Cheri L. Canon, M.D.

UAB Department of Radiology

Revised June 2006

GUIDELINES FOR RESIDENTS IN GASTROINTESTINAL RADIOLOGY

The aim of the GI Radiology group at UAB is to provide complete and accurate studies performed in an
expeditious manner, attempting to minimize discomfort and delay to the patient. Achieving this depends
to a large degree on the motivation and consideration of the radiology resident. A professional and
courteous manner in your dealings with patients as well as the technical staff is an important part of
your work.

The GI schedule begins promptly at 7:30 a.m. at University Hospital and Kirklin Clinic. You are
expected to be on time. Many of our patients have been NPO for several hours, so timely performance
of studies is crucial. In the hospital, it is helpful if you review the morning’s schedule and contact the
referring clinician if there are questions. Since studies in the hospital are seldom ready to begin at 7:30,
you can preview and predictate the abdominal radiographs from the “Unread ABD” list on the PACS.

It is standard procedure to review briefly each patient’s chart as well as to elicit pertinent history from
the patient prior to the start of the examination. Four things should ALWAYS be determined:
1) Name on request and patient’s name coincide (check bracelet on hospitalized patients)
2) Patient’s symptoms
3) Related surgeries
4) NPO status/adequacy of bowel prep

In addition, it is wise for the resident to discuss a case with the staff radiologist if there are any
questions. Always review prior studies when they are relevant, such as when you are about to begin a
UGI to document change in an ulcer.

In some cases, examinations are ordered which are not actually needed, especially at the start of a
new academic year. For example, if a physician wants us to rule out the presence of hiatal hernia, it is
not necessary for him to order both a barium swallow and and an UGI. In such instances the resident
may do the UGI and check for gatroesophageal reflux. Check with the staff radiologists before
canceling or adding on any study. If an additional study is needed, such as a small bowel follow through
after an UGI, the referring clinician must be contacted before beginning the study to approve the
additional study. This is a medicare billing issue.

An attempt should be made to ascertain the possibility of pregnancy in any female patient of
child-bearing age. Radiation to the abdomen is particularly likely to be harmful between the second
and sixth week post-conception but unnecessary radiation should be avoided at any stage of
pregnancy. You should inquire of the patient, “Is there any possibility that you are pregnant?” If the
answer is “yes” or if her menstrual period is overdue, the patient can be sent to the lab for a urine
pregnancy test. Alternatively if the procedure is elective, it may be possible to postpone it until the onset
of menses.

One of the responsibilites of the GI resident(s) is to transcribe the weekly GI Conference, which occurs
at 4:30 p.m. on Wednesdays in the Tishler Conference room. The GI resident should take brief notes
during the conference and submit a transcription via email to Peg Williamson, Dr. Canon’s Assistant.
Transcipts need to be completed by the Monday following the Wednesday conference. Residents can
use voice-recognition dication system with a dummy request number to generate the report, and then
cut and paste into a word document. Dr. Canon will review the transcriptions and keep on file as part of
our Quality Assurance Program. It is the responsibilty of the GI resdient to find another resident to take
notes during the conference if they will be absent (vacation, meeting, etc.). If there are two GI residents,
this responsibilty can be shared.
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DON’T’S IN G.I. RADIOLOGY

DON’T use a rectal balloon in a patient with known or suspected proctitis or rectal carcinoma. In
our patient population, proctitis is usually secondary to radiation therapy (cervical and
prostate carcinoma) or inflammatory bowel disease. Radiographically, the rectum may or
may not be nondistensible with loss of the normal rectal values of Houston and a
granular mucosa (Addendum A).

DON’T inflate a rectal balloon except under fluoroscopic vision in a rectum already distended
with barium.

DON’T do a barium enema in a patient with fulminant colitis or toxic megacolon.

Radiographically, the latter appears as a dilated colon, particularly the transverse colon,
with loss of the normal haustra and fold thickening (thumb printing).*

DON’T do a barium enema if free colonic perforation is suspected. Diluted water-soluble

contrast material (MD-Gastroview) is indicated.*

DON’T give barium by mouth if a free perforation of the GI tract is suspected. Again, a water-
soluble agent is a better choice.*

DON’T give barium by mouth to a patient who has or may have a colonic obstruction.

DON’T give oral preparations of iodinated water-soluble contrast material to patients with known
or suspected aspiration or TE fistula. If a water-soluble contrast agent is desired, low-
osmolar intravenous contract (e.g., Omnipaque 350) can be substituted.

DON’T give orally more than 120 ml or 4 oz of undiluted MD-Gastroview.

NOTE: Water-soluble contrast media, such as MD-Gastroview, is usually supplied as
76% solutions (66% meglumine diatrizoate and 10% sodium diatrizoate). The label
states that the concentration of the drug itself. Don’t let this confuse you.

DON’T vigorously insert or inflate the compression paddle under elderly patients or others with
fragile bones.

DON’T begin a GI procedure in a woman of childbearing age without inquiring about the
possibility of pregnancy.

DON’T do a fistula or sinus tract study or a post-surgical study without a preliminary scout film of
the area to be studied. This should be obtained digitally.

DON’T do a barium enema if a polypectomy has been performed in the last 72 hours.
Colonoscopic forceps biopsy is not a contraindication to a barium enema.

DON”T leave an obtunded patient unattended or let them leave the radiology dept with contrast
material in their stomach. Aspiration on gastric contrast material is the most frequent
cause of death caused by fluoroscopic GI examinations.

*Get a scout radiograph if in doubt (or consider CT).

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FLUOROSCOPIC GI STUDIES
* Conventional abdominal radiograph (KUB, flat and upright, lateral decubitus)
* Barium swallow (esophagram) (BS)
* Water-soluble esophagram
* Modified barium swallow (with speech therapist) (MBS)
* Upper GI series (UGI)
* Barium enema (BE)
* Air-contrast or double-contrast barium enema (ACBE/DCBE)
* Full-column or single-contrast barium enema (FCBE/SCBE)
* Water-soluble contrast enema
* Interactive small bowel follow-through (SBFT)
* Fistulogram
* T-tube cholangiogram
* Enteral feeding tube placement
* Endoscopic retrograde cholangiopancreatography (ERCP)
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BRIEF OVERVIEW OF CONTRAST AGENTS

In general, there are two types of GI contrast agents: barium sulfate-based and iodine-based. The type
of contrast used should be determined by study requested and clinical history.

Barium sulfate is relatively inert, but it can incite an inflammatory response if spilled into the
mediastinum or peritoneal cavity with bowel contents. For this reason, a water-soluble agent is
preferred if perforation is suspected. Barium must be used cautiously when performing diagnostic
enemas in patients suspected of having mechanical obstruction of the colon. The single-contrast
barium enema is useful in delineating the site and nature of the obstructing lesion. Because of the
danger of barium becoming inspissated above a colonic obstruction, however, do not allow much
barium to pass above a point of significant obstruction. If barium flows freely through a narrowed area
of the colon, in all likelihood it will pass just as freely in the other direction. Barium is not contraindicated
in small bowel obstruction, but an abdominal CT can demonstrate small bowel obstruction, the point of
transition, and concomitant pathology in a significantly shorter period of time.

Iodine-based contrast agents are water-soluble. There are high osmolality contrast media (HOCM),
including Hypaque meglumine, Hypaque-76, and Conray, and low osmolality contrast media (LOCM),
such as Omnipaque, Oxilan, and Isoview, which are nonionic as well. LOCM include both ionic and
nonionic compounds. All HOCM are ionic. The above named agents are prepared for intravascular use,
and are therefore sterile. MD-Gastroview and Gastrografin are HOCM (ionic); they are flavored and
prepared for enteric use and are not suitable for parenteral injection.

HOCM can cause bronchospasm, pulmonary edema, pneumonitis, even death, and is
contraindicated in patients at risk for aspiration or with a tracheoesophageal fistula (TEF). In our
adult patient population TEF usually results from esophageal carcinoma. LOCM (Omnipaque 350, 50-
100 mL) can be used more safely in these patients. Also remember, the risk of aspiration of refluxate in
obtunded patients after performing any contrast study of the UGI tract. Residual contrast should be
removed from the stomach via an NG tube in these patients.

Gastroview and Gastrografin are limited in the volume that can safely be administered orally, 120 ml’s
(4oz). Volumes higher than this can drastically alter fluid balance. These agents are hyperosmotic and
draw fluid into the bowel lumen. This is particularly a concern in dehydrated, elderly patients and in
infants.

A final consideration is allergic or idiosyncratic reactions to iodinated contrast agents. These reactions,
which are life threatening, have been documented with intravascular iodinated contrast administration
and are volume-independent. Small amounts of water-soluble contrast can be absorbed by the GI
mucosa into the bloodstream. If significant mucosal inflammation is present, an even larger amount of
absorption takes place. Therefore, history of anaphylactoid reaction to iodinated agents is a
contraindication to their administration enterally as well as parenterally.
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BARIUM PRODUCTS
“Thick” Maxibar (TKC) 210% w/v 80% w/w
(Double-contrast BS, UGI) E-Z-HD (UH) 250% w/v 98% w/w

“Thin” Liquid E-Z-Paque 60% w/v 41% w/w

(Single-contrast BS, UGI, BE)

SBFT Entero-H 80% w/v 49% w/w

Enterobar (preferred) 50% w/v

DCBE Liquid Polibar 100% w/v 56% w/w

PATIENT POSTIONING (Relative to top of fluoro table)

Supine AP (on back)
Left posterior oblique LPO
Right posterior oblique RPO

Prone PA (on abdomen)

Left anterior oblique LAO
Right anterior oblique RAO

Left lateral LLD (left side down)

Right lateral RLD (right side down)

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BARIUM SWALLOW (BS)

The two most common indications for a barium swallow are dysphagia and odynophagia. An upper G.I.
(UGI) is indicated for most other symptoms. Particularly in patients with symptoms of gastroesophageal
reflux (GER) such as “heartburn” or epigastric pain, an UGI should be performed because these
symptoms could be secondary to ulcer disease not just GER. We test for GER during both a BS and
UGI. A biphasic study (combined double- and single-contrast images) is usually performed.

BARIUM SWALLOW: Summary of Technique

Patient Preparation:
NPO after midnight

Materials:
1 ampule of Baros Bicarbonate with 10 cc water
2 oz., E-Z-HD or Maxibar, 250% and 210% w/v, respectively (“thick barium”)
7 oz., Liquid E-Z-Paque Barium, 60 % w/v (“thin barium”)
12.5 mm barium tablet

Procedure:

1. Have technologist turn on DVD/CD recorder. Start with the patient erect and in lateral position
facing you. Have patient swallow one mouthful of thin barium, and watch it pass through the
pharynx and esophagus. Watch for aspiration, leak, stricture, obstruction, or delayed emptying.
If there is significant aspiration, the study should be discontinued at this point. (Take a lateral
and AP Spot view of the pharynx to document extent of aspiration). If there are abnormalities
suggesting achalasia (dilated, nonperistaltic esophagus with obstruction at the lower
esophageal sphincter, and a barium column in the esophagus), please convert to Special
Protocol in Achalasia Patients (below).

2. If all goes well, center the image intensifier over the pharynx and cervical esophagus and
videotape three consecutive single swallows of thin barium in the lateral view. If the patient
double swallows, give instructions to “swallow only one time with each mouthful”. Instruct the
technologist to turn recorder off.

3. With the patient in the AP position, record the pharynx during three more consecutive swallows.
Instruct the patient to hold the cup of barium to the side of their face with the straw in the corner
of their mouth with their chin forward. In order to accurately evaluate for symmetry of swallow,
the patient must be centered, facing forward, without head tilt or turn.

4. Place the patient in erect LPO position. Give Baros Bicarbonate with 10 ml water followed by 2
oz. thick barium. Obtain 3 views of the air-distended thoracic esophagus using a 3-on-1 format
on a 14X14 CR cassette without magnification. The first image should include the upper
thoracic esophagus. The other two should include the lower esophageal sphincter. When using
CR cassette films, the “Full” button on the tower should be selected or inappropriate spot film
collimation will occur. While in digital mode, this button should be changed to “MAN” (manual).
 7

1. Standing LPO thoracic esophagus

(3:1, 14 x14 CR film).

5. Obtain AP and CR lateral air-contrast views of pharynx digitally using a 6” image intensifier (II)
setting. Instruct the patient to phonate a long “E”.

2. Standing AP pharynx 3. Lateral pharynx

(digital, 6” II). (digital, 6” II).

6. Turn patient to face table in a RAO position (prone GI position) and lower table to horizontal.

7. Record three separate, single swallows of thin barium, following the tail of each peristaltic wave
with the fluoroscope. Watch emptying at the gastroesophageal junction (GEJ) junction, and
make sure the image is not magnified.

8. Position the fluoroscope over the pharynx/upper thoracic esophagus and record 3 swallows. Do
the same for lower esophagus/GEJ region.

9. Obtain three, nonmagnified digital views, single–contrast, barium-filled, thoracic esophagus.

Center the first on over the upper thoracic esophagus. Include the open lower esophageal
sphincter (LES) on the last 2 views.
 8

4, 5, 6. Prone RAO thoracic esophagus

(digital, 12” II).

10. Evaluate for reflux. At this point you should make an attempt to demonstrate GER unless
already been identified during the proceeding parts of the exam. Place the patient in the supine
RPO position so that the cardia is filled with barium. Observe the GEJ fluoroscopically while the
patient performs a Valsalva maneuver and coughs. If no reflux is elicited by this maneuver,
watch while the patient rolls unassisted from the supine to the right lateral position. The straining
associated with rolling over will often elicit reflux. A fourth maneuver that can be attempted is
the water siphon test. Perform this test with the patient in the supine RPO position and have the
patient drink three swallows of water. The water serves to clear the esophagus of any residual
barium and the act of swallowing may trigger the occurrence of reflux. Lastly administering
water while the patient rolls to a decubitus position may elicit reflux. Be sure to note in your
report the following (It is helpful if you jot this information on the patient’s request at the end of
the study):

1) Maneuver eliciting reflux

2) Height of the refluxed barium
3) Time it takes for the esophagus to clear the refluxate

11. BARIUM TABLET. A 12.5 cm (38 Fr) barium sulfate tablet is given to patients with:

1) Dysphagia unexplained by the findings on the routine study (i.e., the study looks normal
fluoroscopically).
2) A stricture wide enough to warrant measurement to assess clinical significance. Tight
strictures need no tablet.

This size tablet is used because strictures less than 13 mm usually cause dysphagia in most
patients. Strictures ranging from 13 to 19 mm may or may not cause dysphagia. Remember,
images on films are magnified. Refer to conversion tables for measurements.
 9

“MODIFIED” BARIUM SWALLOW (BS)

SINGLE-CONTRAST PHARYNGEAL SPOT FILMS are occasionally obtained to demonstrate
cervical esophageal strictures or problems with the cricopharyngeal sphincter. Change the film
speed on the tower (GE digital rooms) to 4/second. Instruct the patient to hold a mouthful of barium
and swallow on the count of 3. Begin obtaining exposures on “3.”

VARICES: If the clinical question involves the possibility of esophageal varices, recording of the
distal esophagus can be helpful. Varices are best seen in the collapsed esophagus after passage of
the primary wave when the mucosa is coated with barium. High density mucosal barium is
employed. When the distal esophagus is distended with large volume of barium, the varices can
disappear. Varices empty with the passage of a peristaltic wave and slowly refill over the next few
minutes. If your clinical suspicion is high and you do not see varices on the initial collapsed views,
try coating the esophagus with high density barium and spot filming the lower esophagus after
waiting 2-5 minutes from the time of the last peristaltic wave while the patient avoids swallowing
(patient may have to spit saliva into a cup).

WATER-SOLUBLE ESOPHAGRAM: The decision concerning the use of barium vs. a water-
soluble contrast relates to the likelihood of esophageal perforation and aspiration. For most
esophageal problems, a barium suspension should be employed. If the history suggests a
perforation of the esophagus or if the patient has recently had an esophagogastrectomy, a water-
soluble contrast agent such as Gastroview should be used. If no contrast extravasation is identified
with the water-soluble contrast, then “thick” barium should be given; barium suspensions have been
shown to be more sensitive in detecting perforations. Also, in cases of suspected aspiration, a sip of
water should be given to the patient prior to initiation of the study to assess for choking entering the
airway. If the clinical concern is for a perforation and the patient is also at risk for aspiration, a low-
osmolar contrast agent (Omnipaque 350) can be administered orally without the risk of hypertonic
pneumonitis.

ACHALASIA: The patient begins in the standing LPO position. Fluoroscope for air-fluid level in the
esophagus and absence of a gastric bubble. While watching with video fluoroscopy, give thin
barium until the lower esophageal sphincter opens for the first time. Make sure patient is not
aspirating. Then turn recorder off. Obtain 3-on-1 CR images of the esophagus at 1, 2, and 5
minutes, with times denoted on the films. All images should be obtained at the same level of the
esophagus, including both the gastroesophageal junction and above the air-fluid column. Then
study the pharynx in the lateral position, specifically assessing the cricopharyngeal relaxation.
Supine imaging and provocative testing for reflux are not necessary.

MODIFIED BARIUM SWALLOW is performed in conjunction with a speech therapist. Patients are
observed with video/fluoroscopy swallowing various substances, usually in the lateral position.
Laryngeal penetration and aspiration are noted. The pharynx can be studied in the AP position if a
unilateral abnormality is suspected (e.g., stroke patient).

NOTE: Of critical importance in any patient with DYSPHAGIA is the demonstration of the cause for
the symptoms before the patient leaves the fluoroscopy room. If the routine exam fails to show an
abnormality, the patient may be able to tell you what induces their symptoms. This may be eating a
particular food in a particular way. We make it a point to observe such patients fluoroscopically
while eating or drinking the food they suggest in the way they suggest. Some of our referring
clinicians arrange to have their patients bring the offending food (biscuit, fried chicken, apple, etc.)
with them on the day of their barium swallow. If, however, this situation was not anticipated prior to
the patient’s arrival to the GI suite, the technologist in charge or the patient can obtain food
samples, (e.g., sausage biscuit from cafeteria).
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UPPER GASTROINTESTINAL EXAMINATION (UGI)

The most common indications for an UGI include epigastric pain, anemia, heme + stools, symptoms of
GER, or suspect hiatal hernia. We perform a biphasic (combined double-contrast and single-Contrast)
technique in most patients. A single contrast or modified study is often needed in the following clinical
situations:

Obtunded or immobile patient

Food or fluid in stomach; gastric distension (gastric outlet obstruction)
Post-surgical patient
Patient with NG tube

Upper GI: Summary of Technique

Patient Preparation:
NPO after midnight

Materials:
1 ampule of Baros Bicarbonate with 10 cc water
2 oz., E-Z-HD or Maxibar, 250% and 210% w/v, respectively (“thick barium”)
5 oz., Liquid E-Z-Paque Barium, 60% w/v (“thin barium”)
12.5mm barium tablet (optional)

Procedure:

1. Patient standing, fluoro abdomen. Look for four things:

1) Full stomach
2) Bowel obstruction
3) Free air
4) Barium in small bowel or colon overlying UGI tract

2. Place the patient in erect LPO position. Give Baros Bicarbonate with 10 ml water followed by 2 oz.
“thick” barium. Obtain 3 views of the air-distended thoracic esophagus using a 3-on-1 format on a
14X14 CR cassette without magnification. The first image should include the upper thoracic
esophagus. The other two should include the lower esophageal sphincter. While obtaining CR
images, the “Full” button on the tower should be selected. While in digital mode, this button should
be changed to “MAN” (manual). Quickly tilt table down to horizontal before barium enters
duodenum.

1. Standing LPO thoracic esophagus

(3:1, 14 x14 CR film): first image should center on
upper thoracic esophagus. Next two should
include the lower esophageal sphincter.
 11

3. To coat stomach, roll patient through left lateral to prone position and back through left lateral to
supine to coat stomach. Two rolls may be necessary. (Roll to right lateral briefly only if necessary
to obtain good antral coating.) Check the lesser curve of the stomach for adequate coating. This is
usually the last portion to get coated with barium.

4. Obtain air-contrast digital spot images in the following positions with the image intensifier setting
shown. Note, the remainder of the images should be obtained digitally.

2. LPO stomach 3. RPO stomach 4. Lateral stomach

(9” II): This view provides (9” II): (Check for reflux at (12” II): This view assesses
detail of the body and this time.) This view is the gastric cardia (“rosette”)
antrum. optimized for the lesser and fundus as well as the
curve. anterior wall of stomach.

5. Roll the patient into the left lateral decubitus position to empty the duodenal bulb. Then roll the
patient slightly back, stopping at the LPO position.

6. Obtain the following spot images:

5. LPO antrum 6. LPO antrum 7. LPO bulb 8. LPO bulb

(4.6 or 6” II). and bulb (4.6 or 6” II). (4.6 or 6” II).
(4.6 or 6” II).
 12

7. Place the table in the erect position and obtain a 6” or 9” II view of the fundus
with patient in LPO position.

9. Erect LPO fundus

(9” II).

8. Turn patient around to face table and tilt down to horizontal, patient in prone RAO (GI position).
First observe esophageal peristalsis by watching two separate single swallows of thin barium.
Obtain three, nonmagnified views, single-contrast, barium-filled, thoracic esophagus digitally.
Center the first on the upper thoracic esophagus. Include the open LES on the last 2 views.

10, 11, 12. Prone RAO thoracic esophagus

(12” II).

9. Place compression paddle under patient. Obtain 3 or 4 digital images (4.5” or 6” II) of the
antrum and duodenum. Make sure compression is adequate so the barium is “see through.” To
obtain adequate compression in both regions, the paddle will have to be moved from the
duodenum to the antrum in most patients. Do not “drag” the paddle under the patient. Have
them lift or “push-up.”

13. Prone RAO antrum 14. Prone RAO bulb 15. Prone RAO bulb
(4.6 or 6” II). (4.6 or 6” II). & c-loop
(4.6 or 6” II).
 13

10. Final 3 images should include as much of the stomach, duodenum, and small bowel as possible:

16. Prone RAO (12” II). 17. Prone (12” II).

11. Roll through left lateral to supine. (If the earlier air-contrast views of the duodenal bulb were
suboptimal, another view can be obtained at this time before placing the patient supine).

18. Supine (12” II).

12. Check for GER (see page 10) unless reflux has already been observed.

13. If there is a question of distal esophageal stricture, give the patient a 12.5 mm barium tablet while
in the erect position.

14. Jot reflux notes and other abnormal findings on patient request sheet.

The esophagus is certainly part of the upper gastrointestinal tract. While we do not take films of the
entire esophagus and pharynx with every UGI, a careful fluoroscopic look at the esophagus is indicated
on every study, especially if the patient has symptoms that relate to swallowing. If the patient complains
of dysphagia, odynophagia or a lump in the throat, discuss with your attending the possibility of adding
on an esophagram, even if only an upper GI was requested. Non-radiologists often have an unclear
picture of the area emphasized in a barium swallow vs. an upper GI series. We should always be on
the lookout for situations where altering or augmenting an exam may be to the patient’s benefit.

It should be remembered that when a barium swallow is combined with an UGI, the erect portion of the
videotape study (pharyngeal motility) should be performed last, after all films of the stomach have been
obtained. Otherwise excessive amounts of barium in the stomach will diminish the value of the UGI
study.

A few words about dismissing the patient are in order. The GI attending will be involved in most of the
decisions regarding the extra spot films, additional work-up needed, and patient dismissal during your
first month on GI. However, the resident needs to quiz him/herself about these issues to develop skill in
 14

the art of declaring a study finished. This is an important decision with outpatients especially, since they
may not be able to come back to the department in the case of an early departure. For out-of-town
patients, it is crucial to check all the films and arrive at the conclusion of the radiographic evaluation
prior to letting the patient go. Important areas to evaluate are the number and quality of spot films and
overheads; critical examination of problem areas which often require fluoroscopy to allow distinction of
normal vs. pathologic; radiographic technique; and finally, does the study answer the clinical question.
Challenge yourself to go through this process even though the attending does it as well. It is a critical
step in GI radiology.
 15

CONTRAST STUDIES OF THE SMALL BOWEL

The most common indications for a small bowel study are Crohn’s disease (known or suspected),
abdominal pain, and heme + stools and/or anemia. In the majority of cases, a small bowel series is
preferred over an enteroclysis as the former is less invasive. The small bowel series performed at our
institution is interactive with careful fluoroscopic evaluation. We do not rely solely on the overhead
radiographs, which improves examination sensitivity.

We use six methods for examining the small intestine radiographically:

1) Interactive small bowel series

2) Small bowel follow-through after UGI series (SBFT)
3) Peroral Pneumocolon
4) Small bowel study through indwelling tube
5) Water soluble contrast small bowel study (rarely)

Interactive Small Bowel Series: Summary of Technique

Patient Preparation:
NPO after midnight

Materials:
16 oz., Enterobar or Entero-H

Procedure:

The conventional small bowel examination is done with fluoroscopic evaluation, digital spot films and
overhead films. The overhead films are done with the patient prone to minimize radiographic
magnification and unsharpness. The diagnostic yield of the examination is clearly related to the
skill and effort that goes into the fluoroscopy. It is not enough to simply obtain films every 30
minutes and hope to spot the abnormality at the viewbox.

1. A scout radiograph is obtained by the technologist, particularly when there is a question of

bowel perforation or mechanical obstruction.

2. Give 16 oz. of Entero-H or Enterobar by mouth. If the patient is having an UGI first, Entero-H or
Enterobar is substituted for the thin barium portion of the exam. Start the time clock when the
patient begins drinking the barium. Have all overhead films marked with clock time and time
elapsed since the beginning of the examination.

3. Obtain a 15-minute prone overhead radiograph.

4. Study each film as it is taken. Additional overheads are obtained at roughly 30-minute intervals
but the spacing needs to be adjusted to fit the rate of progress of barium through the bowel.
Ideally, there will be three or four overhead films per study.

5. Also check each film to determine the best times to fluoroscope the patient. Two or three trips
should be made to the fluoroscopy room, at least one when the jejunum is well filled and one
when the ileum is well filled.

6. Watch the rate of gastric emptying. Patient can drink other liquid (coffee, soda, etc.) if transit is
slow, but the stomach is empty.
 16

7. Once barium has reached the ascending colon and the terminal ileum is well filled, fluoro and
digitally spot the terminal ileum.

Modified SBFT

SMALL BOWEL FOLLOW-THROUGH (SBFT) AFTER AN UGI: This study is conducted in a fashion
similar to the conventional small bowel series. During the UGI series the patient will have been given 7
oz of barium to drink. For the small bowel follow-through, give another 8 oz of the Entero-H or
Enterobar and obtain the first overhead small bowel film 15 minutes later.

PERORAL PNEUMOCOLON: This is an examination of the right colon and distal ileum. It produces
very detailed images of the distal small bowel in most patients. The study begins as an interactive small
bowel series. Once barium has reached the hepatic flexure or mid ascending colon, an enema tip is
used to insufflate air per rectum. Once the right colon and distal ileum are distended with air, digital
spot films and sometimes overheads are obtained. When you see findings in the terminal ileum on a
conventional small bowel series which need further clarification, this is a good way to augment the
study and get a more detailed look.

WATER-SOLUBLE SMALL BOWEL STUDY: As useful as water-soluble contrast material is in the

colon and upper GI tract, it has relatively few applications in the small intestine. When iodinated
contrast material is given by mouth, it becomes sufficiently dilute in the small bowel, particularly if
obstruction is present, that films of the small intestine are usually not of sufficient quality to permit
diagnostic evaluation. (Remember that the oral dose of undiluted water-soluble contrast material should
be limited to 120 ml). It is possible to determine whether or not contrast eventually reaches the colon,
but anatomic detail is usually not recognizable on an examination performed in this way.
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CONTRAST STUDIES OF THE COLON

Contrast studies of the colon can be performed in three standard ways: double-contrast barium enema
(DCBE), single-contrast barium enema (SCBE) and water-soluble contrast enema. Water-soluble
contrast medium is used whenever a colonic perforation is suspected. It is also used when it is
necessary to study the portion of the colon which lies proximal to a relatively high grade mechanical
obstruction.

The routine enema we perform is the DCBE. This examination is more sensitive for detection of polyps
than is the SCBE, which is especially important in patients over age 50, those with occult blood loss,
and those with suspected carcinoma, polyps, or colitis. SCBE is preferred, however, in certain
situations, such as in patients in whom a colonic obstruction is suspected. The demonstration of colonic
fistulae such as in patients with diverticulitis or recto-vaginal or rectovesical fistula is often best
demonstrated by the single-contrast technique. The DCBE requires that the patient lie prone during
much of the examination. For this reason, the alternative single-contrast study is preferred in patients
who are unable to lie prone because of a recent or open surgical wound or in patients whose mobility is
restricted by severe arthritis, plaster casts on the extremities, etc. We usually do a single-contrast study
in patients over 70 or 75 years of age, depending upon their mobility.

Regardless of the type of enema to be performed, remember to briefly review the patient's history and
indications for the study. Be careful that you detect patients in whom colonic perforation, toxic
megacolon, or fulminant colitis are likely possibilities before you begin the exam. These are
contraindications to performing a barium enema.

DOUBLE CONTRAST BARIUM ENEMA(DCBE)-Summary of Technique

Patient Preparation: (Instructions given to patient)

Day before barium enema:
1. Eat no solid foods after 10:00 a.m.
2. For lunch, take only clear liquids as listed below. NO FOOD.
3. At 1:00 p.m. drink one full glass of water (8 oz.).
4. At 3:00 p.m. drink one 10 oz. bottle of the Magnesium Citrate laxative. It's better chilled.
5. At 4:00 p.m. drink one full glass of water
6. For supper, take only clear liquids. NO FOOD.
7. At 6:00 p.m. take the 3 laxative tablets you were given. Swallow them whole with at least one
glass of water or other clear liquid.
8. At 8:00 p.m. drink one full glass of water.
9. At 10:00 p.m. drink one full glass of water, Gatorade or a carbonated soft drink.

Day of barium enema:

1. At 6:00 a.m. drink one full glass of Gatorade, apple juice or carbonated soft drink.
2. If you are taking daily prescribed medications, take them as usual.

Materials:
Liquid Polibar, undiluted (E-Z-EM, Inc.)
Enema bag with 0.5 inch I.D. tubing and “Miller” tip with end-hole and 8 side holes
Glucagon, 0.5-1.0 mg, (if needed for spasm)

Procedure:

1. A routine scout radiograph is not obtained at the Kirklin Clinic. If the patient reports to you or the
technologist that his or her bowel movements are still formed or semiformed, a scout radiograph
to determine adequacy of the bowel prep may be prudent. Examine the scout film carefully.
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Decide whether or not the colon is sufficiently well prepared to allow you to proceed. In most
circumstances, the patient should receive another day's colonic preparation before the enema is
done if stool is present in the colon. Until you gain experience in how much stool or barium will
preclude an adequate examination, ask the staff radiologist to help you decide whether or not to
reschedule.

2. Next, do a careful rectal examination. Early in your experience, this will be helpful in orienting you
to the proper direction of the anal canal and rectum (these two portions of the GI tract usually lie
at right angles to one another) as a guide to inserting the enema tip. In addition, you should be
able to detect the presence of a rectal mass or stricture and can decide whether or not there is
stool in the rectal ampulla. Insert the enema tip with the patient in the left lateral decubitus position
with knees drawn up toward the chest. Roll patient to prone position and tape buttocks together
tightly and tape tube in place. Turn on barium.

3. Start with patient prone. Turn on barium. Tilt head of table down to speed flow of barium. You will
also want to squeeze the bag to get the viscous barium to flow fast enough. However, remember
patient tolerance is inversely proportional to the rate of rectal distension.

4. Turn off barium when column reaches distal transverse colon (proximal transverse if colon is
unusually long and tortuous). This may require the addition of more barium into the enema bag in
patients with a redundant colon.

5. Tilt table erect and place enema bag on floor to drain rectum. Clamp the tube after draining.

6. Tilt table head down and place patient in prone RAO position. Gradually and continuously pump
air into colon.

7. As barium column reaches proximal transverse, bring table up to horizontal and place patient in
right lateral position. Keep pumping air.

8. As barium reaches hepatic flexure, roll patient to supine RPO. Keep pumping air.

9. As barium enters ascending colon roll patient supine, left lateral decubitus, and prone.

10. If there is barium left in the rectum, place table erect and drain it again and redistend rectum with
air.

11. Check one last time to make sure colon is well distended.

NOTE: When an unusual amount of colonic muscular spasm prevents filling of the colon and causes
the patient to experience undue cramping, it is helpful to administer (0.5-1.0) mg of Glucagon
(Addendum B).

12. Obtain the following digital spot radiographs:

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1. Prone rectum 2. Right lateral 3. LPO sigmoid 4. RPO sigmoid (9”

(9” II): Make sure no rectum (12” II): (9” or 12” II): or 12” II): If the
residual pooled barium. Make sure acetabuli After turning prone sigmoid is redundant,
If there is, stand patient are superimposed. to left lateral. may need additional
again and drain. spots.

13. Place table erect, spot both flexures. The cecum fills with barium now. Rare patients also need
an erect spot of the sigmoid.

5. RPO splenic flexure 6. LPO hepatic flexure

(12” II). (12” II).
If the flexures are redundant, may need additional spots.

14. To fill cecum with air, go to right lateral and tilt table down to horizontal, or head down if
necessary, to drain cecum. Roll back toward supine and spot cecum. If this does not adequately
drain the cecum, roll the patient supine, left lateral decubitus, prone, right lateral decubitus, and
slowly down to supine (a complete 360˚ turn). Then place in Trendelenburg position and spot.

7. Supine cecum
(9” II).
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Make sure colon is adequately distended with air prior to leaving the room.

Overheads: (Obtained by the technologist)

1. Supine (AP)
2. Prone (PA)
3. Prone sigmoid with 35˚ caudal angulation
4. Right lateral decubitus
5. Left lateral decubitus

NOTE: In rare instances when the cecum or ascending colon is inadequately studied with a double-
contrast technique, a repeat full-column enema may be necessary after the patient evacuates.

NOTE: In patients suspected of having Crohn’s Disease, a post-evacuation film may be helpful in
assessing the terminal ileum. Often, evacuation results in small bowel reflux.
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SINGLE-CONTRAST (FULL COLUMN) ENEMA (SCBE) – Summary of Technique

Patient Preparation:
Same as for DCBE

Materials:
500 cc Liquid E-Z-Paque or Gastroview
Enema bag with 0.5 inch I.D. tubing and “Miller” tip with end-hole and 8 side holes
Glucagon, 0.5-1.0 mg, (if needed for spasm)

Procedure:

1. Perform rectal exam.

2. Insert enema tip. If anal sphincter tone is moderate to good, do not inflate the balloon. If sphincter
tone is absent or if patient loses barium during the procedure, inflate balloon unless patient has
rectal pathology (Addendum A).

To inflate balloon, first distend rectum with barium with patient supine. While watching
fluoroscopically, add enough air to balloon to bring it near but not all the way to the lateral rectal
walls.

Do not inflate a retention balloon in any patient with rectal narrowing, radiation proctitis, or
ulcerative proctitis.

NOTE: Balloon inflation may also be helpful with a double contrast technique. The same
directions apply.

3. Start Supine LPO. Add barium till column reaches descending colon.

4. Stop barium and spot rectum AP and sigmoid LPO once adequately distended (spot in two or
three different oblique projections if long and tortuous). All spot images are digital.

1. Supine rectum 2. LPO sigmoid

(9“ II). (9 or 12” II).

5. Add barium till column reaches transverse colon. Stop barium.

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6. Turn to supine RPO and spot splenic flexure. Alternatively, splenic flexure may be spotted in
steep LPO if that looks best*.

3. RPO splenic flexure

(12” II).

7. Add barium till column reaches ascending colon. Stop barium.

8. Turn to supine LPO and spot hepatic flexure*.

4. LPO hepatic flexure

(12” II).

9. Add barium to fill cecum. It may help to turn table semi-erect. Stop barium as soon as terminal
ileum begins to fill.

10. Use “banjo” paddle to obtain compression spot of cecum in supine or slight oblique position. If
uncertain whether cecum is well filled, turn patient prone and reassess.

11. Examine the entire colon fluoroscopically while palpating it carefully with a gloved hand. It is
helpful to magnify the image while doing this (6” or 9” II setting). Check with your attending to see
whether he or she wishes to fluoroscope the colon with you. Most will.

Overheads:
1. Supine LPO
2. Left lateral rectum
3. Supine AP
4. Supine AP of sigmoid with 35˚ caudal angulation
5. Post evacuation film

COLOSTOMY: If a patient with a diverting colostomy is sent for evaluation of the proximal portion of
the colon, a special technique must be employed to introduce the barium. There are various devices for
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introducing barium through a colostomy stoma. A balloon on the end of a Bardex catheter can be
inflated outside the patient. The catheter tip is then inserted into the opening of the colostomy and the
balloon is held against the skin of the anterior abdominal wall by the patient's hand. Barium and air are
introduced in retrograde fashion into the colon and appropriate spot films are obtained. Alternatively, a
plastic cone is available which will fit snugly into the colostomy stoma. This also is held in place by the
patient's hand. The staff radiologist will instruct you in the use of these devices. Remember never to
inflate a balloon of any type inside the colostomy stoma.

The distal limb of a colostomy can be studied either from the anus in standard fashion or from the
colostomy stoma using the methods just described. If a colonic leak is suspected in the postoperative
period, water-soluble contrast material should be used.
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POSTSURGICAL PROCEDURES
We are often asked to evaluate post surgical patients. Examinations should be modified based upon
the surgery and clinical concern. In order to avoid certain pitfalls, a few procedures warrant discussion.

T-tube Cholangiogram: Summary of Technique

This study is most commonly performed in patients post liver transplant or post hepatico- or
choledochojejunostomy.

Preparation:
None needed unless referring clinician decides to administer prophylactic antibiotic. All
transplant patients receive oral antibiotics 1 hour prior to the study. Confirm this before
beginning.

Contrast:
Sterile, injectable, ionic iodinated contrast material is used in most patients, typically
Isovue in appropriate dilution:

*Undiluted in liver transplant or other post-surgical patients with small caliber bile duct.
*40%-60% when looking for extravasation.
*15-20% when looking for calculi in a very dilated bile duct (over 1.5 cm).

Procedure:

1. Obtain digital scout image (12” II).

2. Inject contrast via tube using sterile technique. Be careful not to allow air bubbles to enter the
duct if there is a question of stones.

3. Obtain a spot film after the first few ml. of contrast enters the duct to show initial pattern of flow
or early leak.

4. Obtain AP and both obliques views of the duct. It helps to expose while injecting.

5. Obtain one magnified view of the anastomosis.

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Pancreaticoduodenectomy (Whipple’s Procedure) Study: Summary of Technique

Whipple's operation is most often performed in patients with ductal adenocarcinoma of the pancreas.
The duodenum, part of or entire pancreas, and distal common bile duct are resected. The common bile
duct, pancreas, and proximal duodenum are anastomosed to a loop of jejunum, Roux-limb:

Pancreaticojejunostomy
Choledochojejunostomy
Duodenojejunostomy

Fig 1: Pylorus-preserving Whipple

Preparation:
NPO

Contrast:
4 oz.Gastroview

Procedure:

1. Perform t-tube cholangiogram as above, evaluating for choledochojejunostomy anastomotic

patency and lack of extravasation.

2. A modified UGI is then performed using undiluted water-soluble contrast (Gastroview) through
the in dwelling NG tube. REMEMBER, limit contrast to 4 oz. Again, duodenojejunostomy
patency and lack of extravasation are determined.

REMEMBER, these patients are postsurgical and may have delayed gastric emptying;
residual contrast should be removed from the stomach before the patient is sent to the
floor to reduce the risk of aspiration.

Pouchogram: Summary of Technique

Another surgical procedure we occasionally see (usually in the outpatient setting) is the
total proctocolectomy with ileal pouch and ileo-anal anastomolis (J-pouch) after total proctocolectomy
for ulcerative colitis or familial polyposis. These patients undergo radiologic evaluation of the J-pouch
before the diverting ileostomy is closed, approximately 8 weeks after the initial surgery. You are
evaluating for contrast extravasation, stenosis of the pouch, or obstruction proximally. Two important
pitfalls to avoid:
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NEVER perform a rectal examination on these patients!

DO NOT use the standard rectal tube! The anastomosis is at the anus is usually
stenotic, and if not handled appropriately, can be torn with the finger. (The anastomosis
will be gently dilated under anesthesia at a later time).

Ileum

Pouch

Anus

Fig 2: J Pouch

Preparation:
None needed

Contrast:
Gastroview (4oz. Diluted with 8 oz water) in BE bag w/ tubing
Blue pediatric rectal tip or 14 Fr. red rubber catheter

Procedure:

1. Insert blue pediatric rectal tip gently into the pouch via the anus.

2. Obtain a digital scout film (12” II).

3. Fill pouch until contrast refluxes out the right lower quadrant ileostomy.

4. Obtain the following digital images centered over the pouch:

1) Supine (9“ II)

2) Both obliques (9 or 12” II)
3) Lateral (12” II)
4) Supine center over proximal ileum, including the ostomy
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Gastric Bypass: Summary of Technique

Gastric bypass is the most common bariatric surgery performed at our institution. A pouch is formed
from the cardia of the stomach, and a jejunal Roux-en-Y limb is brought through the transverse
mesocolon. A side gastrojejunostomy is created between the pouch and jejunum.

Gastrojejunostomy

Roux-
limb

Stump

Gastric bypass surgery patients are challenging. They may exceed table weight limits (GE
digital: 350 lbs., Philips: 400 lbs.). In this case, remove the footplate and have the patient stand
on the floor.

Preparation:
NPO

Contrast:
4 oz. Gastroview

Procedure:

1. Obtain digital scout film of left upper quadrant (12” II).

2. In a standing lateral position, have the patient swallow one swallow of water-soluble contrast
(Gastroview) and fluoro the lateral pharynx. If there is no aspiration, place patient erect AP and
have them drink a few swallows of contrast, centering over left upper quadrant. Watch for
emptying and extravasation. Table spot image over pouch.

3. If possible, place patient supine. Obtain 3 to 4 digital spot images of the gastric pouch and
Roux-limb in several obliquities. Do not magnify these images as most patients are so large that
exposure time would be long and result in motion artifact.

4. Have technologist obtain a 10-minute film of the upper abdomen to confirm contrast emptying
into the distal jejunum, beyond where the Roux-limb courses through the transverse mesocolon.

These are not aesthetically pleasing studies because of body habitus, but they can usually answer
the two clinical questions:
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1. Is there a leak? This usually occurs at the gastrojejunostomy anastomosis or the blind
jejunal stump.
2. Is there obstruction? Usually at gastrojejunostomy, as the Roux-limb traverses the
mesocolon, or at the jejunojejunostomy.
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Addendum A: Dr. Morgan's Top 5 Things Regarding Radiation Colitis

1. NEVER inflate the rectal balloon in a patient who has received pelvic radiation.
2. Pelvic radiation is usually seen in patients with cervical or prostate carcinoma.
3. Barium enemas are rarely performed during the acute phase (first week after radiotherapy).
Findings would include spasm, edema, and granular mucosa.
4. Barium enema in chronic radiation damage reveals a smooth, featureless mucosa with absent
valves of Houston and a narrowed lumen.
5. The etiology of radiation colitis is progressive destruction of colonic microvasculature.

Addendum B: Glucagon

Glucagon is an endogenous hormone produced by pancreatic islet cells. In addition to its role in
glucose metabolism, is an antispasmotic of smooth muscle. It causes transient hypotonia of the
stomach, duodenum, small bowel, and colon. It does not alter esophageal motility, but it decreases
lower esophageal sphincter pressure.

It is indicated in UGI studies in patients with partial gastric resection. It is also helpful in barium enema
examination when there is pain, spasm or increased colonic tone, manifest as inability to retain barium.

Contraindications to glucagon administration include pheochromocytoma, insulinoma, and insulin

dependent diabetes. It can cause severe hypertension secondary to catecholamine release by a
pheochromocytoma and hypoglycemia secondary to insulin release by an insulinoma. It causes
hyperglycemia, but is probably safe to administer to diabetic patients taking oral hypoglycemics if badly
needed. Its effect should be explained to the patient, so they can monitor their glucose level after
completion of the study.

Glucagon must be mixed before it is injected. Dose ranges from 0.1-1.0 mg (1.0 mg=1cc=1 unit dose).
Standard dose for BE is 0.5-1.0 mg and 0.15 mg for UGI. It is injected intravenously with a 26g needle.
Alternatively, it can be given intramuscularly or subcutaneously. It can cause nausea and vomiting if a
full mg is given rapidly. This risk is decreased with slower injection and smaller doses. If unable to
obtain IV access, it can be injected intramuscularly or subcutaneously. See package insert.

Dose Route Onset Duration

0.5 mg IV 1 min 9-17 min
1.0 mg IV 1 min 22-25 min
IM 8-10 min 12-27 min