Patient Management

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Lecture 4
Barium enema study
Definition
Anatomy of the large intestine
Indications and contraindications
Patient preparation for barium
enema studies
The barium enema procedure
Special circumstances in barium
enema studies

Objectives

At the end of the session, students should be

able to:
Define the term Barium enema
Outline the anatomy of the large intestine
Discuss the indications and contraindications of
barium enema studies
Give details of the patient preparation for barium
enema studies
Outline patient care procedures for barium
enema studies

Objectives
Outline procedures for rectal
catheterization for barium enema studies
Define terminology associated with bowel
pathology
Outline the care of patients with colostomy
Outline special procedures to be followed
for diabetics, infants, ward, and elderly
patients

Barium Enema
Definition
A suspension of barium sulphate introduced
via the rectum as a contrast agent for
radiologic examination of the large intestine
Can be single or double-contrast study

Anatomy of the large intestines

Single and double contrast studies

Single contrast study

Double contrast study

Barium Enema
Indications:

Diverticulosis Polyps
Malignancies
Tumours
Ulcerative colitis
Recurrent / chronic constipation
Hirschsprungs disease
Recurrent diarrhoea

Barium Enema

Contraindications:

Pregnancy
Intestinal obstruction
Perforation / fistula
Allergy to Barium Sulphate

Barium enema Patient preparation

Includes:
General abdominal preparation
Psychological preparation
Local preparation

Barium enema Patient preparation

General abdominal preparation
Low residue diet for 4 - 7 days prior to
examination (gives the least possible fecal
residue e.g. gelatin, fish, chicken, broth, fruit,
meat, hard-boiled eggs)
Diet restricted to fluids only 24 hours prior to
the procedure)
Liquid intake encouraged
Suitable aperient on each of two nights
preceding the examination

Barium enema Patient preparation

Abdominal preparation contd
Patient to remain as ambulant as possible to
assist in the prevention of accumulated gas
NPO for 8-10 hrs. (or NPO after 10pm on
night prior to examination: alternatively, take
light breakfast just before examination)
No smoking 4-6 hrs. prior to examination
High colonic cleansing enema administered
on morning of examination just prior to
Barium enema procedure

Barium Enema contd

Contraindications to washout

Babies and toddlers

Ulcerative colitis
Diarrhoea
Dehydration
Congenital megacolon
Gross bleeding from GI tract

Barium enema Patient preparation

Psychological and local preparation
Explain the procedure/answer questions the
patient may ask about the procedure
Make enquiries of the patients bowel
preparation
Patient to completely undress in privacy
Patient is given clean gown to be placed with
its opening to back
Patient to use bathroom before examination

Barium enema trolley setting

Trolley setting

Enema bag and tubing

Foley catheter (16-30)
Forceps / clamp for catheter
Air bulb for introducing air contrast into
intestines for double contrast studies
Lubricant

Barium enema trolley setting

Trolley setting contd

Drip stand
30 ml syringe for catheter balloon
Incontinence pad
Large kidney dish
Bedpan
Gloves

Barium enema - Catheterizing the

patient
Rectal catheters

Are of two main designs:

without retainer balloon
with retainer balloon
Are made of firm but fairly flexible plastic
The olive-shaped tip has end and side holes
and is designed for easy insertion
Care to be taken to avoid perforation of rectal
walls during insertion of this type

Barium enema - Catheterizing the

patient
Rectal catheter with
retainer balloon

Rectal catheter
without retainer
balloon

Barium enema - Catheterizing the

patient
The Foley catheter

Barium enema - Catheterizing the

patient

Barium enema - Catheterizing the

patient
Foley catheter is commonly used in local
practice, having the advantages of flexibility
and self-retention
Steps are to be taken to ensure that the
foley catheter is secure and that patient is
able to retain catheter before introducing
barium suspension
The foley catheter is secured by:

Advancing catheter to appropriate distance

Inflating the balloon
Tightening the sphincter around the catheter
Use of adhesive tape to secure catheter to patients skin

Barium enema - Catheterizing the

patient

Explain the procedure to the patient

Ensure good lighting
Patient instructed to lie on left side
Knees and hips flexed
Don gloves
The catheter is clamped and its tip is
lubricated
Buttocks parted at natal cleft to reveal
anal orifice

Barium enema - Catheterizing the

patient
Inspect the anus for haemorroids and other
abnormalities
If no abnormalities are evident, advance the
catheter until 3- 4 inches of catheter is
inserted
Inflate the retainer balloon
Tug slightly on catheter to check its security
in the rectum and further secure with
adhesive tape to the patients skin.

Barium Enema - The procedure

After catheterization, the radiologist releases the
clamp on the catheter and tubing and allows a
quantity of barium suspension to run in to
partially fill the large intestine
The barium flow is then suspended (by
clamping the catheter) and air is introduced via a
hand pump or bulb.

Barium Enema - The procedure

As the air advances the barium suspension
along the tract, the patient is manipulated into
various positions and spot radiographs are
taken
Attention is to be paid to the patients level of
cooperation, any deterioration in his health
status, and any complaints of discomfort
resulting from the procedure
The barium and air are allowed to flow to the
ileo-caecal junction

Barium Enema - The procedure

Fluoroscopy spot films are done to include the
following projections:

Left lateral rectum

Sigmoid (RAO)
Descending colon (LAO)
Splenic flexure (LAO)
Transverse colon
Hepatic flexure (RAO)
Ascending colon (RAO)
Caecum

Barium Enema - The procedure

Overcouch exposures
1.
2.
3.
4.

Supine Abdomen
Prone Abdomen
Right and Left Lateral Decubitus
Post- evacuation abdomen

Left lateral rectum

Left lateral rectum

LAO colon

LAO Colon

Supine Colon

Supine colon

Right Lateral Decubitus

Right Lateral Decubitus

Left Lateral Decubitus

Left Lateral Decubitus

Barium enema - Aftercare

Excess barium and air are to be released
through catheter into bedpan or suitable
container on completion of the study before the
patient is directed to the bathroom
The catheter is deflated and withdrawn from
rectum
The patient is directed/ assisted to bathroom
for further evacuation and clean-up

Barium enema - Aftercare

The patient is informed of
White stools for a few days post - study
Possibility of constipation
Diet to follow to assist in clearing the bowel of the
barium suspension (fruits, fruit juices, water)
Return to normal diet & medication regime
Return to referring physician in the event of adverse
effects of the study

Barium Enema - special circumstances

1. Post-operative patients
Water-soluble contrast agent is used in place
of Barium Sulphate suspension e.g.

Gastrograffin, Urografin, Ultravist

The use of barium sulphate increases the risk

of peritonitis if the barium seeps into the
peritoneum via surgically- created connection

Barium Enema - special circumstances

2. The colostomy patient
Definition of colostomy
A surgical procedure in which the colon is
opened onto the surface of the abdomen to
provide an artificial outlet for faecal contents
Surgically formed fistulas from the large or small
bowel through the abdominal wall that terminate in an
external opening called a stoma.

Barium Enema - special circumstances

The patient with a colostomy

Barium Enema - special circumstances

Types of colostomy
a) Temporary
Performed to rest the bowel and allow it to
heal after surgery, massive trauma,
infection, or chronic disease. After the bowel
is healed, the healthy portions are reconnected, and the temporary opening is
closed

Barium Enema - special circumstances

Types of colostomy
b) Permanent
When the diseased portion of bowel is
removed and a permanent artificial opening
is created
Performed on patients with imperforate anus
which is the result of developmental error,
the rectum does not open normally into the
anal canal

Barium Enema - special circumstances

Location of the temporary colostomy

involves a loop of the transverse colon and
the colostomy bag is usually sited to the
right of the midline in the upper abdomen
between the umbilicus and lower costal
margin
Often has a double-barreled construction (two
entrance points at the colostomy opening)

Barium Enema - special circumstances

Location of the temporary colostomy
Openings separated by a spur of tissue
organized to prevent bowel contents passing
from one opening to the other. Usually, the
opening to the right is the active end. The left
opening will fill the distal colon.
Distal loop may also be examined via the rectum and the
barium exits the colostomy site

Barium Enema - special circumstances

Location of the permanent colostomy
Where the rectum was surgically removed
the sigmoid is brought out as a colostomy
opening sited in the left iliac fossa
Any examination of the remaining bowel
must be carried out via the colostomy
opening

Barium enema - special circumstances

The colostomy bag

Barium enema - special circumstances

The Colostomy Patient for Barium enema study
Barium Enema is administered via
colostomy opening or via rectum
Because of lack of control of evacuation the
radiographer must prepare for mopping up
procedures
the radiographer should know how to
attach /remove /operate the colostomy
apparatus

Barium enema - special circumstances

The Colostomy Patient for Barium enema study
The patient may be sensitive about wearing the
colostomy bag because:
The bag collects faeces
The accompanying alteration in body image
difficult to accept
Any expression of revulsion by the
radiographer may be perceived as disgust or
rejection

Barium enema - special circumstances

The Colostomy Patient for Barium enema study
When booking procedures which will require the
removal of the colostomy bag, remind the
patient to bring their own supplies
Provide private facility for the patient to empty
the colostomy bag
provide facilities for cleaning reusable bags
Provide assistance in replacing bag where
necessary

Barium enema - special circumstances

The Colostomy Patient for Barium enema study
When booking procedures which will require the
removal of the colostomy bag, remind the
patient to bring their own supplies
Provide private facility for the patient to empty
the colostomy bag
provide facilities for cleaning reusable bags
Provide assistance in replacing bag where
necessary

Barium enema - special circumstances

The Colostomy Patient for Barium enema study
Bowel preparation as instructed by the
radiologist in consultation with referring doctor
Patient to follow low residue diet
Enema to be delivered at low pressure
(keep enema bag at reasonable height above
patient)
Consider patients sensitivity to his condition;
allow him to operate the bag on his own if
he can

Barium enema - special circumstances

The Colostomy Patient for Barium enema study
Have spare colostomy bags available in the
department
Careful catheterization of the stoma is
required
Study requires more dilute suspension than
regular barium enema
Do not force catheter if resistance is
encountered
Do not overfill the bowel

Barium enema - special circumstances

The Colostomy Patient for Barium enema study

Make facilities available for patient to wash
his hands
Clean site with warm water and soap
Thoroughly clean and dry the skin

Barium enema - special circumstances

3. Patients with enlarged colon
May require the use of water-soluble contrast
medium to prevent impaction of barium
suspension in the large intestines.
Hirschsprung's disease / congenital megacolon
neurological deficiency in distal portion of
intestines hence peristalsis is impaired
Enlarged colon leads to greater opportunity for
water absorption of water from the bowel (larger
surface area) leading to impaction

Barium enema - special circumstances

Patients with enlarged colon contd
Where barium sulphate is used, the
suspension should be prepared with saline
solution instead of water. This reduces
the loss of water from the colon during
the study

Barium enema - special circumstances

4. The diabetic patient

Starvation period to be kept minimal
There should be little disturbance to their
diet and medication regime
5. The infant patient
special bowel preparation and starvation
instructions

Conditionsof the colon

Diverticulosis

Intussusception

Conditions of the colon

Volvulus

Tutorial questions
1. Outline the after-care you would provide a patient following a
Barium Enema study.
2. With reference to a colostomy:
Define the term.
Give ONE indication each for a:
Temporary colostomy
Permanent colostomy
What psychological considerations are to be given for
barium enema patients with colostomy apparatus attached?

Tutorial questions
3. Under what situations should consideration be
given to the use of water-soluble contrast medium
for enema study?
4. Define the following terms:
Volvulus
Diverticulosis
Diverticulitis
Intussusception
Imperforate anus
Hirschsprungs disease

References
Culmer, P. (7th edition) Chesneys Care of the Patient
in Diagnostic Radiography. Blackwell Science.
Chapter 6, p73 95
Ehrlich, R., Daly, J. (7th edition) Patient Care in
Radiography Mosby. Chapter 6, p 194 195