from the edge of the
nostril . The marks are graduated in centimeters up to 85 cm and are given in feet thereafter.
The lumen of the tube is asymmetrically divided into the following: (1) a small balloon lumen
that communicates with the balloon only and is used for the inflation and deflation of the
balloon and for the injection of mercury to weight the balloon and (2) a large aspiration lumen
that communicates with the gastrointestinal tract through perforations near and at the distal
end of the tube. Gas and fluids are withdrawn through the aspiration lumen, and liquids are
injected through it.

The introduction of an intestinal tube is an unpleasant experience for the patient, especially
one who is acutely ill. Depending on the condition of the patient, the tube is more readily
passed if the patient can sit erect and lean slightly forward or if the patient can be elevated
almost to a sitting position.

With the i ntestinal tube in place, the patient is turned to an RAO position, a syringe is
connected to the balloon lumen, and the mercury is poured into the syringe and allowed to
flow into the balloon . The air is then slowly withdrawn from the balloon. The tube is secured
with an adhesive strip beside the nostril to prevent regurgitation or advancement of the tube.
The stomach is aspirated, either by syringe or by attaching the large position of the lumen to
the suction apparatus.

With the tip of the tube situated close to the pyloric sphincter and the patient i n the RAO
position (a position in which gastric peristalsis is usually more active), the tube should pass
into the duodenum in a reasonably short time. Without intervention, however, this process
sometimes takes many hours. Having the patient drink ice water to stimulate peristalsis is
often successful. When this measure fails, the examiner guides the tube into the duodenum by
manual manipulation under fluoroscopic observation. After the tube enters the duodenum, it is
again inflated to provide a bolus that the peristaltic waves can more readily move along the
intestine.

When the tube i s i nserted for decompression of an i ntestinal obstruction and possible later
radiologic i nvestigation, the adhesive strip is removed and replaced with an adhesive loop
attached to the forehead. The tube can slide through the loop without tension as it advances
toward the obstructed site. The patient is then returned to the hospital room. Radiographs of
the abdomen may be taken to check the progress of the tube and the effectiveness of
decompression. S i mple obstructions are sometimes rel i eved by suction; others require
surgical i ntervention.

If the passage of the i ntestinal tube is arrested, the suction i s discontinued and the patient is
returned to the radiology department for an M-A tube study. The contrast medium used for
studies of a localized segment of the small i ntestine may be e i ther a water-sol uble,
iodinated solution (Fig. 1 7-70) or a thjn barium sulfate suspension. Under fluoroscopic
observation the contrast agent is i njected through the large l u me n of the tube with a
syringe. Spot and conventional radiographs are obtained as i ndicated.

When the intestinal tube is introduced for the purpose of perform i ng a small intestine enema,
the tube is advanced into the proxi mal loop of the j ejunum and then secured at this level with
an adhesive strip taped beside the nose. Medical opinion varies as to the quantity of barium
suspension required for this examination (Fig. 1 7-7 1 ). The medium i s i njected through the
aspiration l umen of the tube in a continuous, low-pressure flow. Spot and conventional
radiographs are exposed as indicated. Except for the presence of the tube in the upper
jejunum, the resultant radiographs resemble those obtained by the oral method.

CONTRAST STUDIES
There are two basic radiologic methods of examining the large in testine by means of
diagnostic or contrast enemas the: (1) the single-contrast method ( Fig. 1 7-72), in which the
colon is examined with a barium sulfate suspension only, and (2) the double-contrast method
(Fig.17-73 ) , which may be performed as a two-stage or single-stage procedure. In the two-
stage double-contrast procedure, the colon is examined with a barium sulfate suspension and
then, immediately after evacuation of the barium suspension, with an air enema or another
gaseous enema. In the single-stage double-contrast procedure the fluoroscopist selectively
injects the barium uspen ion and the gas.

The contrast medium demonstrates the anatomy and tonus of the colon and most of the
abnormalities to which it is subject. The gaseous medium serves to distend the lumen of the
bowel and to render visible, through the transparency of its shadow, all parts of the barium-
coated mucosallining of the colon and any small intral uminallesion , such as polypoid
tumors.

Contrast media
Commercially prepared barium sulfate products are generally used for routine retrograde
examinations of the large intestine. Some of these products are referred to as colloidal
preparations because they have finely divided barium particles that resist precipitation,
whereas others are referred to as suspended or flocculation-resistant preparations because they
contain some form of suspending or dispersing agent.

The newest barium products available are referred to as high-density barium sulfate. These
products absorb a greater percentage of radiation, similar to the older "thick" barium products.
High density barium is particularly useful for double-contrast studies of the all mentary canal
in which uniform coating of the lumen is required.

Air is the gaseous medium usually used in the double-contrast enema study. Therefore the
procedure is generally called an air-contrast study. Carbon dioxide may also be used because
it is more rapidly absorbed than the nitrogen in air when evacuation of the gaseous medium is
incomplete. Specifically prepared water-soluble, iodinated contrast agents are administered
orally to selected patients when retrograde filling of the colon with barium is not possible or is
contraindicated. A disadvantage of the iodinated solutions is that evacuation often is
insufficient for satisfactory double-contrast visualization of the mucosal pattern. However,
when a patient is unable to cooperate for a successful enema study, orally administered
iodinated medium allows satisfactory examination of the colon. With these oral agent, transit
time from ingestion to colonic filling is fast, averaging 3 to 4 hours. Furthermore, iodinated
solutions are practically non absorbable from the gastrointestinal mucosa. As a result, the oral
dose reaches and outlines the entire large bowel . in contrast to an ingested barium sulfate
suspension, this medium is not subject to drying, flaking, and unequal distribution in the
colon. It frequently delineates the intestine almost as well as the BE does.