2015 PM Lecture 4 Barium Enema

Patient ManagementLecture 4

Barium enema study1. Definition2. Anatomy of the large intestine3. Indications and contraindications4. Patient preparation for barium

enema studies5. The barium enema procedure6. Special circumstances in barium

enema studies

Objectives

At the end of the session, students should be able to:

• Define the term “Barium enema”• Outline the anatomy of the large intestine• Discuss the indications and contraindications of

barium enema studies• Give details of the patient preparation for barium

enema studies• Outline patient care procedures for barium

enema studies

Objectives

• Outline procedures for rectal catheterization for barium enema studies

• Define terminology associated with bowel pathology

• Outline the care of patients with colostomy• Outline special procedures to be followed

for diabetics, infants, ward, and elderly patients

Barium Enema

Definition

• A suspension of barium sulphate introduced via the rectum as a contrast agent for radiologic examination of the large intestine

– Can be single or double-contrast study

Anatomy of the large intestines

Single and double contrast studies

Single contrast study Double contrast study

Barium Enema

Indications:

• Diverticulosis - • Polyps• Malignancies• Tumours • Ulcerative colitis• Recurrent / chronic constipation• Hirschsprung’s disease• Recurrent diarrhoea

Barium Enema

Contraindications:

• Pregnancy• Intestinal obstruction• Perforation / fistula• Allergy to Barium Sulphate

Barium enema – Patient preparation

Includes:

• General abdominal preparation • Psychological preparation • Local preparation


General abdominal preparation

• Low residue diet for 4 - 7 days prior to examination (gives the least possible fecal residue e.g. gelatin, fish, chicken, broth, fruit, meat, hard-boiled eggs)

• Diet restricted to fluids only 24 hours prior to the procedure)

• Liquid intake encouraged• Suitable aperient on each of two nights

preceding the examination


Abdominal preparation cont’d

• Patient to remain as ambulant as possible to assist in the prevention of accumulated gas

• NPO for 8-10 hrs. (or NPO after 10pm on night prior to examination: alternatively, take light breakfast just before examination)

• No smoking 4-6 hrs. prior to examination• High colonic cleansing enema administered

on morning of examination just prior to Barium enema procedure

Barium Enema cont’d

Contraindications to washout

• Babies and toddlers• Ulcerative colitis• Diarrhoea• Dehydration• Congenital megacolon• Gross bleeding from GI tract


Psychological and local preparation• Explain the procedure/answer questions the

patient may ask about the procedure• Make enquiries of the patient’s bowel

preparation• Patient to completely undress in privacy• Patient is given clean gown to be placed with

its opening to back• Patient to use bathroom before examination

Barium enema – trolley setting

Trolley setting

• Enema bag and tubing • Foley catheter (16-30)• Forceps / clamp for catheter• Air bulb for introducing air contrast into

intestines for double contrast studies• Lubricant

Barium enema – trolley setting

Trolley setting cont’d

• Drip stand• 30 ml syringe for catheter balloon• Incontinence pad• Large kidney dish• Bedpan• Gloves

Barium enema - Catheterizing the patient

Rectal catheters

• Are of two main designs:– without retainer balloon– with retainer balloon

• Are made of firm but fairly flexible plastic• The olive-shaped tip has end and side holes

and is designed for easy insertion– Care to be taken to avoid perforation of rectal

walls during insertion of this type


• Rectal catheter with retainer balloon

• Rectal catheter without retainer balloon


The Foley catheter



• Foley catheter is commonly used in local

practice, having the advantages of flexibility and self-retention

• Steps are to be taken to ensure that the foley catheter is secure and that patient is able to retain catheter before introducing barium suspension

• The foley catheter is secured by:– Advancing catheter to appropriate distance– Inflating the balloon– Tightening the sphincter around the catheter– Use of adhesive tape to secure catheter to patient’s skin


• Explain the procedure to the patient • Ensure good lighting• Patient instructed to lie on left side• Knees and hips flexed• Don gloves• The catheter is clamped and its tip is

lubricated• Buttocks parted at natal cleft to reveal

anal orifice


• Inspect the anus for haemorroids and other abnormalities

• If no abnormalities are evident, advance the catheter until 3- 4 inches of catheter is inserted

• Inflate the retainer balloon• Tug slightly on catheter to check its security

in the rectum and further secure with adhesive tape to the patient’s skin.

Barium Enema - The procedure

• After catheterization, the radiologist releases the clamp on the catheter and tubing and allows a quantity of barium suspension to run in to partially fill the large intestine

• The barium flow is then suspended (by clamping the catheter) and air is introduced via a hand pump or bulb.


• As the air advances the barium suspension along the tract, the patient is manipulated into various positions and spot radiographs are taken

• Attention is to be paid to the patients level of cooperation, any deterioration in his health status, and any complaints of discomfort resulting from the procedure

• The barium and air are allowed to flow to the ileo-caecal junction


Fluoroscopy spot films are done to include the following projections:

• Left lateral rectum • Sigmoid (RAO)• Descending colon (LAO)• Splenic flexure (LAO)• Transverse colon• Hepatic flexure (RAO)• Ascending colon (RAO)• Caecum


• Overcouch exposures

1. Supine Abdomen2. Prone Abdomen3. Right and Left Lateral Decubitus4. Post- evacuation abdomen

Left lateral rectum

Left lateral rectum

LAO colon

LAO Colon

Supine Colon

Supine colon

Right Lateral Decubitus

Right Lateral Decubitus

Left Lateral Decubitus

Left Lateral Decubitus

Barium enema - Aftercare

• Excess barium and air are to be released through catheter into bedpan or suitable container on completion of the study before the patient is directed to the bathroom

• The catheter is deflated and withdrawn from rectum

• The patient is directed/ assisted to bathroom for further evacuation and clean-up

Barium enema - Aftercare

The patient is informed of

– White stools for a few days post - study– Possibility of constipation– Diet to follow to assist in clearing the bowel of the

barium suspension (fruits, fruit juices, water)– Return to normal diet & medication regime– Return to referring physician in the event of adverse

effects of the study

Barium Enema - special circumstances

1. Post-operative patientsWater-soluble contrast agent is used in place of Barium Sulphate suspension e.g. Gastrograffin, Urografin, Ultravist

– The use of barium sulphate increases the risk of peritonitis if the barium seeps into the peritoneum via surgically- created connection


2. The colostomy patient

Definition of colostomy– A surgical procedure in which the colon is

opened onto the surface of the abdomen to provide an artificial outlet for faecal contents

– Surgically formed fistulas from the large or small bowel through the abdominal wall that terminate in an external opening called a stoma.


• The patient with a colostomy

http://www.wjso.com/content/5/1/52/figure/F2


Types of colostomya) Temporary

– Performed to rest the bowel and allow it to heal after surgery, massive trauma, infection, or chronic disease. After the bowel is healed, the healthy portions are re-connected, and the temporary opening is closed


Types of colostomyb) Permanent

– When the diseased portion of bowel is removed and a permanent artificial opening is created

– Performed on patients with imperforate anus which is the result of developmental error, the rectum does not open normally into the anal canal


Location of the temporary colostomy

• involves a loop of the transverse colon and the colostomy bag is usually sited to the right of the midline in the upper abdomen between the umbilicus and lower costal margin

• Often has a double-barreled construction (two entrance points at the colostomy opening)

Location of the temporary colostomy

•Openings separated by a spur of tissue organized to prevent bowel contents passing from one opening to the other. Usually, the opening to the right is the active end. The left opening will fill the distal colon.

– Distal loop may also be examined via the rectum and the barium exits the colostomy site



Location of the permanent colostomy

– Where the rectum was surgically removed the sigmoid is brought out as a colostomy opening sited in the left iliac fossa

– Any examination of the remaining bowel must be carried out via the colostomy opening

Barium enema - special circumstances

The colostomy bag


The Colostomy Patient for Barium enema study– Barium Enema is administered via colostomy

opening or via rectum– Because of lack of control of evacuation the

radiographer must prepare for mopping up procedures

– the radiographer should know how to attach /remove /operate the colostomy apparatus


The Colostomy Patient for Barium enema studyThe patient may be sensitive about wearing the

colostomy bag because:– The bag collects faeces– The accompanying alteration in body image

difficult to accept– Any expression of revulsion by the

radiographer may be perceived as disgust or rejection


The Colostomy Patient for Barium enema study• When booking procedures which will require the

removal of the colostomy bag, remind the patient to bring their own supplies

• Provide private facility for the patient to empty the colostomy bag

• provide facilities for cleaning reusable bags• Provide assistance in replacing bag where

necessary


The Colostomy Patient for Barium enema study• When booking procedures which will require the

removal of the colostomy bag, remind the patient to bring their own supplies

• Provide private facility for the patient to empty the colostomy bag

• provide facilities for cleaning reusable bags• Provide assistance in replacing bag where

necessary


The Colostomy Patient for Barium enema study• Bowel preparation as instructed by the

radiologist in consultation with referring doctor• Patient to follow low residue diet• Enema to be delivered at low pressure

(keep enema bag at reasonable height above patient)

• Consider patient’s sensitivity to his condition; allow him to operate the bag on his own if he can


The Colostomy Patient for Barium enema study• Have spare colostomy bags available in the

department• Careful catheterization of the stoma is

required• Study requires more dilute suspension than

regular barium enema• Do not force catheter if resistance is

encountered• Do not overfill the bowel


The Colostomy Patient for Barium enema study• Make facilities available for patient to wash

his hands• Clean site with warm water and soap• Thoroughly clean and dry the skin


3. Patients with enlarged colon– May require the use of water-soluble contrast

medium to prevent impaction of barium suspension in the large intestines.

Hirschsprung's disease / congenital megacolon – neurological deficiency in distal portion of

intestines hence peristalsis is impaired– Enlarged colon leads to greater opportunity for

water absorption of water from the bowel (larger surface area) leading to impaction


Patients with enlarged colon cont’d

– Where barium sulphate is used, the suspension should be prepared with saline solution instead of water. This reduces the loss of water from the colon during the study


4. The diabetic patient– Starvation period to be kept minimal– There should be little disturbance to their

diet and medication regime 5. The infant patient

– special bowel preparation and starvation instructions

Conditionsof the colon

• Diverticulosis • Intussusception

Conditions of the colon• Volvulus

Tutorial questions1. Outline the after-care you would provide a patient following a

Barium Enema study.2. With reference to a colostomy:

– Define the term.– Give ONE indication each for a:

• Temporary colostomy• Permanent colostomy

– What psychological considerations are to be given for barium enema patients with colostomy apparatus attached?

Tutorial questions3. Under what situations should consideration be given to the use of water-soluble contrast medium for enema study?4. Define the following terms:

– Volvulus– Diverticulosis– Diverticulitis– Intussusception– Imperforate anus– Hirschsprung’s disease

References• Culmer, P. (7th edition) Chesney’s Care of the Patient

in Diagnostic Radiography. Blackwell Science. Chapter 6, p73 – 95

• Ehrlich, R., Daly, J. (7th edition) Patient Care in Radiography Mosby. Chapter 6, p 194 – 195

Documents

2015 PM Lecture 4 Barium Enema