BARIUM PROCEDURES
FLUOROSCOPY
• UTILIZES X-RAYS
• REAL-TIME IMAGING
• UTILIZES IMAGE INTENSIFIER
• INVOLVES USE OF CONTRAST AGENTS
CONTRAST MATERIALS FOR GI EXAMS
• BARIUM SULFATE
• THICK: USED IN DOUBLE CONTRAST STUDIES
• THIN: USED IN SINGLE AND DOUBLE CONTRAST EXAMS
• PASTE: MOD BA SWALLOW AND DEFOGOGRAPHY
• GASTROGRAFFIN
• FULL STRENGTH: RARELY USED
• DILUTE
Barium vs Gastrograffin
Barium Swallow Study Gastrograffin Swallow Study
BARIUM SULFATE
• MOST WIDELY USED
• BETTER IMAGES THAN GASTROGRAFFIN
• ‘CHALKY TASTE’
• PERITONITIS MAY DEVELOP IF PERFORATION
• IF DELAYED TRANSIT, MAY FORM CONCRETIONS IN COLON
GASTROGRAFFIN
WATER SOLUBLE
FOUL TASTE
POOR MUCOSAL COATING
BASICALLY USED FOR R/O OBSTRUCTION
WON’T CAUSE PERITONITIS IF PERFORATION
MAY CAUSE SEVERE CHEMICAL PNEUMONITIS IF ASPIRATED
OSMOTIC PRESSURE DRAWS FLUID INTO BOWEL LUMEN
PROGRESSIVE DISTENTION IN SMALL BOWEL OBSTRUCTION
‘THERAPEUTIC’ ENEMA IN CONSTIPATION
PATIENT FACTORS IN GI FLUOROSCOPY
ABILITY TO INGEST CONTRAST
IN ORDER TO GET HIGH QUALITY IMAGES, A RELATIVELY LARGE VOLUME OF CONTRAST
NEEDS TO BE INGESTED FAIRLY QUICKLY
MOBILITY
MULTIPLE POSITIONS REQUIRED FOR GI EXAMS, PARTICULARLY DOUBLE CONTRAST EXAMS.
LIMITED MOBILITY = LESS DIAGNOSTIC IMAGES
WEIGHT
TABLES HAVE WEIGHT LIMITS
REQUIRES MAXIMAL RADIOGRAPHIC TECHNIQUE AND EXPOSURE IS OFTEN SUBOPTIMAL
SINGLE CONTRAST VS
DOUBLE CONTRAST
SINGLE CONTRAST
GENERALLY USES JUST THIN BARIUM
DISTENDS LUMEN WITH HIGH DENSITY MATERIAL
EASIER FOR PATIENT/LESS MUCOSAL DETAIL
DOUBLE CONTRAST/AIR CONTRAST
THICK BARIUM COATS LUMEN
EFFERVESCENT TABLETS INGESTED TO DISTEND LUMEN WITH AIR
PRODUCES ‘SEE-THROUGH’ IMAGES WITH GREATER MUCOSAL DETAIL
GREATER SENSITIVITY FOR SMALL LESIONS, POLYPS, ULCERS
Single Contrast vs Double Contrast
Single Contrast Double Contrast
Barium Enema Barium Enema
• MATERIALS OPAQUE TO X-RAYS CAN BE
INTRODUCED IN HOLLOW ORGANS. THIS MEANS
THAT THERE IS ‘CONTRAST’ BETWEEN THE CONTENTS
OF THE CAVITY AND THE WALL. THE CAVITY SHOWS
UP AS WHITE IN AN X-RAY IMAGE.
• IN SOME ORGANS WE CAN ALSO INTRODUCE AIR
OR A GAS SO THAT IT SHOWS UP AS BLACK.
• THESE TWO MODES ARE SOMETIMES DESCRIBED AS
POSITIVE OR NEGATIVE CONTRAST.
• MATERIALS THUS INTRODUCED FOR THIS PURPOSE
ARE CALLED CONTRAST MEDIA.
DILUTION SYSTEM
1) Weight by weight
30% w/w suspension is to weigh 30 g of barium sulphate and add 70
ml of water to it for a total wt of 100 g.
2) Weight by volume
80% w/v suspension is to weigh 80 g barium sulphate and add
enough water to make the total volume up to 100 ml suspension.
3) Volume by volume
This system is possible bit not recommended.
A unit volume of dry barium sulphate can vary considerably,
depending on the degree of packing.
COMMERCIALLY PREPARED BARIUM FORMULATIONS IN INDIA
1) MICROBAR PASTE
100% high viscosity paste in collapsible tubes
2) MICROBAR SUSPENSION
95% moderate density and viscosity suspension. Marketed in one litre bottle
3) MICROBAR HD
200% high density, low viscosity preparation, supplied in powder form.
4) MICROBAR FOR ENEMA
One and half kg packs of powder are available.
BA STUDY
• ROUTINE PROCEDURE
• BA SWALLOW – FOR OESOPHAGUS
• BA MEAL OF STOMACH AND DUODENUM
• BA MEAL FOLLOW THROUGH – FOR SMALL INTESTINE
• SPECIAL PROCEDURE
• SMALL BOWEL ENTEROCLYSIS
• BA ENEMA FOR LARGE BOWEL
ROUTINE PROCEDURES
1) BA SWALLOW
INDICATIONS
1) Dysphagia and obstruction
2) Pain during swallowing
3) Assessment of mediastinal masses
4) Assessment of left atrial enlargement
5) Pre-op assessment of CA bronchus and oesophagus
6) Motility disorders of oesophagus
7) Assessment of site of perforation
8) Zenkers diverticulum and cricoid webs
TECHNIQUE
Patient will need to be NPO after midnight before the exam.
One mouthful of barium paste is given and fluoroscopic observation
of act of deglutition is observed in frontal and lateral view with patient
erect.
For this a string is tied just above the level of the larynx.
Exposure is triggered at the time when hyoid bone is at the highest
point during swallowing.
The rotor is kept running and patient is asked to swallow.
Exposure is released when larynx comes above the string.
Lateral film is taken in erect and frontal film in supine position.
NORMAL BARIUM SWALLOW
ZENKERS DIVERTICULUM Achalasia
STRICTURES DIFFUSE ESOPHAGEAL SPASM CARCINOMA
GERD ESOPHAGEAL VARICES
SIPHON TEST
LEIOMYOMAS FIBROVASCULAR POLYP
DOUBLE AORTIC ARCH COARCTATION OF AORTA
OESOPHAGEAL OBSTRUCTION MULTIPLE STRICTURES
DUE TO METASTATIC DUE TO ACID
MEDIASTINAL LN INGESTION
UPHILL VARICES DOWNHILL VARICES
2) BARIUM MEAL STOMACH AND DUODENUM
INDICATIONS
1) Peptic ulcerations
2) Upper abdominal mass
3) Gastro-intestinal haemorrhage
4) Gastric or duodenal obstruction
5) Malignancies
6) Motility disorders
Method
A)Double contrast –
the method of choice to demonstrate mucosal pattern
B)Single contrast-
used in children (not necessary to demonstrate mucosal pattern)
And very ill adults (only gross pathology)
TECHNIQUE
• HYPOTONIC AGENT BUSCOPAN(HYOSCINE BUTYL BROMIDE,20 MG I.V) OR 0.1-0.2 MG I.V GLUCAGON IS
INJECTED INTRAVENOUSLY -RELAX STOMACH AND SUSPEND PERISTALSIS.
• A PACKET OF EFFERVESCENT GRANULES SWALLOWED WITH SMALL AMOUNT OF WATER- RELEASES CO2 AND
GASTRIC DISTENSION.(APPROX 400ML CO2)
• HIGH DENSITY BARIUM IS SWALLOWED(120 ML- 250% W/V) AND DOUBLE CONTRAST VIEWS OF OESOPHAGUS
IS OBTAINED STANDING RAO.
• PATIENT FACES XRAY TABLE,LOWERED TO HORIZONTAL
• THEN TURNED ONTO LEFT SIDE AND FINALLY SUPINE.
• PATIENT ROLLED FROM SIDE TO SIDE SO AS BARIUM COATS MUCOSAL SURFACES PROPERLY-WASHES OVER THE
MUCUS .
• SEQUENCES OF FILMS OF STOMACH OBTAINED
• WHEN BARIUM ENTERS DUODENUM, PATIENT IS TURNED RAO – FILLS DUODENUM WITH GAS, DC FILMS ARE
TAKEN.
• BIPHASIC EXAMINATION–PRONE SWALLOW OF THIN (125%W/V LOW DENSITY) BARIUM GIVEN AFTER
CONTRAST VIEW OBTAINED TO OPTIMIZE COMPRESSION VIEWS OF STOMACH AND DUODENUM
• UNDER FLUOROSCOPIC GUIDANCE, ON THE COMPRESSION VIEWS-FILLING DEFECTS OR ABNORMAL
COLLECTIONS ARE DETECTED.
Normal findings
Cardiac
Incisure
Angular
Incisure
Antrum
supine
Double-contrast upper GI
BENIGN GASTRIC ULCER
1. CRATER : BARIUM COLLECTION WITHIN THE ULCER CRATER
PROFILE VIEW(A): PENETRATION OF THE ULCER PROJECTING BEYOND
THE NORMAL BARIUM-FILLED GASTRIC LUMEN (ARROW)
EN-FACE VIEW(B): ROUND OR OVAL BARIUM COLLECTION ON
DEPENDENT PART (ARROW)
RADIATION OF SMOOTH THICKENED FOLDS (ARROW) EXTENDING
DIRECTLY TO THE EDGE OF THE CRATER (ARROWHEAD) ON
PROFILE VIEW(A) AND EN-FACE VIEW (B)
INCISULA DEFECT :SMOOTH,
DEEP, NARROW, SHARP
INDENTATION ON GREATER
CURVATURE(GREEN
ARROW) OPPOSITE A
CRATER (WHITE ARROW)
ON LESSER CURVATURE:
SPASTIC CONTRACTION OF
CIRCULAR MUSCLE
DUODENAL ULCER
Chronic duodenal ulcer : Deformity of the duodenal bulb from fibrotic healing
- Cloverleaf deformity (A) : symmetric narrowing of the midportion of the bulb with dilatation
of the inferior and superior recesses at the base of the bulb (arrow)
- Pseudodiverticulum (B) : asymmetric narrowing of the bulb
MALIGNANT GASTRIC ULCER
• 5% OF GASTRIC ULCERS ARE MALIGNANT
• RADIOGRAPHIC APPEARANCES:
1. INTRALUMINAL ULCER (NOT PROJECT
BEYOND THE EXPECTED MARGIN OF THE
STOMACH ) (ARROW)
2. IRREGULAR, NODULAR MASS
(ARROWHEAD) SURROUNDING THE
ULCER
3. IRREGULAR OR NODULAR THICKENED FOLDS THAT
RADIATE TO THE MASS
4. CARMAN MENISCUS SIGN :
SEMICIRCULAR OR MENISCOID ULCERS
(ARROW) WITH ITS INNER MARGIN CONVEX TOWARD THE
LUMEN
GASTRIC CANCER
FOCAL CONSTRICTING LESION:
LOCALIZED INFILTRATING
CARCINOMA OR LOCALIZED
SCIRRHOUS CARCINOMA
ANNULAR FILLING DEFECT
(ARROW)
FOCAL CONSTRICTING
fundus LESION
: LOCALIZED INFILTRATING
CARCINOMA OR LOCALIZED
bulb antrum body
SCIRRHOUS CARCINOMA
- CIRCUMFERENTIAL
IRREGULAR NARROWING
OF THE LUMEN WITH
RIGIDITY
LINITIS PLASTICA PATTERN
- TUMOR INVASION OF THE
GASTRIC WALL
- DIFFUSE IRREGULAR
NARROWING AND RIGIDITY
OF THE STOMACH
Features suggesting benign gastric ulcer
•outpouching of ulcer crater beyond the gastric contour (exoluminal)
•smooth rounded and deep ulcer crater
•smooth ulcer mound
•smooth gastric folds that reach the margin of the ulcer
•Hampton's line
Features suggesting malignant gastric ulcer
•does not protrude beyond the gastric contour (endoluminal)
•irregular and shallow ulcer crater
•nodular and angular ulcer mound
•nodular gastric folds that do not reach the ulcer margin
•Carman meniscus sign
EXTRINSIC LESION
MASS
3) Small bowel follow-through
•The passage of the barium through the stomach, and small intestine
is monitored on the fluoroscope.
•The test usually takes around three to six hours.
INDICATIONS
1) Low suspicion of small bowel disease – Abdominal pain
and diarrhoea
2) Suspected near complete or complete small bowel
obstruction
3) Suspected chrons disease
4) Patients who refuse placement of nasogastric tube/failed
intubation
TECHNIQUE
This is performed following a barium meal examination of the
esophagus, stomach and duodenum
150ml 250%w/v—200ml 20-25%--250ml40-45%
As the barium column progresses through the small intestine large
radiographs of the abdomen are taken at intervals
First one is taken with the patient supine about 15 minutes after the
barium meal and shows the proximal jejunum
The remaining radiographs are normally taken at half hourly intervals
with the patient prone.
When the barium column reaches the caecum spot views of the
terminal ileum are taken
It takes from 2 to 6 hours for the head of the barium column to reach the
caecum
The pattern of the mucosal lining of the first part of the duodenum is
different from the other parts. longitudinal pattern of the mucosa of the first
part of the duodenum forming what is known as the duodenal cap This
pattern is very similar to that of the pylorus of the stomach. This pattern
changes to a more flecked appearance in the distal duodenum
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MALROTATION PANCREATIC HEAD CARCINOMA
ASCARIASIS MECKLES DIVERTICULUM
CHRONS DISEASE SCLERODERMA
SPECIAL PROCEDURES
1) ENTEROCLYSIS
A tube is placed down through the stomach into the
small intestine, often under fluoroscopic control.
INDICATIONS
1) Partial small bowel obstruction
2) Chrons disease
3) Meckel's diverticulum
4) Malabsorption
5) Tumours of small intestine
6) Occult GIT bleeding
•single-contrast enteroclysis
• easier technique and less patient discomfort, but evaluation of the
mucosa is less than with the other techniques
•air-contrast enteroclysis
• better for evaluation of mucosal detail of proximal small bowel loops
• may be better for long segment disease
• more discomfort for the patient than single contrast
•methylcellulose enteroclysis
• better for evaluation of mucosal detail than single-contrast
• may be better for short segment disease
• easier to visualise through bowel loops
• some consider it a more consistent double-contrast exam than air-
contrast enterocylsis
• more discomfort for the patient than single contrast
TECHNIQUE
1.Patient is fasting after midnight.
2.Some centres administer metoclopramide (Reglan) immediately before the
exam to aid in intubation and speed small bowel motility. This is
contraindicated in patients with paraganglioma or patients with some
neurologic conditions.
3.Some centres administer anxiolysis and anaesthesia for conscious sedation
(e.g. fentanyl and midazolam).
4.An enteric tube (e.g. a nasoduodenal tube) is advanced beyond the pylorus:
1. If a single-contrast or double contrast enteroclysis is to be performed, the
tip may rest in the second portion of the duodenum.
2. If methycellulose is to be used, the tip should be in the proximal jejunum.
5.After proper positioning of the tip, barium is instilled through the catheter with
syringes or a pump.
1. The optimal flow rate depends on the patient's specifics, but may be
around 50-150 mL/min
2) BARIUM ENEMA
INDICATIONS
1)abdominal pain
2)bleeding from the rectum or melena
3)change in bowel habit
4)chronic diarrhoea or constipation
5)palpable mass
Single Contrast vs Double Contrast
Single Contrast Double Contrast
Barium Enema Barium Enema
DIVERTICULAR DISEASE LEAD PIPE BOWEL
SIGMOID APPLE CORE TUMOR RECTAL CARCINOMA
POLYPS APPLE CORE APPEARANCE
3) DEFECOGRAM
• BARIUM PASTE IS INSERTED INTO RECTUM
• PATIENT IS ASKED TO DEFECATE UNDER FLUOROSCOPY
• ANO-RECTAL AND PELVIC FLOOR DYNAMICS CAN BE ASSESSED
• RECTOCELE, INTUSSUSCEPTION, PELVIC FLOOR RELAXATION, STRESS INCONTINENCE
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