Module 3: Lower

Gastrointestinal Tract
Abby Louisse Pearl A. Ventura, RRT
TABLE OF CONTENTS

01 03
Anatomy Lower GI Series
Small and large Contraindications,
intestine
02 indications, contrast media,
patient preparation

Small Bowel Procedures

Contraindications, indications, contrast
media, patient preparation
Small Intestine
■ 7 m (23 feet) in length
■ 3 parts: duodenum, jejunum, and ileum
Large Intestine
■ Begins in the right lower quadrant (RLQ) with its connection to the small intestine
■ 1.5 m (5 feet) long and about 6 cm (2.5 inches) in diameter
■ Consists of four major parts: cecum, colon, rectum, anal canal
Large Intestine
■ Barium enema of large intestine
Large versus Small Intestine
■ Internal diameter
■ Presence of multiple haustra
■ Relative positions
Digestive Functions of the Intestines
■ Digestion (chemical and mechanical)
■ Absorption
■ Reabsorption of water, inorganic salts, vitamin K, and amino acids
■ Elimination
Contrast Examinations of the Small Intestine
1. Small Bowel Series
2. Upper GI Small Bowel Combination
3. Complete Reflux Examination
4. Enteroclysis
5. Intubation Method
Indications
■ Enteritis – describes inflammation of the intestine, primarily of the small intestine
■ Regional enteritis (segmental enteritis or Crohn’s disease) – form of inflammatory bowel
disease of unknown origin, involving any part of the gastrointestinal tract but commonly
involving the terminal ileum
■ Giardiasis – common infection of the lumen of the small intestine that is caused by the
flagellate protozoan (Giardia lamblia)
■ Ileus – obstruction of the small intestine
a. Adynamic/paralytic – ileus due to the cessation of peristalsis
b. Mechanical obstruction – physical blockage of the bowel that may be caused by
tumors, adhesions, or hernia
■ Meckel’s diverticulum – common birth defect caused by the persistence of the yolk sac
(umbilical vesicle) resulting in a saclike outpouching of the intestinal wall
Indications
■ Neoplasm – term that means “new growth”
■ Lymphoma and adenocarcinoma – malignant tumors of the small intestine
○ Lymphomas – demonstrated during a small bowel series as the “stacked coin” sign
○ Adenocarcinomas – produce short and sharp “napkin-ring” defects within the
lumen, which may lead to complete obstruction
■ Sprue and malabsorption syndromes – conditions in which the gastrointestinal tract is
unable to process and absorb certain nutrients
■ Celiac disease – form of sprue or malabsorption disease that affects the proximal small
bowel, especially the proximal duodenum. It commonly involves the insoluble protein
(gluten) found in cereal grains
■ Whipple’s disease - rare disorder of the proximal small bowel whose cause is unknown
Contraindications
■ Pre-surgical patients
■ Patients suspected to have a perforated hollow viscus
■ Barium sulfate by mouth is contraindicated in patients with a possible
large bowel obstruction
Contrast Media
■ Thin mixture of barium sulfate
■ Water-soluble iodinated contrast medium
Patient Preparation
■ Soft or low residue diet for 2 days before the small intestinal study
■ Cleansing enema
■ Empty urinary bladder before and during the procedure
Small Bowel Series
Radiographic examination of the small intestine
Purpose
■ To study the form and function of the three components of the small bowel
■ To detect any abnormal conditions
Contrast Medium
■ E-Z Paque 70% w/v.
■ Alternative way for a double contrast effect: 600 ml of 0.5% methylcellulose
after 500 ml of 70% w/v barium
Patient Position
■ Supine
○ To take advantage of the superior and lateral shift of the barium filled
stomach for visualization of the retrogastric portions of the duodenum &
jejunum
○ To prevent possible compression overlapping of the intestine
■ Prone
○ To compress the abdominal content which increases radiographic quality
■ Final radiographs in thin patients: Trendelenburg position
Procedure
■ Plain abdomen radiograph (scout)
■ 2 cups (16 oz) of barium ingested (noting time)
■ 15- to 30-minute radiograph (centered high for proximal small bowel)
■ Half-hour interval radiographs (centered to crest) until barium reaches large bowel
(usually 2 hours)
■ 1-hour interval radiographs, if more time is needed (some routines including continuous
half-hour intervals)

Note:
■ Some patients are given:
○ a glass of ice water after 3 or 4 hours of administrating barium sulfate
○ a water-soluble gastrointestinal contrast medium, tea, or coffee
Projection for the Small Intestine
PA/AP Projection
■ Prone/supine
■ Sthenic Patients: Center the IR at the level of L2 for radiographs taken within 30 minutes after the
contrast medium is administered
■ Delayed radiographs: Center the IR at the level of the iliac crest
■ Respiration: Suspend at the end expiration
■ CR: Perpendicular to the midpoint of the IR (L2) for early radiographs or at the level of iliac crest for
delayed sequence exposures
Projection for the Small Intestine
PA/AP Projection
Projection for the Small Intestine
PA/AP Projection
Projection for the Small Intestine
PA/AP Projection
Projection for the Small Intestine
PA/AP Projection
 Upper GI Small
Bowel Combination
Routine upper GI series is performed first followed by the study of the entire
small bowel
Procedure
■ Routine upper GI first
■ Notation of time patient ingested first cup (8 oz) of barium
■ Ingestion of second cup of barium
■ 30-minute PA radiograph (centering high for proximal small bowel)
■ Half-hour interval radiographs, centered to iliac crest, until barium reaches large bowel (usually 2
hours)
■ 1-hour interval radiographs, if more time is needed after 2 hours

Optional
■ Fluoroscopy and spot imaging of ileocecal valve and terminal ileum (compression cone may be used)
 Complete Reflux
Examination
For a complete reflux examination of the small intestine, the patient's colon and
small intestine are filled by administering a barium enema to demonstrate
the colon and small bowel.
Complete Reflux Examination
■ Before examination, glucagon may be administered.
■ A 15% w/v barium suspension & about 4500 ml suspension is often used.
■ A retention enema tip is used.
■ Supine position.
■ The enema bag is then lowered to the floor to drain the colon before
radiographs of the small intestine are obtained.
Enterocylsis
Injection of nutrient or medicinal fluid into the bowel
Procedure
Patient Preparation: Cleansed colon
■ Special catheter advanced to duodenojejunal junction
■ Thin mixture of barium sulfate instilled
■ Air or methylcellulose instilled
■ Fluoroscopic spot images and conventional radiographs
taken

Projections: AP, PA, obliques, lateral

Intubation Method
Procedure in which a long, specifically designed tube is inserted through the
nose and passed into the stomach
Diagnostic Intubation/Small Bowel Enema
■ A single-lumen tube is passed into the proximal jejunum.
■ Placing the patient into a RAO position may aid in passage of the tube from the
stomach into the duodenum by gastric peristaltic action.
■ A water-soluble iodinated agent or a thin barium sulfate suspension is injected
through the tube.
■ Radiographs are taken at timed intervals similar to in a standard small bowel
series
Therapeutic Intubation
■ Performed often to relieve postoperative distention or to decompress a small
bowel obstruction.
■ A double-lumen catheter, termed a Miller-Abbott (M-A) tube, is advanced into
the stomach.
■ Through peristalsis, the catheter is advanced into the jejunum. The technologist
may be asked to take radiographs at timed intervals to determine whether the
catheter is advancing.
■ Gas and excessive fluids can be withdrawn through the catheter.
Lower GI Series/
Barium Enema
Radiographic study of the large intestine
Contraindications
■ Possible perforated hollow viscus
■ Possible large bowel obstruction
Clinical Indications
■ Colitis – inflammatory condition of the large intestine that may be caused by many
factors, including bacterial infection, diet, stress, and other environmental conditions
■ Ulcerative colitis - severe form of colitis that is most common among young adults
■ Diverticulum – outpouching of the mucosal wall that may result from herniation of the
inner wall of the colon
■ Intussusception – telescoping or invagination of one part of the intestine into another
■ Annular carcinoma (adenocarcinoma) – one of the most typical forms of colon cancer,
may form an “apple-core” or “napkin-ring” appearance as the tumor grows and infiltrates
the bowel walls
■ Polyps – saclike projections similar to diverticula except that they project inward into the
lumen rather than outward, as do diverticula
■ Volvulus – twisting of a portion of the intestine on its own mesentery, leading to a
mechanical type of obstruction
Patient Preparation
■ Section of alimentary canal to be examined must be empty
○ Includes dietary restrictions, laxative, & cleansing enemas
Equipment and Supplies
■ Closed-system enema container
■ 3 most common enema tips: plastic disposable, rectal retention, & air-contrast retention
Contrast Media
■ Single-contrast barium enema: 12%-25% w/v
■ Double-contrast barium enema: 75%-95% w/v or greater

■ Warm barium - 85°-90° F

■ Cold barium - 41° F (recommended)
Preparation for Rectal Tip Insertion
Before the rectal tip is inserted, instruct the patient:
■ To keep the anal sphincter tightly contracted against the tubing to hold it in
position and prevent leakage
■ To relax the abdominal muscles to prevent intraabdominal pressure
■ To concentrate on deep oral breathing to reduce the incidence of colonic spasm
and resultant cramp
Enema Tip Insertion
1. Describe the tip insertion procedure to the patient. Answer any questions.
2. Place the patient in Sims’ position. The patient should lie on the left side, with the right leg
flexed at the knee and hip.
3. Shake the enema bag once more to ensure proper mixing of barium sulfate suspension.
Allow barium to flow through the tubing and from the tip to remove any air in the system.
4. Wearing gloves, coat the enema tip well with water-soluble lubricant.
5. On expiration, direct the enema tip toward the umbilicus approximately 2..5 to 4.
6. After initial insertion, advance up superiorly and slightly anteriorly. The total insertion
should not exceed 3 to 4 cm. Do not force enema tip.
7. Tape tubing in place to prevent slippage. Do not inflate retention tip unless directed by the
radiologist.
8. Ensure the intravenous pole/enema bag is no more than 60 cm (24 inches) above the
table. Ensure the tubing stopcock is in the closed position, and no barium flows into the
patient.
Single Contrast Barium Enema
■ Procedure in which only positive-contrast media are used
■ Barium sulfate in a thin mixture
■ Water-soluble contrast material
Procedure
1. At the radiologist request, release the control clip and ensure the enema flow.
2. The rectal ampulla fills slowly.
3. The flow of the barium suspension is usually stopped for several seconds at frequent
intervals during the fluoroscopically controlled filling of the colon.
4. During the fluoroscopic procedure, the radiologist rotates the patient to inspect all
segments of the bowel.
5. The radiologist takes spot radiographs as indicated and determines the positions to be
used for subsequent radiographic studies.
6. On completion of the fluoroscopic examination, the enema tip is removed.
7. After the IRs have been exposed, the patient is escorted to a toilet or placed on a bedpan
and instructed to expel as much of the barium suspension as possible.
8. Post-evacuation radiograph is taken.
Double Contrast Barium Enema
1. Two-stage double-contrast examination– described by Welin, in which the
entire colon is filled with barium suspension. After the enema administration,
the patient evacuates the barium and immediately returns to the fluoroscopic
table where air or another gaseous medium is injected into the colon.
2. Single-stage double-contrast examination - barium and air are instilled in a
single procedure that reduces time and radiation exposure to the patient.
Single-Stage Procedure
■ 22% w/v
■ Miller – described a 7-pump method for performing single-stage double-contrast
examinations.
■ Fluoroscopy is performed to check the location of the barium, and additional air is
instilled under fluoroscopic control.
■ The patient is slowly rotated 360 degrees and placed in the supine position.
■ Then spot radiographs and overhead radiographs are taken.
Welin Method
■ Welin – developed a technique for double-contrast enemas that reveals even the smallest
intraluminal lesions.
○ the colon must be cleansed as thoroughly as possible
○ the colonic mucosa must be prepared in such a way that an extremely thin and
even coating of barium can adhere to the colonic wall
Welin Method
■ Stage one
○With the patient in the prone position to prevent possible ileal leak, the colon is
filled to the left colic flexure, after which a conventional radiograph is taken.
○ Air is instilled into the bowel, pushing the barium through to the right side.
■ Stage two
○ When the patient returns to the examining table, the enema tip is inserted and the
patient is again turned to the prone position.
○ Spot radiographs are made as indicated.

■ Welin stressed the importance of instilling enough air (1 800 to 2000 ml or more) to
obtain proper distention of the colon.
Projections
Barium Enema
PA Projection
■ Prone
■ Place the fluoroscopic table in a slight Trendelenburg position
■ CR: Perpendicular to the IR to center the midline of the body at the level of the iliac crest
PA Projection
PA Axial Projection
■ Prone
■ Center the IR at the level of the iliac crest
■ CR: 30-40 degrees caudad to enter the midline of the body at the level of ASIS
PA Axial Projection
PA Oblique Projection (RAO Position)
■ Prone
■ 35-45 degree rotation with the anterior right side of the body against the IR
■ IR at the level of the iliac crest
■ CR: Perpendicular to the IR and entering approximately 1-2 inches lateral to the midline of
the body on the elevated side at the level of the iliac crest
PA Oblique Projection (RAO Position)
PA Oblique Projection (LAO Position)
■ Prone
■ 35-45 degree rotation with the anterior left side of the body against the IR
■ IR at the level of the iliac crest
■ CR: Perpendicular to the IR and entering approximately 1-2 inches lateral to the midline of the
body on the elevated side at the level of the iliac crest
PA Oblique Projection (LAO Position)
Lateral Projection (R/L Position)
■ Lateral recumbent position on either left or right side
■ Flex the knees slightly for stability
■ Center of the IR to the ASIS
■ CR: Perpendicular to the IR to enter the midcoronal plane at the level of the ASIS
Lateral Projection (R/L Position)
AP Projection
■ Supine
■ Adjust the center of the IR at the level of the iliac crest
■ CR: Perpendicular to the IR to enter the midline of the body at the level of the iliac crest
AP Projection
AP Axial Projection
■ Supine
■ Center the IR at a level approximately 2 inches above the level of the iliac crest
■ CR: 30 to 40 degrees cephalad to enter the midline of the body approximately 2 inches
below the level of the ASIS
AP Axial Projection
AP Oblique Projection (LPO Position)
■ Supine
■ 35-45-degree rotation with the left posterior surface of the body against the IR
■ CR: Perpendicular to the IR to enter approximately 1-2 inches lateral to the midline of the
body on the elevated side at the level of the iliac crest
AP Oblique Projection (LPO Position)
AP Oblique Projection (RPO Position)
■ Supine
■ 35-45 degree rotation with the right posterior surface of the body against the IR
■ CR: Perpendicular to the IR to enter approximately 1-2 inches lateral to the midline of the
body on the elevated side at the level of the iliac crest
AP Oblique Projection (RPO Position)
AP/PA Projection (R lateral decubitus)
■ Px on the right side with the back in contact with the IR
■ IR to the level of the iliac crest
■ CR: Horizontal & perpendicular to the IR to enter the midline of the body at the level of
the iliac crest
AP/PA Projection (R lateral decubitus)
■ This position best demonstrates the "up" medial side of the ascending colon and the lateral side of the
descending colon when the colon is inflated with air.
PA/AP Projection (L lateral decubitus)
■ Px on the left side with the back in contact with the IR
■ IR at the level of the iliac crest
■ CR: Horizontal & perpendicular to the IR to enter the midline of the body at the level of
the iliac crest
PA/AP Projection (L lateral decubitus)
■ This position best demonstrates the "up" lateral side of the ascending colon and the
medial side of the descending colon when the colon is inflated with air.
Lateral Projection (R/L ventral decubitus)
■ Prone with either the R or L side against the IR
■ Center the IR at the level of the iliac crest
■ CR: Horizontal and perpendicular to the IR to enter the midcoronal plane of the body at
the level of the iliac crests
Lateral Projection (R/L ventral decubitus)
■ This position best demonstrates the "up" posterior portions of the colon and is most
valuable in double-contrast examinations.
Axial Projection
Chassard-Lapine Method
■ Used to demonstrate the rectum, rectosigmoid
junction, and sigmoid
■ Instruct the patient to sit well back on the side
of the table.
■ Center the I R to the midline of the pelvis, and
ask the patient to lean directly forward as far
as possible.
■ Have the patient grasp the ankles for support.
■ CR: Perpendicular through the lumbosacral
region at the level of the greater trochanters
Axial Projection
Chassard-Lapine Method