Radiol Clin N Am 41 (2003) 365 – 376
Double-contrast barium enema technique
Stephen E. Rubesin, MDa,*, Dean D.T. Maglinte, MDb
a
Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
b
Department of Radiology, Indiana University, Indianapolis, IN, USA
Every barium enema differs slightly, because
every patient has varying anatomy and pathology
and different capabilities of performing the examina-
tion [1,2]. Although the radiologist may enter the
fluoroscopic suite with an approach to study the
colon, the game plan is altered as the study progresses
following principles of technique and interpretation.
With knowledge of normal and abnormal radio-
graphic findings, the radiologist paints a picture of
each individual’s colon [3,4].
What does the radiologist look at?
In viewing images of the colon, the radiologist
first examines the big picture: colonic position and
rotation, length, and diameter. The radiologist then
analyzes individual segments. Luminal contour is
demonstrated in air-contrast as a continuous barium-
etched white line (Fig. 1) [3]. Luminal contour is
demonstrated in the barium pool as a gently curved
surface (see Fig. 1). The colon is characterized by
its haustral sacculations and interhaustral folds (see
Fig. 1). The sacculations are created by the teniae
coli, the longitudinal muscle layer of the colon that
is divided into three thick bands, separated by
120 degrees. The rows of haustral sacculations lie
between the teniae coli. In the right and transverse
colon, the haustral sacculations are fixed structures;
in the left colon the sacculations are transient out-
pouchings, created by the tone of the teniae coli.
* Corresponding author.
E-mail address: rubesin@oasis.rad.upenn.edu
(S.E. Rubesin).
0033-8389/03/$ – see front matter D 2003, Elsevier Science (USA). All rights reserved.
doi:10.1016/S0033-8389(02)00074-X
The mucosal surface spanning opposing colonic
contours is seen en face, either in the barium pool or
in air contrast. The normal mucosal surface is smooth
(see Fig. 1). An abnormal mucosal surface may have
a granular, finely nodular (Fig. 2), or ulcerated
surface. The nondependent surface (the ‘‘up’’ side)
is seen with the mucosal surface etched in white by
barium, appearing gray (see Fig. 1). If the dependent
surface (the ‘‘down’’ side) is bathed in the barium
pool, its detail is obscured by the white barium pool.
If the barium pool has been removed from the
dependent surface, this surface also appears gray.
Structures appear differently en face, whether they
are etched in white by barium or in the barium pool
(Fig. 3). A lesion protruding into the lumen from the
anterior surface (an elevated lesion, such as a polyp)
may appear as a ring shadow or barium-etched lines
(Fig. 4). An anterior wall lesion may also be obscured
by the barium pool on the opposing dependent
surface. A lesion protruding into the lumen from
the posterior wall may appear as a radiolucent filling
defect in the barium pool, or may be obscured by a
deep barium pool. A lesion that protrudes outside of
the expected luminal contour on the posterior wall (a
depressed lesion, such as an ulcer or diverticulum)
may appear as a focal barium collection if it is filled
with barium (Fig. 5). A depressed lesion may appear
as a ring shadow on either the anterior or posterior
wall, if the barium pool has been removed from the
posterior wall.
Goals of barium enema examination
The goal of the barium enema examination is to
visualize each portion of colon in various projections,
366 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376
Fig. 1. Elements of the double-contrast radiograph. Spot
radiograph of ascending colon and splenic flexure obtained
with patient in recumbent left posterior oblique position
shows the normal smooth mucosal surface (open arrow)
appearing gray. The luminal contour is demonstrated in the
barium pool (large black arrow) as a dense pool of white
and in air contrast as a thin white line (small white arrow).
Note how columns of dense barium obscure the mucosal
surface en face (arrowhead). The colon is defined radio-
logically by the haustral sacculations (one sac, large white
arrow) and the interhaustral sacculations that form it (small
black arrows).
with enough luminal distention to spread apart the
colonic walls. It is easier to see the mucosal surface
en face than along a curved surface; adequate luminal
distention is a must. It is also easier to see the
mucosal surface when a colonic segment is not
overlapped by another segment. By turning the
patient and compressing portions of abdomen with
a soft compression device, the colonic loops easily
can be splayed apart.
Adequate mucosal coating is a must. The barium
is the radiologist’s paint [4]. The colonic mucosal
surface is the canvas. As the radiologist turns the
patient, the barium pool is washed across the mucosal
surface, etching the surface in white (Fig. 6). If there
is not enough barium to scrub the mucus off the
mucosa or adsorb intraluminal fluid, the mucosal
coating is patchy. If there is too large a pool of
barium, the high-density barium obscures lesions in
the barium pool or lesions on the anterior wall. There
should be not too much or too little barium, but just
the right amount [3]. The right amount of barium
varies with the degree of luminal distention; the
length of the colon; and the presence of diverticula,
sacs that sequester the barium pool. By the end of the
examination about one fourth of the luminal diameter
should be filled with barium, regardless of colonic
length or diverticula. The mantra of the double-
contrast examination is ‘‘projection, distention, coat-
ing’’ (numerous projections, adequate distention, and
good mucosal coating).
Preparation
A colon free of feces is a must for a good
examination. There have been numerous preparations
created over the years, a fact that reflects the dif-
Fig. 2. Abnormal mucosal surface in patient with ulcerative
colitis. Spot radiograph of mid transverse colon obtained
with patient in supine position shows that the normally
smooth mucosal surface has been diffusely replaced by a
nodular surface manifested as tiny radiolucencies and barium
flecks. The colonic anatomy is abnormal: the haustral
sacculations and interhaustral folds are absent. The dense
barium column (black arrow) obscures the mucosal
nodularity. (From Rubesin SE, Levine MS. Principles of
performing a double contrast barium enema. Westbury (NY):
E-Z-EM;1998. p. 1 – 36, Fig. 21; with permission.)
 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376 367

Fig. 3. Air contrast versus the barium column. (A) Spot radiograph of proximal sigmoid colon obtained during barium filling
shows a 3-cm asymmetric narrowing (arrow) with shelf-like margins and an ulcerated surface. (B) Spot radiograph of the annular
lesion now obtained in air contrast shows the proximal shelf-like margin (white arrow) and mucosal nodularity (black arrow) that
were not seen in single contrast.

ficulty of colon cleansing in all patients [5 – 11].
Standard 1-day preparation results in a clean colon
in most healthy, mobile, young outpatients who have
good colonic motility. Colon cleansing is more prob-
lematic in patients with colonic hypomotility, such as
patients with hypothyroidism, diabetes, and patients
who take narcotics or medications with anticholiner-
gic side effects. Immobile inpatients may be difficult
to prepare.
The variation of preparations is endless, including
a 3-day low-residue diet and cleansing enemas. This
radiologist does not advise a particular preparation,
but does strongly believe that the use of large-volume
colonic lavage agents, such as Golytely, leave a large-
volume residue of fluid in the colon and ruin barium
coating [2].
Examination specifics
the colonic preparation clearly has been unsuccessful.
A clean-appearing colon on a plain film, however, may
harbor a large amount of small particulate feces. The
authors do not obtain scout radiographs unless indi-
cated by clinical history. Preliminary radiographs may
be of value in patients with abdominal pain, to look for
abnormal calcifications or dilated bowel segments.
Preliminary radiographs may also be helpful in
patients who have undergone prior surgery.
Similar to current research trends in colonic pre-
paration for virtual colonography, tagging of fecal
debris with a tracer has also been suggested for
double-contrast barium enema examination [13]. A
recent prospective single-blind, randomized, con-
trolled evaluation has confirmed that the addition of
an oral barium tracer with the colonic preparation
improves the ability of the scout radiograph to predict
the adequacy of colonic cleansing particularly in the
difficult to prepare patient [14].

Scout radiograph Who is a candidate for a double-contrast study?

A scout radiograph is usually not necessary before To undergo a double-contrast barium enema, a
a barium enema [12]. Plain radiographs do not reveal patient has to be able to roll around a fluoroscopic
the adequacy of colonic cleansing in many patients. If table and have enough rectal tone to hold the barium
large fecal balls or barium-impregnated stool are seen, and air within the colon. Although a patient need not be
368 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376

copy. There should be a 7-day waiting period between

the barium enema and a previous large forceps biopsy,
polypectomy, or electrocautery [17,18].

Principles of performing the study

The enema tip

The enema tip [19] is inserted with steady gentle
pressure, first anteriorly along the course of the anal
canal, then posteriorly along the course of the sacrum.
The enema tip balloon is not distended routinely. This
balloon is only insufflated in patients who are unable
to retain barium or air. The balloon is only inflated
after a normal contour of rectum is demonstrated by

Fig. 4. Protruding lesion in air contrast. Spot radiograph of

mid sigmoid colon with patient in left posterior oblique
position shows a large pedunculated polyp as barium-etched
lines (arrows) that should not be present normally. The stalk
(arrowhead) has a smooth surface; the head of the polyp has
a nodular surface. (From Rubesin SE, Levine MS. Principles
of performing a double contrast barium enema. Westbury
(NY): E-Z-EM; 1998. p. 1 – 36, Fig. 10A; with permission.)

able to stand during a double-contrast examination,

erect views are extremely helpful. The radiologist must
also be able to communicate with the patient. If a
patient does not speak the language of the radiologist, a
translator should be provided. A double-contrast
examination also is difficult for a patient with mental
deficiencies. With these requirements in mind, the
radiologist enters the fluoroscopic suite to assess the
patient just before performing a double-contrast study.
During the initial patient interview, the radiologist
assesses whether the patient is able to follow instruc-
tions. A rectal examination tests for rectal tone and
rectal feces [15]. If rectal tone is poor, a single-contrast
examination should be considered. If there is concern
that the patient will not be able turn on the fluoroscopic
table, the radiologist can ask the patient to turn
360 degrees about the tabletop. The young, mobile,
patient is an excellent candidate for double-contrast
Fig. 5. Diverticula as examples of depressed lesions. Spot
examination. The debilitated, immobile, postopera-
radiograph of the hepatic flexure obtained with patient in
tive, or mentally challenged patient is a poor candidate recumbent right posterior oblique position shows diverticula
for a double-contrast examination. as barium-filled (white arrow) or barium-etched sacs
The radiologist should not use examination gloves (arrowhead) protruding from the contour of the colon.
or an enema tip that contains latex [16]. The radiologist Barium-filled diverticula seen en face appear as round
should inquire about prior surgeries and recent endos- collections of barium (black arrow).
 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376 369

Fig. 6. Mucosal coating. (A) Spot radiograph of mid sigmoid colon obtained before cecal filling and patient turning shows patchy
coating of the luminal contour (arrows) and a blob of mucus (arrowheads). Note the circular muscle thickening and diverticula.
(B) Spot radiograph of mid sigmoid colon obtained after the patient has been turned several times and compressed shows that the
mucus has been washed into the barium pool and that the coating of the luminal contour (white arrow) is now adequate. The
cecum (C) and appendix are now filled with barium.

barium instillation. In general, the balloon should not
be inflated in patients with rectal inflammatory dis-
ease (eg, ulcerative or radiation proctitis) [20]. The
authors only inflate the balloon in about 5% to 10%
of patients.
Glucagon
At the authors’ institution, 1 mg of glucagon is
routinely given intravenously to relax the colon [1].
Glucagon allows the radiologist to insufflate more air
into the colon and helps prevent colonic spasm
[14,21,22]. Glucagon enables a more comfortable
double-contrast examination [23,24].
Barium
A medium viscosity, medium density barium is
used. In the United States, typically a 100% W/V
barium suspension is used [1]. In some countries, as
low as a 70% W/V barium is used. The barium must
be thin enough to flow quickly through the colon and
thin enough to wash feces and mucus into the barium
pool (see Fig. 6). The barium must, however, be thick
enough to coat the colon without flocculating [1].
The authors prefer to instill barium to the mid
transverse colon while the patient lies in the prone
position. The patient may be turned to the left anterior
oblique or Trendelenburg’s position to aid barium
passage. Once the barium column reaches the mid
transverse, the enema bag is lowered to remove
barium from the rectum. The goal is not to clear the
rectosigmoid colon of barium, but to remove barium
from the rectum so that when air is insufflated,
bubbles are not formed.
Air insufflation
Air is insufflated into the colon with gentle,
intermittent squeezes on the air-bulb. Rapid insuffla-
tion may be painful. During air insufflation, the
patient is turned into various positions so the air
and barium are distributed throughout the colon.
The radiologist manipulates the barium pool and
the air column with the principle that barium is heavy
and flows with gravity. The radiologist turns the
patient so that the portion of colon to be filled by
barium is in the most dependent position. Air does
not block the passage of barium. Only a redundant
colon and an insufficient amount of barium prevent
passage of barium to the cecum.
In most patients, it takes a total of two or three
360-degree turns to scrub the colon of mucus and
coat the mucosal surface with barium (see Fig. 6). In
the routine patient, however, the authors obtain some
spot films of the sigmoid colon before the ascending
colon is filled with barium. Early views of the
sigmoid colon are needed, because if barium fills
the cecum and terminal ileum, these structures may
obscure portions of the sigmoid colon. These insur-
ance shots of the sigmoid colon are obtained just after
370 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376

the barium column has reached the mid transverse
colon, by insufflating air and turning the patient onto
their left side down, then onto their back. Once, the
insurance shots of the sigmoid are obtained, the
patient is turned onto their right side down, moving
barium into the hepatic flexure, then turning the
patient onto their back, moving barium into the
ascending colon. Barium filling of the cecum is
achieved by turning the patient left side down or into
an erect position.
When barium reaches the cecum, the radiologist
now fully distends the colon with air. The haustral
sacculations should be opened up, although not
completely flattened. The haustral sacculations
should be distended enough so the interhaustral folds
are perpendicular to the axis of the lumen. The patient
is now turned 360 degrees once or twice.
If the radiologist discovers that the patient is much
less mobile than expected, a one-turn double-contrast
examination can be performed by turning the patient
onto their right side down, moving the barium to the
hepatic flexure, then onto their back, moving the
barium into the ascending colon. Air is insufflated
to an adequate amount, the patient is rocked back and
forth for better coating, and spot filming commences.
Spot radiographs
The order of spot radiographs is not important,
except for the early shots of the sigmoid colon before
cecal and terminal ileal filling. The radiologist keeps
a mental check list of the portions of colon imaged
(Do I have this? Do I have that? How do I turn the
patient to get that segment?). During spot filming, the
radiologist turns the patient to manipulate the barium
pool to coat the mucosa, then spills most of the
barium pool from the segment to be imaged so
lesions are not obscured. Each segment is viewed in
several obliquities, including prone and prone oblique
positions. If a segment is well-coated by barium, an
image is obtained (the philosophy of ‘‘get it while
you can’’).
The enema tip is removed as early as possible,
often to the great relief of the patient [25]. Enema tip
removal allows adequate visualization of the distal
rectum (Fig. 7A) [26].
Box 1 lists the patient positions that the authors
use to obtain spot radiographs (Figs. 7 – 10).
Overhead images
With real-time spot images, the radiologist has the
ability to position the patient just right so there is

Fig. 7. Prone versus supine views of the rectum and sigmoid colon. (A) Spot radiograph of rectum and sigmoid colon obtained
with patient in supine position after the enema tip has been removed. The distal rectum (R) is seen in air contrast. The lowest loop
of the sigmoid colon (arrow) is obscured by the barium pool. (B) Spot radiograph of the rectum and sigmoid colon obtained with
the patient in the prone position. Note that the radiograph has been rotated 180 degrees to allow direct comparison with A. The
distal rectum (R) is now partially obscured by the barium pool, but the most inferior loop of the sigmoid colon (arrow) is now
seen in air contrast. (From Rubesin SE, Levine MS. Principles of performing a double contrast barium enema. Westbury (NY):
E-Z-EM; 1998. p. 1 – 36, Figs 14A and 14B; with permission.)
 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376 371

Box 1. Spot radiograph positions for

doublecontrast barium enema

Part of colon Patient position

Rectum Prone, enema tip in
Lateral, enema tip in
Opposite lateral,
enema tip out
Supine, enema tip
out (Fig. 7)
Sigmoid Supine, left posterior
oblique, right posterior
oblique (Figs. 3, 4, 6)
Prone: for inferior loop
(Fig. 7)
Fig. 8. Spot radiograph of mid transverse colon obtained with
Descending Supine (Fig. 5) and
the patient standing in the frontal position. An air-barium
colon erect right posterior level (arrow) is seen. (From Rubesin SE, Laufer I. Double
oblique contrast barium enema: technical aspects. In: Levine MS,
Splenic flexure Erect and recumbent, Rubesin SE, Laufer I, editors. Double contrast gastrointesti-
right posterior oblique nal radiology. Philadelphia: WB Saunders; 2000. p. 331 – 56,
(Fig. 5) Fig. 11 – 16.)
Mid transverse Erect and supine
colon (Figs. 2, 8)
Hepatic flexure Erect (Fig. 9) and
recumbent left
posterior oblique
Ascending Erect (Fig. 9) and
colon recumbent left
posterior oblique
Cecum Left or right posterior
oblique (Fig. 10)
Prone for anterior wall

little overlap of colonic segments. During spot film-

ing, the radiologist also has the advantage of being
able to manipulate the barium pool and volume of air
in the segment to be imaged. Overhead images, on
the other hand, cover a larger area and demonstrate
the big picture and overall position of focal lesions.
The most valuable overheads are those obtained with
techniques that are not possible with a standard
fluoroscope, such as decubitus and angled images.
For example, at the authors’ institution, only five over-
head images are obtained, four that are not possible
with a standard fluoroscope (Box 2) (Figs. 11 – 13).
Fig. 9. Spot radiograph of hepatic flexure and ascending
The overhead obtained with the patient in the prone
colon obtained with the patient standing in the left posterior
position with the radiographic tube angled 30 degrees oblique position. (From Rubesin SE, Laufer I. Double con-
cephalad opens the distal sigmoid colon (Fig. 14). trast barium enema: technical aspects. In: Levine MS,
Postevacuation radiographs may be obtained as ei- Rubesin SE, Laufer I, editors. Double contrast gastrointesti-
ther spot radiographs or overheads. These images nal radiology. Philadelphia: WB Saunders; 2000. p. 331 – 56,
demonstrate barium tracking into fistulas or fissures Fig. 11 – 18.)
372 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376
Fig. 10. Spot radiograph of cecum obtained with patient in
right posterior oblique position. The appendix (arrow) is
filled with barium.
(Fig. 15) or barium filling previous unfilled divertic-
ula, terminal ileum, or appendix.
Modification of double-contrast barium enema
technique when using remote-control fluoroscopy
The ability of remote control fluoroscopic equip-
ment to angle the x-ray tube and the compression
device allows radiologists to optimize visualization
of tortuous or hidden segments that may be hidden
by overlap. All radiographs obtained are ‘‘spot’’ ra-
Box 2. Overhead radiograph positions
for doulbecontrast barium enema
Cross-table lateral view of rectum with
patient in prone position (Fig. 11)
Cross-table lateral view of colon with
patient in left-side down decubitus
position
Cross-table lateral view with patient in
right-side down decubitus position
(Fig. 12)
View of rectosigmoid colon with tube
angled 30 degrees cephalad and patient
prone (Fig. 13)
View of colon with patient prone
diographs. The source film distance is fixed and
magnification is less compared with conventional
fluoroscopic equipment. Scattered radiation to person-
nel is less. Because the operator visualizes on fluo-
roscopy the appropriate patient position and tube
angulation required to obtain optimum double-contrast
radiographs of a segment of the colon compared with
overhead radiography, patient room throughput is
more efficient.
The steps designed for remote-control radio-
graphy are a modification of the original seven
step – seven pump, simplified barium pneumocolon
method described by Miller and Maglinte [27] for
mobile adults who can turn prone. The aim is to
visualize each segment of the colon in double contrast
at least two to three times. By using opposite views
per segment (ie, supine and prone or right lateral and
left lateral projections or opposing obliquities for
each segment) opposing walls are delineated more
than twice with the number of radiographs obtained
in this sequence [28].
The precise sequence of steps and CO2 insufflation
is easy to teach to residents and radiologic technolo-
gists [28]. Because with remote control fluoroscopy
one obtains what is seen, reproducible optimal quality
study at the minimal radiation dose is possible even
with inexperienced fluoroscopists and technologists.
Barium-filling phase
After inserting the rectal tube, introduce a small
amount of barium and ensure that the tip is in the
lower rectum and not in the anal canal. Barium is
squeezed gently in the left lateral position until the
head of the column reaches the splenic flexure. The
patient is then turned prone. CO2 or air is then
Fig. 11. Cross-table lateral overhead radiograph of rectum
with patient in prone position.
 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376
Fig. 12. Cross-table lateral overhead radiograph of colon
with patient in right side down decubitus position. (From
Rubesin SE, Levine MS. Principles of performing a double
contrast barium enema. Westbury (NY): E-Z-EM; 1998.
p. 1 – 36, Fig. 28B; with permission.)
introduced by slow puffs to push the head of the
barium column to the proximal transverse colon. The
table (with patient prone) is elevated 30 degrees and
the rectum is drained to ensure patient comfort and to
trap enough barium in the transverse colon to push to
the cecum and ascending colon. The table is returned
flat. The patient is returned to the left lateral position
and the seven step – seven pump method begins. One
should administer in slow, full squeezes seven pumps
of CO2-air in the following positions:
1. Left lateral position.
2. Left anterior oblique position.
3. Prone position. A radiograph is obtained of
the sigmoid with the tube angled caudad 10 to
15 degrees. A fast rectal drainage is done at this
time if the patient experiences discomfort or
there is too much barium in the sigmoid.
4. Right anterior oblique position.
5. Right lateral position.
6. Right posterior oblique position.
7. Supine position.
373
A radiograph of the sigmoid with the tube angled
10 to 15 degrees cephalad (the opposite of the first
radiograph) is obtained. The table is then elevated
upright to bring barium to the cecum and a final rectal
drainage is done. This again ensures diminished
patient discomfort. With the rectal tube still open, the
table is lowered halfway to the supine position. If
visualization of the terminal ileum is desired, the
patient is asked to turn left then prone and the table
brought horizontal. If no visualization of the terminal
ileum is desired or if more barium is needed, the patient
is turned to the right then prone before the table is
brought horizontal. Rectal drainage is then completed
and CO2-air distention begins. The amount of CO2-air
administered can be diminished in patients who
already have air from prior endoscopy or who experi-
ence discomfort during insufflation. In the barium-
filling phase, it is the seven-step that is important to
bring the right amount of barium to the cecum. The
amount of CO2-air insufflated merely pushes the
barium in this phase.
CO2-air distention phase
One should administer seven pumps CO2-air in
each of the three positions (prone, left lateral, and
supine). Examine all segments to ensure adequate
distention. Add additional squeezes of CO2 with the
nondistended segment slightly elevated. If all seg-
Fig. 13. Radiograph of rectosigmoid colon with tube angled
30 degrees cephalad and patient in prone position. Note how
the distal sigmoid colon (arrow) is opened-up in this view.
(From Rubesin SE, Levine MS. Principles of performing a
double contrast barium enema. Westbury (NY): E-Z-EM;
1998. p. 1 – 36, Fig. 29; with permission.)
374 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376

Fig. 14. Value of the prone-angled view. (A) Spot radiograph of the distal sigmoid colon obtained with the patient in the prone
position while a balloon-compression device is used. A ring-like radiolucent tumor (arrows) is seen in the barium pool. (B)
Overhead radiograph with tube angled 30 degrees cephalad obtained immediately after A, leaving patient in prone position with
compression device in place. A centrally ulcerated, plaque-like tumor is demonstrated. Both the edge of the ulcer (thin arrows)
and the scalloped edge of the tumor (thick arrows) are etched in white.

ments are distended, a supine view of the entire colon
is obtained. The patient is then positioned left lateral
and instructed ‘‘to hold on to everything’’ as the
rectal tube is removed. This ensures patient comfort
during the filming phase. Before rectal tube removal,
three to five pumps of CO2-air can be given. The
rectal tube should not be removed if the ileocecal
valve is incompetent or the patient showed inconti-
nence during the procedure. Rectal filming is done last
in this situation. In addition to the three radiographs
obtained during the barium filling and the CO2-air
distention phases, the following radiographs are ob-
tained in sequence. This can be done by the radiologist
or a trained technologist.
Radiographic (filming) phase
The steps of the radiographic (filming) phase are
as follows:
1. Left lateral projection of rectum.
2. Left posterior oblique of rectosigmoid with
tube angled cephalad 10 to 15 degrees.
3. Left posterior oblique of hepatic flexure.
4. Right lateral projection of rectum.
5. Right posterior oblique projection of splenic
flexure (include sigmoid also in the position).
6. Right anterior oblique projection of rectosig-
moid with tube angled 10 to 15 degrees caudad.
7. Prone projection of entire colon. The patient
is then turned right lateral then supine.
8. Supine or mild left posterior oblique position
(mild compression radiographs of cecum and
ileocecal valve).
9. Erect anteroposterior view of transverse colon
and flexures.
10. Right posterior oblique upright view of
splenic flexure.
11. Left posterior oblique view of hepatic flexure.
Upright views of sigmoid or rectum may be
obtained if they remain distended at this time. The
patient is then sent to the bathroom and additional
views may be obtained as needed. The seven-step
barium filling method allows just enough barium to
enter and coat the cecum in almost all instances.
Occasional patients with very redundant hepatic flex-
ures may require special maneuvers to bring just
 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376 375

Fig. 15. Value of postevacuation radiographs. (A) Spot radiograph of sigmoid colon shows a 5-cm tapered circumferential
narrowing with preservation of the mucosa and a few deformed diverticula (arrow), findings compatible with chronic
diverticulitis. (B) Spot radiograph of the same area obtained after the patient has gone to the bathroom (the previously identified
diverticulum is identified by a short arrow for reference). A pericolic track (long arrows) is now filled with barium, confirming
the diagnosis of diverticulitis. (From Rubesin SE, Laufer I. Double contrast barium enema: technical aspects. In: Levine MS,
Rubesin SE, Laufer I, editors. Double contrast gastrointestinal radiology. Philadelphia: WB Saunders; 2000. p. 331 – 56,
Fig. 11 – 27.)

enough barium proximal to the flexure before putting Summary

the table upright during the barium-filling phase [29].
With increasing experience, the remote-control
barium pneumocolon technique may be modified to
produce examinations of equal or greater quality as
warranted by clinical circumstances and the condi-
tions of the patient.
During a double-contrast barium enema the radi-
ologist interacts with the patient, the controls of the
fluoroscope, and the image on the television monitor.
The radiologist paints an image of the colon; the
barium is the paint, the colon is the canvas. The
376 S.E. Rubesin, D.D.T. Maglinte / Radiol Clin N Am 41 (2003) 365–376
radiologist manipulates the barium pool, the air
column, and the patient to create images. Although
the radiologist may have a plan going into the
examination, the game plan is altered by the patient’s
ability to tolerate and perform the study, the length of
the colon, and pathology encountered. If the radiolo-
gist understands the goals to be achieved, the studied
can be tailored to fit what is happening in the
fluoroscopic suite.
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