Barium Study:- Types of Study, Procedure, Common

Disease Interpretation.

Presenter : Sudhir Jha Moderator : Ranjit kr Jha

Assistant Professor BPKIHS , Dharan
BSc.MIT 2017 batch 1
PROPERTIES OF BARIUM

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BARIUM STUDIES:

Ba as a contrast media is used in the form of BaSo4.

Inert, suspended in water and there is very little absorption

from GIT.

Contrast agent of choice in majority of examinations in

which “bowel lumen must be visualised”.

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Atomic no. 56

It is insoluble & stable & will pass through GIT without

dissolving or changing its form of substances poisonous.

Causes little upset to the tract. (may aggravate

constipated condition)

The additive present in the preparation ensure that there is

no undue flocculation or sedimentation.

Cheap

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Particle size: 5 to 12 µm.

No. of additives are added like

❖ Suspending.
❖ Deforming.
❖ Flavouring agents like lemon, mint,
Strawberry.
❖ Coating agent.
❖ Viscosity varying agent.

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PROPERTIES

Form White crystalline powder.

Mol wt. 233

Specific gravity 4.5

PH 5.3
At. Num. 56
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● Used along with negative contrast agent such as air,
CO2 to achieve double contrast effect.
● Co2 is said to cause less abdominal pain but inferior
bowel distention compared to air.
● For upper GIT CO2 is administered in form of gas
producing granules / powder.

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➢ For large Bowel – Room air is administered into the rectum
via pump attached to enema tube.

➢ Some commonly used other gas producing agents are

like:-

Sodium bicarbonate .
Eno,coke
Tartic acid
Citric acid(citricacid+Na2Co3= Carbex granules)

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.
The major advantage of barium sulphate preparation over water soluble
contrast agent are:-

● Lack of significant absorption from bowel results in

radiographic contrast that is not significantly degraded
throughout bowel.

● Coats the mucosa in a thin layer for long period of

time, allowing introduction of second or negative
contrast agent without significant degradation.

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DISADVANTAGES:
● Barium sulphate outside the bowel lumen is treated
as foreign.

● Barium impaction.

● Subsequent abdominal CT and US are rendered

difficult to interpret.

● Patients may be asked to wait for up to 2 weeks to

allow satisfactory clearance of the barium.
(Magnetic Resonance Enterography is rapidly
replacing Barium study now a days).

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Types of Barium Study:

❖ SWALLOW :Pharynx, Esophagus

❖ MEAL: Stomach
❖ MEAL FOLLOW THROUGH / Enteroclysis: Small bowel
❖ ENEMA – Rectum, sigmoid, descending,
transeverse ,ascending colon and cecum

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 Barium swallow

Barium meal

Barium
Barium follow
enema through/
Enteroclysis

Barium enema 12
Barium Preparations

❖ Single contrast study: Low to Moderate density:

50-100% w/v
❖ Double contrast study: High Density 200-250
w/v
❖ Enteroclysis: 15-20 % w/v or denser solution
❖ Oral Contrast in CT Studies: 7 %w/v

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Patient Preparation
❖ Overnight (4-6 hour) fasting
❖ Abstain from smoking – alcohol
❖ Anticholinergic agents: Ba meal and enema
Hyoscine/glucagon – hypotonic drugs; reduces peristalsis
– administered before exam – maintain distention, inhibit
peristalsis, reduce secretions
❖ Low fiber diet and high fluid intake esp. for BMFT and Ba-
Enema
❖ Purgative- enema.

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Barium Swallow:-
Indications:-

● Dysphagia
● Odynophagia
● Heartburn
● Retrosternal chest pain
● Regurgitation
● Anaemia
● Assessment of tracheo-esophageal fistulae
● Evaluate esophageal strictures
● Evaluate esophageal mass lesion
● Evaluate suspected achalasia cardia/ hiatus hernia/ congenital
web/diaphragms/Rings

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●
CONTRAINDICATIONS
Practically none.

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CONTRAST MEDIUM

● Barium suspension is made up of pure Barium sulphate.

EQUIPMENTS
● Rapid serial radiography or cineradiography (the filming of
motion pictures through a fluoroscope or x-ray machine)

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● Single contrast study:
● Circumferential carcinoma, strictures, webs, large rings,
ulcers, hiatus hernia, extrinsic compressive masses
● Double contrast study:
● Subtle mucosal lesions, early changes of inflammatory and
neoplastic diseases (better mucosal evaluation)
● Mucosal relief technique- esophageal mucosal folds
in collapsed state: Thickened folds (oesophagitis), Varices
● Barium filling : Contour abnormalities, strictures and large
polypoidal filling defects.

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TECHNIQUE

A. Single contrast swallow :

(Low density: 100 %).
● Position – RAO.
● Patient is asked to take a mouthful of barium and
initial screening is done as it passes along the whole
length of esophagus to note any gross lesion.
● If rapid serial radiography is required, performed in
RAO & PA positions.

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➢ Barium filling method –

● Basic film while examining the full length view of

esophagus distended with barium.
● Position – RAO
● Patient is asked to swallow continuously & either full
length view or at least two spot films showing the upper
& mid and mid & lower part is taken.
● Important to demonstrate structural abnormalities and
secondly for adequate visualization of distal third
esophagus & esophagogastric junction.

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Barium Filling Technique

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Benign Malignant

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➢ Mucosal relief films-

● It is defined as films taken of collapsed esophagus with

esophageal folds visible & coated with barium suspension.

● Patient is asked to take one or two swallows of dense barium

suspension & after peristalsis has stripped most of the
barium into the stomach, radiographs are taken.

● It is important in the diagnosis of reflux esophagitis,

infectious esophagitis & esophageal varices.

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Esophagus mucosa: normal thin, parallel, uniform mucosal folds

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B. Double contrast swallow :

● Hight density barium preparation: 200-250 W/V.

● DC radiographs are obtained after the mucosal surface

has been coated with a thin layer of high density barium
& the viscus has been distended with air.

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Double Contrast Film

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 MODIFICATION

Motility Disorder :

● Swallow in lying down position

● Position : Prone LPO

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External Displacement :

➢ In suspected cases, a PA and lateral radiograph

are useful to demonstrate anatomic relationships
to opacified esophagus.

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Reflux :

● Table is kept in head down position.

● Patient is first placed in Lt decubitus and then
turned supine (which causes Barium to
accumulate in fundus of stomach) Patient is then
slowly turned to Right causing Barium in fundus to
pour over Cardia, during this maneuver reflux may
be seen. (Repeated several times to evaluate the
area.) (Left-Supine-Right).
● Abdominal compression can also be given to help
precipitate reflux.

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Bread Barium :
● Indication :

➢ when a stricture is suspected but can’t be adequately

demonstrated.
➢ Bread soaked with barium.

➢ Gives useful information about localized non-

distentability or areas of poor contraction.

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COMPLICATIONS
1. Leakage of barium from an unsuspected perforation,
2. Aspiration

Some Common Conditions:-

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Achalasia Cardia
X-ray Chest:
❑ Mediastinal widening with air –fluid levels
❑ Small/Absent Gastric fundal bubble
❑ Aspiration pneumonia

Barium swallow findings:

❑ Oesophagus – dilated Proximally, torturous, may
contains food residue

❑ Lower end of oesophagus abrupt narrow , with no

evidence of mucosal destruction or shouldering

❑ GEJ tapered as BIRD-BEAK or RAT TAIL appearance.

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Achalasia Cardia

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Benign Stricture

•Short segment
•Concentric
•Smooth lumen
•Gradual tapering
(hourglass configuration)

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 Malignant Stricture

•Short segment
•Abrupt narrowing with shouldering
•Mucosal irregularity with destruction

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 Strictures: Benign vs. Malignant
BENIGN MALIGNANT
Short (peptic) or long (corrosive) Mostly short segment
segment
Concentric narrowing Eccentric narrowing
Smooth lumen Irregular lumen
No ulceration/mucosal Mucosal
destruction irregularity/nodularity/ulcers
present

Gradual smooth tapering Abrupt, asymmetric transition

Proximal dilatation Proximal shouldering

Hour-glass configuration Apple-core appearance 36
BARIUM MEAL
● A Radiographic exam of the stomach & the
duodenum till the duodenojejunal junction by
giving radio-opaque c/m orally.

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INDICATIONS:
❖ Failed upper GI endoscopy.
❖ Dyspepsia.
❖ GI haemorrhage (or unexplained iron-deficiency
anamia).
❖ Partial obstruction.
❖ Unexplained wt loss .
❖ Palpable mass in upper abdominal.
❖ Pyloric stenosis (GOO).

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CONTRAINDICATIONS:

❖ Complete large bowel obstruction.

❖ Risk of aspiration.

❖ Recent biopsy of stomach- is a relative CI to

upper GI contrast study on the same day.

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PT PREPARATION:

❖ NPO for 5- 6 hrs prior to the examination (false

impression of small growth or ulcers.)
❖ Smoking is prohibited.
❖ It should be ensured that there is no CI to
pharmacological agents .
❖ Female pts should be ask of pregnancy.
❖ Pt is advised to stop taking any medicine e.g.
bismuth.

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CONTRAST MEDIA:

❖ High density and low viscosity BaSo4 of

around 200-250% w/v for double contrast.
❖ For single contrast 80-100%.
GAS:
❖ Effervescent agents in the form of
powder ,granules,tablets,aerated
liquid,ENO, etc.

❖ Sufficient to produce 300-400 ml of gas .

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HYPOTONIC AGENTS:

❖ Smooth muscle relaxant are used to produce a state of

hypotonia in the stomach & duodenum for high quality
double contrast studies .
❖ Buscopan & glucogan are widely used.

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METHODS:
a) Single contrast.

b) Double contrast.

c) Hypotonic duodenography.

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SINGLE CONTRAST STUDY

❖ In this tech only Ba without use of hypotonic

agents is indicated in pts .

It permits better evaluation of:-

❖ Motility diorders.
❖ Visceral rigidity.
❖ Spasms ,stricture .

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❖ It is done in pts who present with vomiting due to
suspected obstructive lesion of the gastric antrum &
duodenum.

❖ Very ill pts where limited study is required to answer a

specific clinical question.

❖ In children where usually it is not necessary to

demonstrate mucosal pattern.

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 TECHNIQUE:
● Pt is checked under fluoro to determine any fluid or food in
the stomach.

❖ Pt is asked to swallow a big mouthful of 100% w/v Ba. &

spot films of esophagus & G.E junction is taken.

❖ By manual manipulation the mucosa is coated & film is

taken in supine RAO position.

❖ Pt is ask to drink rest Ba to fill the stomach & film of filled

stomach is taken in lat position

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● Spot film of duodenum bulb are taken to look
for peptic ulcer ,both in filled & empty phase .

❖ Lastly duodenal loop has to be documented in at least

two positions.

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Filming sequence :

1st film –LPO for lower esophagus & G.E junction.

2nd film-RAO for mucosal film of stomach.

3rd film –R lat of filled stomach.

spots of duodenum –RAO & R lat.

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TECHNIQUE:

❖ Rapid fluoro of chest & abdomen is done to see any

gross pathology.
❖ Buscopan 20mg IV is given (smooth muscle relaxant).

❖ Then gas producing substances are given & also Ba

solution given (100-150ml of contrast ).
❖ Pt lies supine to bring Ba against GE junction to
check for reflux, if it observed film taken to record
the level.

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❖ After taking 100-150ml of contrast asked to roll on Rt side
then on Lt before lying supine or to roll over a complete
circle to finish RAO position.

❖ This maneuver is done to coat the gastric mucosa.

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To ensure proper coating:-

❖ There shouldn't be flocculation

❖ Outline coating should be properly seen

❖ The gastricae (net like structure in the antrum)

are visible.

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HYPOTONIC DUODENOGRAPHY
❖ This is the radiographic exam of duodenal loop in the
relaxed state ,free from peristaltic movement .

❖ This is produced by injection of anticholinergic drug such

as buscopan or glucagon.

❖ INDICATIONS:
❖ Primary lesions of duodenum.
❖ Duodenitis.
❖ Details of duodenum.
❖ Investigations of obscure gastrointestinal bleeding.
❖ Poor distension ,unusual position of duodenal loop.

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.
TECHNIQUE:
❖ The tip of the catheter is placed on lower part of
ascending duodenum (Ivth part) & abt 40 ml of Ba
suspension is injected.

❖ As 2nd part of duodenum fills ,buscopan is given iv

❖ Air is than injected through catheter ,during atonic state.

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❖ Spot films are taken in supine,RAO & prone view
with pad under Rt side.

RECENT YEAR THIS TECH REPLACED BY CT.

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Cont.
AFTER-CARE:
❖ Pt is made aware that bowel motion will be white for few
days .
❖ Pt must leave the department until the blurring of vision
produced by Buscopan has resolved.

COMPLICATIONS:
❖ Aspiration.
❖ Leakage of Ba through & unexpected perforation.
❖ Conversion of partial obstruction into complete
❖ obstruction by impaction of Ba.

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Gastric ulcers
Benign ulcer Malignant ulcer
Commoner on lesser Commoner on greater
curvature and adjacent curvature
posterior wall
In profile, protrudes Ulcer at apex of mass, lies
outside stomach contour within outline of stomach

Smooth folds, radiating Folds are nodular/

from edge of ulcer crater clubbed/ fused/ thick /
don’t reach ulcer margin
Hampton’s line/ ulcer Irregular, nodular tumour
collar present rim seen
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Benign gastric ulcers Malignant gastric Ulcer

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PROCEDURE FOR SMALL INTESTINE

1. BARIUM MEAL FOLLOW THROUGH.

2. SMALL BOWEL ENEMA/ ENTEROCLYSIS.

● Retrograde via ostomy/ reflux from the colon

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 BARIUM MEAL FOLLOW
THROUGH
Definition:
Radiological investigation of the small bowel from the duodenum to
the ileo-caecal junction by administering radiopaque contrast media
orally.

INDICATIONS:-

❖ Chronic pain in abdomen.

❖ Abdominal mass

❖ Diarrhoea.

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❖ SAIO

❖ Blood in stool

❖ Diverticulum

❖ Malabsorption

❖ Inflammatory diseases

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 CONTRA-INDICATIONS
❖ Large gut obstruction

❖ Toxic mega colon

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 PREPARATION
❖ 5 to 6 hrs fasting prior to the investigation.

❖ Laxatives on prior evening

❖ Metaclopromide(mexalon) 20ml orally/ i.v. to

increase gastric emptying and small bowel filling.
CONTRAST MEDIA:

❖ 500 to 600 ml of 50% Barium suspension

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PROCEDURE
SINGLE CONTRAST STUDY

❖ Plain abdominal radiograph is taken.

❖ 50% w/v is divided into 3 glasses of Barium each containing

200 to 300 ml Barium.

❖ First the patient is given 1 glass of Ba and when duodenal

opacification occurs radiograph of stomach and duodenum
are taken in Prone position.

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❖ 2nd glass of Ba is given and radiograph of 1st jejunal
loop is taken.

❖ After 10 to 15 min the patient positioned in RPO to

unfold the coil.

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4
❖ After this another glass of Ba is given and wait for sometime till
the Ba reaches ileum.

❖ Pt lies in RPO and radiographs are taken after 15 min to half an

hour interval till IC junction is opacified.

❖ Now IC junction is imaged in RAO position.

It is imaged in 2 views:-

❖ with compression &

❖ without compression.

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BMFT (Summary)

● Main aim is to deliver a single column of Ba into small bowel–

achieved by lying the pt on the right side after Ba has been
ingested
● Transit time: 60-90 min i.e. 1 to 1.5 hrs. ( transit
time for barium to reach the cecum)
● Prone PA films of abd. taken every 20 minute in first hour; then
every 30 minutes till colon is reached.
● Spot films of terminal ileum with graded compression in supine
position.
● To separate overlying loops of small bowel: Compression
technique, Oblique view, tube angulation, Pt tilted head down,
Air instilled into the rectum, Full bladder

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Double contrast study
❖ It is done by introducing air through anal canal i.e.
per oral pneumocolon (Means Ba is given orally and
air through the anal canal.)

❖ It is specially done in case of contracted caecum.

Air is introduced when Ba is in terminal ileum or
caecum.

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6
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Limitation of BMFT:-
a) Small polyps may remain hidden.

b) Filling rate is not under control.

c) Preferred when intubation is not possible.

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SMALL BOWEL ENEMA/ ENTEROCLYSIS
● Definition: It is a radiological investigation to demonstrate
whole of the small bowel i.e. from the duodenum to IC
junction by intubation method.

▪ Single contrast

▪ Double contrast

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INDICATIONS:-
❖ In case of suspected pathology of small bowel but
normal BMFT.

❖ History of blood in stool.

❖ To see small polyps or lesion.

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Contraindications:-
❖ Suspected perforation.

❖ Complete large bowel obstruction.

❖ Possibility of bleeding from nasal intubation.

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 REQUIREMENTS:-
❖ 12F radiopaque duodenal catheter ( with end hole).

❖ BILBAO-DOTTER tube with central teflon coated guide

wire.

❖ Xylocaine 2%

❖ Silk tube (10 F, 140 cm long made up of polyurethane &

stylet). The internal lumen is coated with a water activated
lubricant to facilitate the smooth removal of stylet after
insertion.

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PATIENT PREPARATION
❖ Patient fasting for at least 6 to 7 hrs prior to the
examination.

❖ Laxatives from 2 days prior to exam

CONTRAST MEDIA

❖ ~ 800 ml of 15-20 % barium suspension.

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PROCEDURE:-
❖ Pts sits on the edge of the x-ray table.

❖ Pharynx is thoroughly anaesthetised with lidocaine

spray.

❖ If pernasal intubation is planned, patency of the nasal

passage is checked by asking the patient to sniff with
one nostril occluded.

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❖ The tube is then passed through the nose or the mouth.

❖ The pts is asked to swallow with neck flexed as the tube

is passed through the pharynx. The tube is advanced into
gastric antrum.

❖ Pts. then lies down on left side.

❖ The tube is passed beyond the duodeno-jejunal

flexure to diminish the risk of aspiration due to reflux
of barium into the stomach.

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❖ ~ 800 ml of 15-20 % W/V barium suspension is placed in
an enema bag, which is hung on an adjustable vertical
stand or IV pole.

❖ Water soluble contrast material (60 ml) is added to

stimulate intestinal peristalsis and shortens the length of
examination.

❖ The Barium suspension is allowed to flow through the

tube by gravity @ (80-120 ml/ min) can be regulated by
adjusting the height of enema bag.

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78
❖ Examination is performed under fluoroscopic guidance
with the pts in supine position.

❖ Careful compression spot images of all loops of small

intestine are obtained under fluoroscopic guidance (as
bowel segments become fully distended with barium to
better depict the subtle abnormalities.)

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❖ Barium infusion is stopped when it reaches colon, the
tube is withdrawn aspirating any residual fluid in
stomach (to decrease risk of aspiration).

❖ Finally prone (aid in separating small bowel loops) and

supine abdominal films are taken.

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 FILMING:
Done in:-
❖ supine,

❖ prone,

❖ With compression &

❖ without compression.

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Small Bowel Calibre
Jejunum 3.5 cm
Ileum 2.0 cm
Mucosal fold thickness 2.0 mm
Inter loop distance 4.o mm

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83
8
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Advantages
❖ Short examination time

❖ Uniform distension of bowel loops

❖ No degradation of barium

❖ Excellent delineation of mucosal details

❖ High accuracy rate

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Disadvantages

❖ Higher radiation dose to pts.

❖ Lack of extra intestinal information.

❖ Patient discomfort.
❖ Technical problems reflux into stomach & duodenum.

❖ Suboptimal evaluation of distal ileum & IC junction.

8
6
BARIUM ENEMA
LARGE BOWEL

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BARIUM ENEMA
Definition:
❖ It is a radiological procedure of investigating the colon by
retrograde injection of c/m.

❖ It provides better visualization of colon due to better filling.

REQUIREMENTS
❖ Barium kit.

❖ For patient with hemorrhage soft rubber catheter is used.

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8
SINGLE CONTRAST
❖ Children.

❖ Reduction of an intussusception.

❖ Localisation of an obstructing colonic lesion.

Double Contrast

❖ Method of choice to demonstrate mucosal

pattern.
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INDICATIONS
❖ Change in bowel habits.
❖ Large intestine obstruction.
❖ Constipation.
❖ Abdominal mass.
❖ Malaena.
❖ Strictures.
❖ Hirchsprung’s disease.
❖ Acute abdomen.
❖ Frequent diarrohea.
❖ Bleeding from rectum due to T.B.
❖ Evaluate colonic mass.
❖ Evaluate Ulcerative colitis, Crohn’s dis.

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CONTRAINDICATIONS

❖ Toxic megacolon.

❖ Pseudo membranous colitis.

❖ Recent rectal biopsy.

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PATIENT PREPARATION
Three days prior to examination:-
❖ Low residual diet.

❖ Colon must be empty when exam is carried out

and for this Tab Bisacodyl (Laxative) 2 tab H.S

On the day prior to examination:-

❖ Fluids only.
❖ Mgso4 suspension 50 % (total 90 ml, 30 ml 6
A.M. , 2 P.M., 10 P.M.).
❖ Tab Bisacodyl 2 tab H.S.

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ON THE DAY OF INVESTIGATION:-

❖ Nil orally 4 to 6 hrs prior to the investigation.

❖ Bisacodyl suppository.

❖ Diabetes first.

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Equipment:

❖ Miller disposable enema tube.

PLAIN FILM:

❖ It is taken to see any calcification, air/ fluid in colon

or any other structural abnormality.

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4
 INSERTION OF ENEMA TIP

❖ Patient is instructed to lie down in left lateral position and then

is asked to lean forward 35 to 45* and rest the flexed knee on the
table above and in front of the other knee. (This position relaxes
abdominal muscles, anal sphincter by reducing intra abdominal
pressure.)

❖ Enema carten (container) should be 60 to 70 cm above the level

of anus.

❖ Orifice of anus should be clearly visible so that enema tip can be

easily inserted.

❖ Rectal tube is well lubricated with water soluble lubricant.

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❖ Gluteal folds are opened by pushing the right buttock
laterally then the rectal tube is inserted into anal
orifice.

❖ It is directed anteriorly 1” to 2” and then superiorly

❖ After insertion enema tip is held in position to prevent

slipping.

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97
 PROCEDURE
❖ Ba is introduced first and patient is turned prone so that Ba runs
more quickly to fill the splenic flexure.

❖ Infusion of barium is terminated when barium reaches the hepatic

flexure.

❖ The column of barium within the sigmoid colon is run back out by
either lowering infusion bag to the floor or tilting the table to the erect
position.

❖ Now, the air is gently pumped into the bowel.

❖ The air forces the Ba forwards, distributing it through out the colon
producing double contrast effect and patient is turned for coating the
colon.

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Spot Films are taken for:
❖ Rectum.
❖ Sigmoid colon.
❖ Descending colon.
❖ Splenic flexure.
Now, patient is turned supine and spot films are taken for:
❖ Hepatic flexure.
❖ Remaining colon.
In the end both decubitus views are done

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Spot radiograph obtained with the patient in a near-erect position shows the middle of the
transverse colon.

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Value of compression in the demonstration of overlapping loops.

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Prone versus supine position for viewing the sigmoid colon and rectum.

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104
Bowler hat: diverticulum or polyp?

Dome of hat away from the Dome of hat inwards towards the
axis of bowel- diverticulum long the axis of bowel- polyp
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The Mexican hat sign
Pedunculated polyp hanging from the non dependent surface

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Bowler Hat Mexican Hat
WATER-SOLUBLE CONTRAST AGENTS
● Indications
1. Suspected perforation.
2. Meconium ileus.
3. To distinguish bowel from other structures on CT.
● A dilutesolution of water-soluble contrast medium
(e.g. 15ml of Gastrografin in 1l of flavoured drink) is
used so that minimal artifact ‘shadow’ is produced.
4. LOCM is used if aspiration is a possibility

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Complications

1. Pulmonary oedema if aspirated (not LOCM).

2. Hypovolaemia in children – due to the

hyperosmolality of the contrast media drawing fluid
into the bowel (not with LOCM).

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“Challenges are what make life interesting;
overcoming them is what makes life
meaningful”

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