ALIMENTARY SYSTEMS.

GASTRO-INTESTINAL TRACT.
Upper alimentary tract investigation.
 Barium swallows.
 Barium meal.

Small bowel investigation

 Barium follow through
 Small bowel enema.

Large bowel.
 Barium enema.

BARIUM SWALLOW.
Indications.
 Dysphagia.
 Pain? Cause.
 Assessment of trachea-esophageal fistula in children.
 Assessment of left atrial enlargement.
 Pre-operative assessment of carcinoma of the bronchus.
 Suspected carcinoma oesophagus.
 Assessment of the site of perforation (water soluble contrast medium e.g. gastrografin)
 Oesophageal varices.

Contraindications.
 None.
Contrast medium.
There are various preparation of barium sulphate in use, some in suspension state and others in powder
state e.g.
 Bari top G powder.
 Microbar powder.
 Microcrast paste.
 Micropaque liquid.
Dosage.
 100mls or more as required.

Note;
 A very dilute barium suspension is used in cases of trachea-oesophageal fistula.

EQUIPMENT.
 Rapid serial radiography.
 Fluoroscopy unit with spot film device, image intensification and TV monitor.

PATIENT PREPARATION.
 None unless the stomach is also to be examined.

TECHNIQUES.
 Patient is placed in right anterior oblique position to throw the oesophagus clear off the spine.
  An ample mouthful of barium is swallowed and spot is film of the upper and lower oesophagus is
taken.
 Oesophageal varices are better seen in the prone right posterior oblique’s position as they will be
more extended.
 If rapid serial radiography is required, it may be performed in the right lateral, RAO and PA
positions.
 To demonstrate a trachea-oesophageal fistula in children, a fine naso-gastric tube is introduced to
the level of mid-oesophagus.
 The diluted barium is syringed in to distend the oesophagus. This will force barium through any
small fistula that could be present.
 Lateral projection must be included during injections of barium as small fistulae may be missed.

AFTER CARE.
 Observe and ensure patient hygiene.
 Further instructions i.e. next appointment date if any?

BARIUM MEAL.
Two methods.
Single contrast uses;
 Children.
 In very ill patients.

Double contrast methods

 Method of choice to demonstrate gastric-mucosal pattern.
 It is therefore allows detection of very small abnormalities.
 It is particularly viable in demonstration of gastric carcinoma and It involves the use of;
a. Baso4 suspension that has good coating qualities.
b. A gas- producing a gents
c. A drug that causes transient gastric a tony e.g. glucagon, buscopan.

Indications.
 Dyspepsia.
 Weight loss? cause
 Upper abdominal mass.
 Gastro-intestinal hemorrhage.
 Partial obstruction assessment of the site of perforation- it is essential that water soluble contrast
media is used.
 Haematemesis.
Contraindications.
 Complete large bowel obstruction.

Contrast medium.
 Any of the baso4 preparation but preferably EZHD 135mls.

PATIENT PREPARATION.
 Nil by mouth for 6 hours prior to the examination.
 No smoking on the day of examination as this increases gastric motility.
 It should be ascertained that the patient is not taking radiopaque drugs e.g. bismuth.
TECHNIQUE.
(Double contrast medium)
1. The patient is given an intraveneous injection of glucagon and buscopan the atonic effects may
last for about 15 minutes
2. The patient is positioned for fluoroscopy
3. A gas producing agent is swallowed, the requirements of these agents are as follows;
a. Production of adequate volume of gas which is 200-400mls
b. Non interference with barium coating
c. No bubble production
d. Rapid dissolution with no residue
e. Easily swallowed
f. Low cost
4. A small amount of barium suspension is given and the patient lies prone.
5. He is then rotated once/twice to end up in the supine position so that the barium is washed across
the surface of the stomach leaving a thin coating on the gastric mucosa. This thin layer is outlined
by gas.
6. More barium is given as needed and the patient is examined in the supine, oblique, prone and
erects positions spot films are taken as required.
Films (views).
 The views vary depending on the departmental routine and the wishes of the radiologists.
 The following is a detailed no of views but in many departments fewer views are taken to reduce
cost and radiation dose.
Spot films of the stomach and the patient lying horizontal.

a) Right anterior oblique;

 To demonstrate the antrum and the greater curve.

b) Supine,
 To demonstrate the antrum and the body.
c) Left anterior oblique
 To demonstrate lesser curve enface.
d) Left lateral tilted head up 45degrees.
 Demonstrate the fundus.
e) From the lateral position, the patient turns prone by rolling first to the left side, to supine and then
to prone this is to avoid barium flooding into the duodenum which would occur if the patient
turns forward to the right then prone.

Spot film of the duodenal loop (patient lying horizontal).

 Prone –demonstrate duodenal loop.

Spot film of the duodenal curve

(a) Prone P.A
(b) Right anterior oblique RAO
(c) Supine AP
(d) Left anterior oblique LAO
Erect right anterior oblique and left anterior oblique.
 Additional views of fundus can be done at this stage if fundal lesion is suspected.

Little more barium is given and a spot film of the oesophagus is taken during swallowing.
AFTER CARE.
 The patient should be warned that his bowel motions will be white in colour for a few days after
examination.
 Encourage the use of laxatives to avoid barium impactions.
 The patient should not leave the department until blurring of vision caused by the buscopan has
resolved.

ROLE OF RADIOGRAPHER IN BARIUM MEAL.

1. Done via appointment.
2. On arrival, identify the patient according to the request form with all titles. (Mr. XYZ), diagnosis,
age, date, sex, x-ray & hospital no.
3. Explain what is to be done to the patient (brief explanation of the procedures).
4. Change the patient clothes and give clean hospital gown.
5. Give the barium suspension to be taken.
6. Position the patient.
7. After the examination gives proper instructions to the patient (wait outside for further direction).
8. When satisfied discharge the patient.

BARIUM FOLLOWS THROUGH.

 This examination is performed to demonstrates the whole of the small-bowel from duodeno-
jejunal flexture to ileocaecal valve.
 It is a mainly an overcouch procedure but fluoroscopy may be employed intermittently.

Indications.
 Pain? Cause.
 Diarrhea.
 Bleeding? cause
 Partial obstruction.
 Jejunal diverticulosis.

Contra-Indications.
 Complete obstruction.
 Suspected perforation ( unless a water soluble is to be used)

Contrast Medium.
 Any barium sulphate suspension e.g. microbar, baritop G 300mls.
 If the barium follow through is to be done following barium meal, only 150 mls is given.

EQUIPMENT.
 Over couch tube
 Fluoroscopy unit.
Patient preparation.
 A laxative on the evening prior to the examination.
 Nil by the mouth for at least five hours prior examination.

Preliminary films
 Plain PA views of the abdomen.
Technique.
  The patient ingests barium suspension and then lies on the right side.
 The aim is to produce a continuous column of barium in the small bowel.
 An accelerating agent may be given at this stage either orally or intravenously at the discretion of
the radiologist.
Views.
 During the first hour the transit of barium through the proximal part of blood is very rapid. Prone
overcouch radiographs are taken every 15mins of the first 1hr.
 Use 35x43cm cassettes with its lower border at the level of A.S.I.S for the earlier radiography
when the stomach is full.
 When the stomach is empty the lower border of the cassette is adjusted to be at the level of the
lower margin of the symphysis pubis. Center in the midline at the level of the mid cassette.
 After the 1st hr prone abdominal radiographs are taken every 30mins until the Barium reaches the
colon. The prone position is used because the pressure on the abdomen helps to separate the loop
of the small bowels also affords self-compression.

Prone views for the terminal ileum.

 The patient lies on the left side and a soft pad is placed in the right iliac fossa.
 The patient is then rolled into prone position with the pad held firmly in place to prevent the
small bowel rolling back against caecum and thus obscuring the terminal ileum.
 A 30x40cm cassette placed transversely is used with its lower border at the level of the
symphysis pubis.
 Centre in the midline at the level of the middle of the cassette.

Additional Views
To separate loops of small bowels.
 Oblique’s ( Posterior; Anterior)
 Caudal angulations of the tube.
 With the patient tilted head down.

To demonstrate diverticulum
 Erect – this position will reveal any fluid level caused by contrast medium retain within the
diverticulum.

AFTER CARE
 As for the barium meal.

Note;
 If the patient for barium follow through is a child the following format is followed;
 Prone abdominal radiograph for the 1st 30 mins.
 Micturation after 30 mins- a full bladder will result in superimposition of segments of small
bowel.
 Prone view for the terminal ileum as for adults.
SMALL-BOWEL ENEMA.
 This examination involves the intubation of the jejunum and rapid injection of barium suspension
directly into the jejunum.
 This examination is preferred to barium follow through in that it’s avoid the following
disadvantages
 Pyloric control over the rate of transit.
  The obscuring of the individual coils of the small bowel by complete filling of the tracts by
barium.
 Flocculation as a result of the barium taking too long to pass through the bowel as in barium
follows through.
Disadvantages of small- bowel enema;
 Intubation may be unpleasant to the patient and it occasionally proves difficult.
 Time consuming for the radiologist.

Patient Preparation.
 Allow residue diet and laxatives for 2 days prior to the examination.
 Antispasmodic drugs must be stopped 1 day prior to examination.
 Lozenge (Amethocaine 30mg) is given 30min before examination.

Contrast medium.
 Micropaque 100% 600-1200mls diluted with1000mls of water to a specific gravity of 1.3;
a) To reduced viscosity.
b) Produces better mucosal coating.
c) Permits better visualization of particular segments of small bowel without superimpositions of
other coils.
EQUIPMENT.
 Fluoroscopy unit.
 Over couch tube.
 Bilbao-Dotter tube with guide wire (or any other suitable type of tube).

Preliminary films (P.A)

 Plain abdominal radiographs in the prone position.

Technique.
 The patient sits on the edge of the x-ray table after the pharynx has been anaesthetized either by
sucking the anaesthetic lozenge or by spraying the pharynx with a topical anaesthetic,
 The tube is passed through the nose and manipulated through the stomach.
 The guide wire is removed after passing through the pylorus but before the tube enters the
duodenum.
 The patient lies supine and 600-1200 mls of barium suspension are infused at the rate of 80-
100mls /min until the column of barium reaches terminal ileum.
 The patient then lies prone.
 Localized views are then taken during infusion using the under couch tube.
 Additional views as for barium follow through may be needed to help separate the
superimposition of the bowel loops.

AFTER CARE.
As for barium meal.
 The patient is also warned that diarrhea may occur due to large volume of barium used.

BARIUM ENEMA.
Methods.
Double contrast.
 The method of choice to demonstrate mucosal pattern.
Single contrast.
 In children since it is not usually necessary to demonstrate mucosal pattern.
 Reduction intussusceptions.

Indications.
 Change in bowel habit.
 Pain? cause.
 Mass (Carcinoma).
 Maleana.
 Partial Obstruction.

Contra-Indications.
 Toxic Megacolon.
 Colitis.
 Rectal biopsy within the previous 3 days (patient should wait for at least 7 days).

Contrast Medium.
 Any Barium suspension preparation e.g. Polibar 125% 500mls (or more as required).

Equipment.
 Fluoroscopy unit with tilting table.
 Overcouch tube.
 Disposable enema container with tubings.

Patient preparation.
 Many procedures for bowel preparations have been revealed.
 A suggested procedure is as follows;
 Patient should keep to a low diet for 3 days prior to the examination.
 The patient should have fluid only on the day prior to the examination. A laxative is given at 8am
in the morning and at 6p.m.
 On the day of the examination the patient should a higher colonic washout with 2litres of tepid
tap water. At least 1 hr must elapse before examination is commenced to allow time for the colon
to absorb excess water.
 The patient must undress completely and wear an open backed gown. Shoes, stocking and socks
should be removed in case of accidental soiling.
 Premedication; Glucogon 1mg I.V- 10mins before exam or buscopan 20mg 1.m -10mins before
examination.

Preliminary films.
Plain abdominal films to;
 Access bowel preparations.
 To exclude toxic megacolon.

Technique.
 The patient lie on his side on an incontinence sheet and the catheter well lubricated is inserted
gently about 10cm into the rectum and tapped firmly on the buttocks.
 The patient is then turned into the prone position connections are made to barium reservoir and
hand pump to inject air.
 An intraveneous injection of glucagon /intramascular injection of buscopan is given.
  The table is tilted 10degrees heads down and infusion of barium is commenced.
 Intermittent screening is required to check the progress of the barium.
 When the barium reaches the spleenic flexure , the infusion is terminated ,
 The tube clipped off and air is gently pumped into the bowel forcing the barium column round
towards the caecum and producing a double contrast effects.
 From the prone position the patient rolled on to his left side and over into a right anterior oblique
(R.A.O) position so that the barium coats the bowel mucosa.

Films (Views).
There is a great variation of views recommended.
 The following is only one of them.
 In many cases fewer views are done to.
i. Reduce costs and
ii. Radiation dose to the patient.

Spot films of the rectum and sigmoid colon,

 The patient is examined in the prone oblique and lateral position during fluoroscopy.

Spot film of the hepatic flexure, spleenic flexure and the rectum with the patient erect.
These are taken in the;
 Left anterior oblique to open out the spleenic flexure.
 Right anterior oblique to open out hepatic flexure.
 Right lateral to demonstrate the rectum.

Spot film of the caecum with compression applied in the right iliac fossa.

Overcouch films following the evacuation of the barium which includes the following;

Antero Posterior (AP) – lie supine.

 Lower border of a 35x43cm cassette is placed at the level of the symphysis pubis.
 Centre in the midline at the level of iliac crest.
Right posterior oblique.
 From supine position the patient is rotated so that the left side is raised 30 0 on a form supported
on a form pad.
 Centre in the midclavicular line on the raised side at the level of the iliac crest.
Left posterior oblique.
 Patient rotated 300 within right side raised and supported on a form pad.
 Centre in the midclavacular line on the raised side at the level of the iliac crest.
Postero Anterior (Prone).
Angled prone view.
 Demonstrates the rectal-sigmoid region, the patient lie prone and pelvic position symmetrically.
 The upper border of 35x43cm cassette is placed at the level of the A.S.I.S Centre in the midline
5cm above the A.S.I.S within the tube angled 450 caudal.

Left lateral decubitus.

 Patient lies on his left side with his arms on the pillow above his head.
 The grid cassette is supported vertically either anterior or posterior to the patient.
 A horizontal beam is used centre in the midline at the level of the iliac crest.
Right lateral decubitus.
 Patient lies on the right side.

Antero- Posterior Erect view.

 Either the fluoroscopy table is tilted into the vertical position or the patient stands in front of an
erect Bucky stand/a vertically placed grid cassette.
 Centre in the midline at the level of iliac crest.

Modifications
Infants.
 Barium suspended in tap water is hypotonic and can cause excessive absorption of water from the
colon especially if the colon is dilated and needs larger amount of barium to fill it.
 For infants,10 grams of salt should be added to every litre of water to make the concentration
isotonic.
Ileastomy and colostomy patients.
 When an examination is done on a patient who has had sigmoid colectomy and temporary
colostomy.
 Water soluble contrast media is used e.g. Urografin 30% or Hypaque 25/45%.
 The proximal end is examined by infusion of barium through a colostomy opening using a
catheter and the distal part is examined by infusion of barium into the rectum.

AFTER CARE.
As for barium meal.
 Laxatives.
 Bowel white.
 Blurring of vision.
 Diarrhoea.