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A lower gastrointestinal series is a medical procedure used to examine and diagnose problems with the human colon of the
large intestine The large intestine, also known as the large bowel, is the last part of the gastrointestinal tract and of the digestive system in tetrapods. Water is absorbed here and the remaining waste material is stored in the rectum as feces before being r ...
.
Radiographs Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
(
X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10  picometers to 10  nanometers, corresponding to frequencies in the range 30&nb ...
pictures) are taken while
barium sulfate Barium sulfate (or sulphate) is the inorganic compound with the chemical formula Ba SO4. It is a white crystalline solid that is odorless and insoluble in water. It occurs as the mineral barite, which is the main commercial source of barium an ...
, a
radiocontrast agent Radiocontrast agents are substances used to enhance the visibility of internal structures in X-ray-based imaging techniques such as computed tomography (contrast CT), projectional radiography, and fluoroscopy. Radiocontrast agents are typically io ...
, fills the colon via an
enema An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum.Cullingworth, ''A Manual of Nursing, Medical and Surgical'':155 The word enema can also refer to the liquid injected, as well as to a device ...
through the
rectum The rectum is the final straight portion of the large intestine in humans and some other mammals, and the Gastrointestinal tract, gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the s ...
. The term barium enema usually refers to a lower gastrointestinal series, although enteroclysis (an
upper gastrointestinal series An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as barium ...
) is often called a small bowel barium enema.


Purpose

For any suspected large bowel disease,
colonoscopy Colonoscopy () or coloscopy () is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (''e. ...
is the investigation of choice because tissue sample can be taken for investigation.
Virtual colonoscopy Virtual colonoscopy (VC, also called CT colonography or CT pneumocolon) is the use of CT scanning or magnetic resonance imaging (MRI) to produce two- and three-dimensional images of the colon (large intestine), from the lowest part, the rectum, ...
(also known as CT colonography) is another preferred investigation, provided that facilities and expertise are available. Virtual colonoscopy also avoids the risk of total blockage of any stricture in the large bowel due to barium impaction. Some conditions are absolutely contraindicated for barium enema namely:
toxic megacolon Toxic megacolon is an acute form of colonic distension. It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock. Toxic megacolon is usually a complica ...
,
pseudomembranous colitis Colitis is swelling or inflammation of the large intestine ( colon). Colitis may be acute and self-limited or long-term. It broadly fits into the category of digestive diseases. In a medical context, the label ''colitis'' (without qualification) ...
, and recent history rigid endoscopy of the large bowel in the past five days and recent history of flexible endoscopy in the past 24 hours. This is because, rigid endoscopy tends to use larger biopsy forceps to take tissue samples from the bowel wall while flexible endoscopy uses small biopsy forceps to take superficial samples. For those with incomplete bowel preparation, the subject can return the next day or the day after next to repeat the procedure. If barium meal was performed recently, then it is advised to wait for another seven to ten days before repeating the procedure. Some frail subject may not be suitable for barium meal. Barium enemas are most commonly used to check bowel health; they can help diagnose and evaluate the extent of inflammatory bowel diseases such as
ulcerative colitis Ulcerative colitis (UC) is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary symptoms of active disease are abdominal pain and diarrhea mixed with blood (hematochezia). Weight loss, fever, and a ...
and
Crohn's disease Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea (which may be bloody if inflammation is severe), fever, abdominal distension ...
.
Polyps A polyp in zoology is one of two forms found in the phylum Cnidaria, the other being the medusa. Polyps are roughly cylindrical in shape and elongated at the axis of the vase-shaped body. In solitary polyps, the aboral (opposite to oral) end i ...
can be seen, though not removed during the exam like with a
colonoscopy Colonoscopy () or coloscopy () is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (''e. ...
—they may be cancerous. Other problems such as
diverticulosis Diverticulosis is the condition of having multiple pouches (diverticulum, diverticula) in the colon (anatomy), colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the col ...
(small pouches formed on the colon wall that can become inflamed) and intussusception can be found (and in certain cases the test itself can treat intussusception). An acute
appendicitis Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a rup ...
or twisted loop of the bowel may also be seen. If the picture is normal a functional cause such as
irritable bowel syndrome Irritable bowel syndrome (IBS) is a "disorder of gut-brain interaction" characterized by a group of symptoms that commonly include abdominal pain and or abdominal bloating and changes in the consistency of bowel movements. These symptoms may ...
(IBS) may be considered. In a healthy colon, barium should fill the colon uniformly and show normal bowel contour, patency (should be freely open), and position. Additional conditions under which the test may be performed: * CMV gastroenteritis/
colitis Colitis is swelling or inflammation of the large intestine ( colon). Colitis may be acute and self-limited or long-term. It broadly fits into the category of digestive diseases. In a medical context, the label ''colitis'' (without qualification) ...
*
Hirschsprung's disease Hirschsprung's disease (HD or HSCR) is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Symptoms usu ...
*
intestinal obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs an ...
* intussusception (children)


Procedure

Barium enema can be done in two ways, namely double contrast and single contrast methods. Double contrast (where air is inflated into the bowel after excess barium are drained through anus) is useful in visualisng mucosal pattern. For single contrast study (whole bowel is filled up with barium without inflating any air), it is used to visualise any obstruction in the large bowel, and it is used in children where visualisation of mucosal pattern is not needed. Barium enema is also used to reduce an intussusception where this disorder is more commonly found in children. 500 ml of Polibar 150% (
barium sulfate suspension Barium sulfate suspension, often simply called barium, is a contrast agent used during X-rays. Specifically it is used to improve visualization of the gastrointestinal tract (esophagus, stomach, intestines) on plain X-ray or computed tomograph ...
) is used to perform this study. Subject should be fasted and Picolax (
sodium picosulfate Sodium picosulfate (INN, also known as sodium picosulphate) is a contact stimulant laxative used as a treatment for constipation or to prepare the large bowel before colonoscopy or surgery. It is sold under the trade names Sodipic Picofast, Laxob ...
) is taken orally to empty the bowels before barium enema procedure. This test may be done in a hospital or clinic. The individual lies on the X-ray table and a preliminary X-ray is taken. The individual is then asked to lie on their side while a well lubricated
enema An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum.Cullingworth, ''A Manual of Nursing, Medical and Surgical'':155 The word enema can also refer to the liquid injected, as well as to a device ...
tube is inserted into the
rectum The rectum is the final straight portion of the large intestine in humans and some other mammals, and the Gastrointestinal tract, gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the s ...
. As the enema enters the body, the individual might have the sensation that they need to have a bowel movement. The barium sulfate, a
radiodense Radiodensity (or radiopacity) is opacity to the radio wave and X-ray portion of the electromagnetic spectrum: that is, the relative inability of those kinds of electromagnetic radiation to pass through a particular material. Radiolucency or hypod ...
(shows as white on X-ray)
contrast medium A contrast agent (or contrast medium) is a substance used to increase the contrast of structures or fluids within the body in medical imaging. Contrast agents absorb or alter external electromagnetism or ultrasound, which is different from radiop ...
, flows through the rectum into the colon. A large balloon at the tip of the enema tube may be inflated to help keep the barium sulfate inside. The flow of the barium sulfate is monitored by the health care provider on an X-ray
fluoroscope Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and function ...
screen (like a TV monitor). Air may be puffed into the colon to distend it and provide better images (often called a "double-contrast" exam). If air is used, the enema tube will be reinserted if it had been removed and a small amount of air will be introduced into the colon, and more X-ray pictures are taken. The individual is usually asked to move to different positions and the table is slightly tipped to get different views. If there is a suspected
bowel perforation Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. Symptoms include severe abd ...
, a water-soluble
contrast agent A contrast agent (or contrast medium) is a substance used to increase the contrast of structures or fluids within the body in medical imaging. Contrast agents absorb or alter external electromagnetism or ultrasound, which is different from radiop ...
(such as
diatrizoate Diatrizoate, also known as amidotrizoate, is a contrast agent used during X-ray imaging. This includes visualizing veins, the urinary system, spleen, and joints, as well as computer tomography (CT scan). It is given by mouth, injection into a vei ...
) is used instead of barium. The procedure is otherwise very similar, although the images will be of poorer quality. If a perforation exists, the contrast will leak from the bowel to the
peritoneal cavity The peritoneal cavity is a potential space between the parietal peritoneum (the peritoneum that surrounds the abdominal wall) and visceral peritoneum (the peritoneum that surrounds the internal organs). The parietal and visceral peritonea are lay ...
; water-soluble material is less obscuring compared to barium should an abdominal incision to remove the contrast be necessary.


Radiographic views

Assume that the x-ray tube is moving above the table and the x-ray film is moving below the table (overcouch): The subject lying supine to give AP (anteroposterior) view of all the bowels. Left lateral view of rectum is to view the rectum from lateral position. Right anterior oblique (RAO) position is to view the caecum, ascending colon, right hepatic flexure and sigmoid colon without overlapping of other bowels. Left anterior oblique (LAO) position is to view the splenic flexure without overlapping of other bowels. Left posterior oblique (LPO) position is to view the sigmoid colon without overlapping of other bowels. Hampton's view (prone caudal view) is taken when the subject is in prone position with the X-ray tube tilted towards the feet at 30 degrees. This is to separate out the loops of sigmoid colon. Other views include right and left decubitus views


Risks

X-rays are monitored and regulated to provide the minimum amount of radiation exposure needed to produce the image. Most experts feel that the risk is low compared with the benefits. Pregnant women and children are more sensitive to the risks of ionizing radiation. A more serious risk is a bowel perforation.


Special considerations

CT scans and
ultrasound Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
s are now the tests of choice for the initial evaluation of abdominal masses, and colonoscopies are becoming the standard for routine colon screening for those over age 50 or with a familial history of polyps or colon cancer, although it is not uncommon for a barium enema to be done after a colonoscopy for further evaluation.


See also

*
Upper gastrointestinal series An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as barium ...


References


External links


Duplicated Colon on Barium Enema
- MedPix Medical Image Database
RadiologyInfo
- The radiology information resource for patients: Barium Enema

{{Medical imaging Barium Diagnostic gastroenterology Digestive system imaging Fluoroscopy