LARGE BOWEL SERIES ◦ Give laxative to patient

◦ NPO at midnight
◦Radiographic examination of the large bowel or ◦Another shot of cleansing enema in the morning
intestine.’ ◦ No breakfast
◦Also known as “BARIUM ENEMA” PURPOSE: to empty alimentary canal
◦Contrast media: Barium Sulfate or Water- soluble
iodinated cm, and Air EQUIPMENT

ANATOMY AND PHYSIOLOGY CATHETER

◦Soft rubber rectal catheter (for those who have
◦ Large Intestine inflamed hemorrhoids, fissures, stricture, or any
-begins in the right iliac region, where it joins the abnormalities in anus)
ileum of the ◦ Disposable rectal retention tips
small intestine, forms an arch surrounding the ◦Air capacity –90 ml at one complete squeeze of
loops of the small inflator
intestine, and ends at the anus -5 feet (1.5 m) long ◦ Enema bags –3 quartz or
and is greater 3000 ml
in diameter than the small intestine. A filter may be used to prevent passage of nay
mixed lumps of barium (18 to 24 inches above the
THE LARGE INTESTINE HAS FOUR rectum)
MAIN PARTS: ◦ Tubing –6 ft long
• Cecum ◦KY Jelly
• Colon INSERTION OF ENEMA TIP
• Rectum ◦ Turn the patient to left in Sim’s position and lean
• Anal canal forward around 35 to 40 degrees
◦Adjust the IV pole so that the enema contents are
BARIUM ENEMA no higher than 24 inches (61 cm) above the level of
INDICATIONS the anus.
◦Colitis ◦ Following the angle of the anus, direct the tube
◦ Diverticulum anteriorly 1 to 1.5 inches. Then following the curve
◦ Intussusception of the rectum, direct the tube slightly superiorly.
◦ Neoplasm Insert the tube for no more than 3.5 to 4 inches.
◦Adenocarcinoma METHODS
◦ Polyps ◦ SINGLE-CONTRAST–12%to 25%for weight/
◦Volvulus volume
CONTAINDICATIONS ◦ DOUBLE- CONTRAST –high- density barium
◦Bowel perforation product; 75%to 95%weight/ volume ratio
◦ Large bowel obstruction 1. Warm barium enema
◦Appendicitis ◦ Temperature below body temperature
◦Anastamosis ◦ 85 deg F to 90 deg F (29 deg to 30 deg C)
2. Cold barium enema
◦ 41 deg F (5 deg C)
PATIENTPREPARATIONS
◦Cleansing enema 1 day before the examination
◦ Light supper
SINGLE-CONTRAST STUDY
◦ The colon is examined with a barium sulfate
suspension only.
◦ When occlusion of the enema tip occurs, displace
soft fecal material by withdrawing the rectal tube
about 1 inch. Then before reinserting the enema
tip, temporarily elevate the enema bag to increase
fluid pressure.
◦ For completion, a post evacuation radiograph is
taken and if shows inadequate for satisfactory
delineation of the mucosa, the patient may give
hot beverage (tea or coffee) to stimulate further
evacuation.
LOCATION OF LARGE INTESTINE
STRUCTURES IN RELATION TO
PERITONEUM:
◦ Intraperitoneal: within the peritoneal cavity
◦ Retroperitoneal: behind the peritoneal cavity
1.Cecum
2.Ascending colon
3.Transverse colon
4.Descending colon
5.Sigmoid colon
6.Upper rectum
7.Lower rectum
RELATIVE LOCATION OF AIR AND BARIUM
LARGE INTESTINE STRUCTURES
• SUPINE POSITION:
AIR: rises and fills the most anterior structures
(intraperitoneal structures)
BARIUM: sinks and fills the most posterior
structures (retroperitoneal structures)
PRONE POSITION: reversed above mentioned!
DOUBLE- CONTRAST STUDY
◦ Two- stage double- contrast procedure (Welin
technique)
◦Single- stage double- contrast procedure
TWO-STAGE DOUBLE CONTRAST
◦ For the investigation of smaller intraluminal
lesions
◦ Early diagnosis of ulcerative colitis, regional
colitis, and polyps
◦ Requirements (1) the colon must be cleansed as
thoroughly as possible, and (2) 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.
◦ Patient does not have to be in the examination
room more than 20 to 25 minutes.
STAGE ONE
◦ Patient is in prone position to prevent possible
ileal leak
◦ The colon is then filled to the left colic flexure
(right lateral projection for rectum).
◦ The patient is then sent to the lavatory for the
evacuation of the material.
STAGE TWO
◦ The patient is again turn to prone position.
◦ Barium mixture to run up to the middle of the
sigmoid.
◦ Patient is then turned to right side, and air is
instilled into the enema tip.
◦ Patient is turned to provide adequate coating of
the
contrast agents.
◦ Instill enough air –1800 to 2000 ml or more –to
obtain proper distention of the colon.
◦ Radiographs are obtained.
SINGLE-STAGE DOUBLE CONTRAST
◦ The patient’s colon should be exceptionally clean.
◦Suitable barium suspension should be used (200%
weight/ volume ratio).
◦ Miller described 7- pump method for performing
this double contrast study.
◦ Patient is slowly turned 360 degrees and placed in
supine position
1. Insertion if enema tip creates closed system
◦ Flow rate controlled by:
◦ Degree of enema bag elevation
◦ Gentle manual pressure on bag
◦ Pressure cuff (for thicker mixture)
◦ Incorporated filter that prevents passage of
clumps into tubing
2. Barium is instilled in colon
3. Passive, controlled evacuation is affected by
lowering bag.
◦ Patient does not leave the table
◦ Enema tip is not removed
4. Amount of barium is adjusted
◦Siphoning of excess in retrograde manner
◦ Lowering bag, which enables bulk of enema to be
withdrawn with immediate relief of distention and
cramps and prevention of spillage
5. Filled colon is filmed
◦Reintroduction of the material as indicated by
condition of the patient
6. Double- contrast study is started immediately by
simply inverting the bag
◦ Carbon dioxide or air is introduced into
colon by applying gentle pressure
◦ Amount and rate of flow are controlled by
fluoroscopic observation
◦ Examination is complete. Closed system
has not been broken. Entire examination has been
performed in single stage.
CONTRAST MEDIA
1. BARIUM SULFATE
◦ Colloidal preparations –finely divided barium
particles that resists precipitation
◦ Suspended or flocculation- resistant preparations
–contain some form of suspending or dispersing
agent
◦ High- density barium sulfate –for uniform coating
of lumen especially for double- contrast studies
2. GASEOUS MEDIUM
◦ Air
◦ Carbon dioxide –more rapidly absorbed when
evacuation is incomplete
3. WATER- soluble, iodinated contrast agent –
used orally when retrograde filling of the colon
with barium is not possible or is contraindicated
◦ Transit time: (ingestion to colonic filling) 3 to 4
hours
PROJECTIONS
◦ PA OR AP PROJECTION
◦ Patient position: Prone/ Supine
◦ Part position: Center at the level of iliac crests.
Trendelenburg to help separate redundant and
overlapping loops of the bowel by spilling them out
of the pelvis.
◦ Central ray: Perpendicular
◦ Structure shown: Entire colon
◦ PA AXIAL OR AP AXIAL
◦ Patient position: Prone/ Supine
◦ Part position: Center at the level of the iliac crests
for PA Axial and 2 inches above the iliac crests if AP
Axial
◦ Central ray: 30 to 40 degrees
caudad if PA Axial and 30 to 40 degrees cephalad if
AP Axial
◦ Structure shown: Rectosigmoid area
with less superimposition.
◦PA OBLIQUE PROJECTION (RAO) OR
AP OBLIQUE PROJECTION (LPO)
◦ Patient position: Prone/ Supine
◦ Part position: 35 to 45 degrees
◦Central ray: Perpendicular
◦Structure shown: Right colic flexure, ascending
portion of the colon, sigmoid portion
◦PA OBLIQUE PROJECTION (LAO) OR
AP OBLIQUE PROJECTION (RPO)
Patient position: Prone/ Supine
◦ Part position: 35 to 45 degrees body rotation
◦Central ray: Perpendicular
◦Structure shown: Left colic flexure, descending
portion of the colon
◦ LATERAL PROJECTION (R OR L)
◦ Patient position: Lateral
recumbent
◦ Part position: Center at the ASIS level.
◦Central ray: Perpendicular
◦Structure shown: Rectum, distal sigmoid portion
◦ AP OR PA PROJECTION (RIGHT LATERAL
DECUBITUS POSITION)
◦ Patient position: Place the patient on his
right side with the back or abdomen against the IR
◦ Part position: Center at the level of the iliac
crests.
◦ Central ray: Horizontal and perpendicular
◦ Structure shown: “up” medial side of the
ascending colon and the lateral side of the
descending colon when the colon is inflated with
air
AP OR PA PROJECTION (LEFT LATERAL
DECUBITUS POSITION)
◦ Patient position: Place the patient on his left side
with the back or abdomen against the IR
◦ Part position: Center at the level of the iliac
crests.
◦ Central ray: Horizontal and perpendicular
◦ Structure shown: “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 OR VENTRAL
DECUBITUS POSITION)
◦ Patient position: Prone with right or left side
against the IR
◦ Part position: Center at the level of the iliac crests
◦ Central ray: Horizontal and perpendicular
◦ Structurer shown: ‘’up” posterior portions of the
colon and is most valuable in double- contrast
examination
◦AP, PA, OBLIQUE, LATERAL – UPRIGHT
◦ Identical to those of in recumbent position
◦ However, the IR is placed at a lower level to
compensate for the drop of the bowel
because of the effect of the gravity.
◦ AXIAL PROJECTION (CHASSARD- LAPINE
METHOD/JACK KNIFE POSITION/
SQUATSHOT)
◦ Patient position: Seat the patient on the
radiographic table.
◦ Part position: Abduct the thighs; Lean directly
forward as far as possible; have the patient grasp
the ankles for support.
◦ Central ray: Perpendicular through the
lumbosacral region at the level of greater
trochanters
◦ Structure shown: Rectum, rectosigmoid junction,
sigmoid in axial projection
MODIFICATIONS
◦BILLING MODIFICATION
◦ Patient/ Part position: Supine
◦Central ray: 35 to 45 degrees cephalad
◦Structure shown: Rectosigmoid junction (to avoid
overlapping of bowel loops)
◦ OPPENHEIMER MODIFICATION
◦ Patient/ Part position: Supine
◦Central ray: 12 degrees caudally to 1 inch
proximal to upper border of pubic symphysis
◦Structure shown: Rectosigmoid junction
◦ FLETCHER MODIFICATION
◦ Patient position: Supine
◦ Part position: Place the patient in Left Anterior
Oblique position
◦Central ray: 30 to 35 degrees cephalad to 2 inches
medial to elevated ASIS
◦Structures shown: best demonstration of
rectosigmoid colon
◦ROBIN MODIFICATION
◦Patient position: Recumbent
◦Part position: Left Lateral
◦Central ray: Perpendicular to 2 inches posterior to
midaxillary plane
◦Structures shown: Demonstrates direct lateral
view of the rectosigmoid colon without
superimposition
DEFECOGRAPHY
◦ This is a relatively new radiologic procedure
performed on patients with deflectional
dysfunction.
◦Also known as “EVACUATION PROCTOGRAPHY
OR DYNAMIC RECTAL EXAMINATION”
CONTRAST MEDIA:
◦ Early investigators mixed a diluted suspension of
barium sulfate, heated it, and added potato starch
to form a smooth barium paste that was semi-solid
and malleable.
◦ Now, 100%weight/ volume barium sulfate pastes
with special injector.
INDICATIONS
◦Rectocele
◦Rectal intussusception
◦ Prolapse of the rectum
EQUIPMENT
1.Fluoroscopic unit
2.Radiolucent commode chair
PROCEDURES
1. Place radiographic table vertical and attach
commode with clamps.
2. Prepare the appropriate contrast media
according to department specifications.
3. Set up imaging equipment (fluoroscopy or digital
recorder), or use digital fluoroscopy.
4. Ask patient to remove all clothing and change
into a hospital gown.
5. Take a scout image using a conventional x-ray
tube.
(Scout image must include the region of the
anorectal angle.)
6. Place patient in a lateral recumbent position on a
cart and instill contrast media.
7. Position patient on the commode and take
radiographs in the rest and strain phases, with
patient in a lateral position.
8. Using fluoroscopy imaging devices or digital
recorder, image patient during defecation.
9.Assist in taking of post evacuation radiograph.
FISTULOGRAM
◦ This procedure is performed to locate and
demonstrate the extent of a sinus or fistulous tract
and its connection to any cavity or hollow viscera.
This can be done by an injection of contrast media
through an orifice on the abdominal wall or
through a drainage tube already placed into the
orifice.
◦Also known as “SINOGRAM”
CONTRAST MEDIA
◦Water- soluble; if there’s any suggestion that
there is a connection with the pleural cavity, an oil-
based contrast medium such as Dionosil issued.
EQUIPMENT
◦ Fluoroscopic unit with a spot film device/ 105 mm
cine
◦ Fine catheter
◦ 20-ml syringe
◦Blunt needle
◦ Gauze padding (4x4)
PROCEDURE
◦AP projection (scout)
◦ The patient is placed on the table so that the
orifice of the sinus is easily accessible to the
radiologist.
◦ The technologist removes the dressing and fills
syringe with contrast medium.
◦A blunt needle is attached to the end of the
syringe.
◦ The filled syringe is attached to the catheter,
which is then inserted into the opening of sinus.
◦ Under fluoroscopic control, an AP projection is
taken immediately before injection.
◦ A pad of gauze is placed over the orifice of the
patent is asked to firmly place a gloved finger on
the gauze. This should prevent a reflux of contrast
medium back onto the skin.
◦ The contrast medium is injected under
fluoroscopic guidance, the amount depending on
the size of the sinus or fistula.
◦Radiographs are taken as required, usually AP,
both obliques, and lateral views.
◦At the completion, the catheter is removed, and a
fresh sterile dressing is placed over the opening.