Gastrointestinal tract
Introduction to contrast media
Barium
There are many varieties of barium suspensions in use. Ingredients are designed to optimise mucosal coating and to make it palatable. In most situations the preparation will be diluted with water to give a lower density (Table 3.1) and must be shaken well immediately before use.
Table 3.1
Barium suspensions and dilutions with water to give a lower density
| Proprietary name | Density (w/v) – use |
| Baritop 100 | 100% – all parts gastrointestinal tract |
| EPI-C | 150% – large bowel |
| E-Z-Cat | 1–2% – computed tomography of gastrointestinal tract |
| E-Z HD | 250% – oesophagus, stomach and duodenum |
| E-Z Paque | 100% – small intestine |
| Micropaque DC | 100% – oesophagus, stomach and duodenum |
| Micropaque liquid | 100% – small and large bowel |
| Micropaque powder | 76% – small and large bowel |
| Polibar | 115% – large bowel |
| Polibar rapid | 100% – large bowel |
1. Barium swallow, e.g. Baritop® 100% w/v or E-Z HD® 200–250% 100 ml (or more, as required).
2. Barium meal, e.g. E-Z HD® 250% w/v. A high-density, low-viscosity barium is required for a double-contrast barium meal to give a good thin coating that is still sufficiently dense to give satisfactory opacification. It also contains simethicone (an anti-foaming and coating agent) and sorbitol (a coating agent).
3. Barium follow-through, e.g. E-Z Paque® 60–100% w/v 300 ml (150 ml if performed after a barium meal). This preparation contains sorbitol, which produces an osmotic hurrying and is partially resistant to flocculation.
4. Small bowel enema, e.g. either one 300 ml can of Baritop 100% w/v or two tubs of E-Z Paque made up to 1500 ml (60% w/v). N.B. As the transit time through the small bowel is relatively short in this investigation, there is a reduced chance of flocculation. This enables the use of barium preparations which are not flocculation-resistant. Gastrografin can be added to the mixture as this may help reduce the transit time still further.
5. Barium enema, e.g. Polibar 115% w/v 500 ml or more, as required. Reduced density between 20% and 40% w/v for single contrast examinations.
Disadvantages
1. Subsequent abdominal CT is rendered difficult (if not impossible) to interpret. Patients may need to wait for up to 2 weeks to allow satisfactory clearance of the barium. There may also be some reduction in US quality. It is advised that CT and/or US are performed before the barium study.
2. High morbidity associated with barium in the peritoneal cavity.
Complications
1. Perforation. The escape of barium into the peritoneal cavity is rare. If large amounts enter the peritoneal cavity it is extremely serious and will produce pain and severe hypovolaemic shock. Treatment should consist of aggressive intravenous fluid resuscitation, emergency surgery with copious washout and antibiotics. A 50% mortality rate is quoted and of those that survive, 30% will develop granulomata and peritoneal adhesions. Intramediastinal barium also has a significant mortality rate. It is imperative that a water-soluble contrast medium be the initial agent used for any investigation in which there is a risk or suspicion of perforation.
2. Aspiration. Aspirated barium is relatively harmless. Sequelae include pneumonitis and granuloma formation. Physiotherapy is the only treatment required (for both aspirated barium and low osmolar contrast material (LOCM)), and should be arranged before the patient leaves hospital.
3. Intravasation. This very rare complication may result in a barium pulmonary embolus, which carries a mortality of 80%.
For further complications (e.g. constipation and impaction), see the specific procedure involved.
Water-soluble contrast agents
Indications
Complications
1. HOCM can precipitate pulmonary oedema if aspirated (not LOCM).
2. HOCM can cause hypovolaemia and electrolyte disturbance due to the hyperosmolality of the contrast media drawing fluid into the bowel (not LOCM).
3. May precipitate in hyperchlorhydric gastric acid (i.e. 0.1 M HCl) – not non-ionic.
Gases
1. Oesophagus, stomach and duodenum – Carbon dioxide and, less often, air are used in conjunction with barium to achieve a ‘double contrast’ effect. For the upper gastrointestinal tract, CO2 is administered orally in the form of gas-producing granules/powder (sodium bicarbonate) which when mixed with fluid (citric acid) produces gas. The requirements of these agents are as follows:
(a) Production of an adequate volume of gas – 200–400 ml
(b) Non-interference with barium coating
2. Large bowel – For the large bowel, room air is administered per rectum via a hand pump attached to the enema tube. Carbon dioxide can also be administered by hand pump and is said to be resorbed more quickly, cause less abdominal pain, but produce inferior bowel distension when compared to air.1 CO2 insufflating pumps are in common usage in CT colonography.
Pharmacological agents
Hyoscine-N-butylbromide (Buscopan®)
Adult dose
The advantages of hyoscine include its immediate onset of action, relatively short duration of action (approx. 5–10 min) and its relatively low cost. Disadvantages include short-lived antimuscarinic side effects which include blurring of vision, a dry mouth, transient bradycardia followed by tachycardia and rare side effects said to include urinary retention and acute gastric dilatation. A particular side effect is that hyoscine can precipitate acute-angle closure glaucoma (AACG) in those patients who are susceptible to this because it dilates the pupil. In the UK patients who have AACG are almost always treated surgically in both eyes to prevent any recurrence. Pupillary dilatation has no role to play in the most common sort of glaucoma, open angle glaucoma, which accounts for 90% cases. Denying patients hyoscine on the basis of previous history of glaucoma is now not thought justified. Instead the following precautions are thought sufficient for the administration of hyoscine.1
Do
• Ask clinicians to identify patients who have unstable cardiac disease
• Ask whether there is a history of allergy to hyoscine
• Warn patients to expect blurred vision and not to drive until this has worn off
• Patient information leaflets should include ‘in the rare event that following the examination you develop painful, blurred vision in one or both eyes, you must attend hospital immediately for assessment.’
Glucagon
Disadvantages
Metoclopramide (Maxolon®)
This dopamine antagonist stimulates gastric emptying and small-intestinal transit.
References
1. Holemans, JA, Matson, MB, Hughes, JA, et al. A comparison of air, carbon dioxide and air/carbon dioxide mixture as insufflation agents for double contrast barium enema. European Radiology. 1998; 8:274–276.
1. Dyde, R, Chapman, AH, Gale, R, et al. Precautions to be taken by radiologists and radiographers when prescribing hyoscine-N-butylbromide. Clinical Radiology. 2008; 63:739–743.
2. Froehlich, JM, Daenzer, M, von Weymarn, C, et al. A peristaltic effect of hyoscine N-butylbromide versus glucagon on the small bowel assessed by magnetic resonance imaging. European Radiology. 2009; 19:1387–1393.
3. van Harten, PN, Hoek, HW, Kahn, RS. Acute dystonia induced by drug treatment. British Medical Journal. 1999; 319:623–626.
Contrast swallow
Contrast medium
1. E-Z HD 200–250% or Baritop 100% w/v, 100 ml (or more, as required)
2. Water-soluble contrast agent if perforation is suspected (e.g. Conray, Gastrografin)
3. LOCM (approx. 300 mg I ml−1) is safest if there is a risk of aspiration.
1. Gastrografin should NOT be used for the investigation of a tracheo-oesophageal fistula or when aspiration is a possibility. Use LOCM instead.
2. Barium should NOT be used initially if perforation is suspected. If perforation is not identified with a water-soluble contrast agent then a barium examination should be considered.
Technique
1. Start with the patient in the erect position, right anterior oblique (RAO) position to project the oesophagus clear of the spine. An ample mouthful of barium is swallowed and this bolus is observed under fluoroscopy for dynamic assessment to assess the function of the oesophagus. Then further mouthfuls with spot exposure(s) to include the whole oesophagus with dedicated AP views of the gastro-oesophageal junction.
2. Coned views of the hypopharynx should be obtained with a frame rate of 3–4 per second to include AP, lateral and oblique views whilst the patient swallows contrast.
3. The patient is placed semi-prone in a ‘recovery position’ in a left posterior oblique (LPO) position with their right arm by their side behind their back and the left arm used to support the cup containing contrast. One further swallow with a single bolus is observed under fluoroscopy to assess motility with the effect of gravity eliminated. A distended single-contrast view should be obtained as the patient rapidly sips and swallows contrast as this best identifies hernias, subtle mucosal rings and varices.
4. Modifications may be required depending on the clinical indication.
(a) If dysmotility is suspected barium should be mixed with bread or marshmallow bolus and observed under fluoroscopy correlating symptoms with the passage of the bolus in the erect position.
(b) If perforation is suspected a control film may be useful to identify pneumomediastinum and ideally the patient should be examined in four positions (prone/supine/left lateral/right lateral) with water-soluble contrast first, and if this is negative then with barium contrast.
(c) To demonstrate a tracheo-oesophageal fistula in infants, a ‘pull back’ nasogastric tube oeosphagogram may be performed if the standard oesophagogram is negative.1 This technique is particularly useful in patients known to aspirate or in ventilated patients. Suction and nursing support should be available should aspiration occur. The patient is positioned prone with the arms up and the table may be tilted slightly head down. A nasogastric tube is introduced into stomach and then withdrawn to the level of the lower oesophagus under lateral screening guidance. Ten to 20 ml of LOCM is syringed in to distend the oesophagus which will force the contrast medium through any small fistula which may be present. The process is repeated for the upper and mid oesophagus. It is important to watch for aspiration into the airway from overspill which can lead to diagnostic confusion.
Barium meal
Indications
Technique
The double contrast method (Fig. 3.1):
Figure 3.1 Barium meal sequence. Note in a, b, c and d, the patient position is depicted as if the operator were standing at the end of the screening table looking towards the patient’s head.
1. A gas-producing agent is swallowed.
2. The patient then drinks the barium while lying on the left side, supported by their elbow. This position prevents the barium from reaching the duodenum too quickly and so obscuring the greater curve of the stomach.
3. The patient then lies supine and slightly on the right side, to bring the barium up against the gastro-oesophageal junction. This manoeuvre is screened to check for reflux, which may be revealed by asking the patient to cough or to swallow water while in this position (the ‘water siphon’ test). The significance of reflux produced by tipping the patient’s head down and simultaneously drinking water is debatable, as this is non-physiological – 24-hour pH probe monitoring is the best current investigation. If reflux is observed, images are taken to record the level to which it ascends.
4. An i.v. injection of a smooth muscle relaxant (Buscopan 20 mg or glucagon 0.3 mg) may be given to better distend the stomach and to slow down the emptying of contrast into duodenum. The administration of Buscopan has been shown not to affect the detection of gastro-oesophageal reflux or hiatus hernia.
5. The patient is asked to roll onto the right side and then quickly over in a complete circle, to finish in an RAO position. This roll is performed to coat the gastric mucosa with barium. Good coating has been achieved if the areae gastricae in the antrum are visible.
Images
There is a great variation in views recommended. One scheme is:
1. Spot exposures of the stomach (lying):
(a) RAO – to demonstrate the antrum and greater curve
(b) Supine – to demonstrate the antrum and body
(c) LAO – to demonstrate the lesser curve en face
(d) Left lateral tilted, head up 45°– to demonstrate the fundus.
2. Spot image of the duodenal loop (lying):
(a) Prone – the patient lies on a compression pad to prevent barium from flooding into the duodenum.
3. Spot images of the duodenal cap (lying):
(b) RAO – the patient attains this position from the prone position by rolling first onto the left side, for the reasons mentioned above
4. Additional views of the fundus in an erect position may be taken at this stage, if there is suspicion of a fundal lesion.
5. Spot images of the oesophagus are taken, while barium is being swallowed, to complete the examination.
Modification of technique for young children
1. Single-contrast technique using 30% w/v barium sulphate and no paralytic agent.
2. A relatively small volume of barium – enough to just fill the fundus – is given to the infant in the supine position. An image of the distended oesophagus is exposed.
3. The child is turned semi-prone into a LPO or RAO position. An image is taken as barium passes through the pylorus. The pylorus is shown to even better advantage if 20–40° caudocranial angulation can be employed with an overhead screening unit. Gastric emptying is prolonged if the child is upset. A dummy coated with glycerine is a useful pacifier.
4. Once barium enters the duodenum, the infant is returned to the supine position, and with the child perfectly straight a second image is taken as barium passes around the duodenojejunal flexure. This image should just include the lower chest to verify that the child is straight.
5. Once malrotation has been diagnosed or excluded, a further volume of barium is administered until the stomach is reasonably full and barium lies against the gastro-oesophageal junction. The child is gently rotated through 180° in an attempt to elicit gastro-oesophageal reflux.
In newborn infants with upper intestinal obstruction, e.g. duodenal atresia, the diagnosis may be confirmed if 20 ml of air is injected down the nasogastric tube (which will almost certainly have already been introduced by the medical staff). If the diagnosis remains in doubt, it can be replaced by a positive contrast agent (dilute barium or LOCM if the risk of aspiration is high).
Aftercare
1. The patient must not drive until any blurring of vision produced by the Buscopan has resolved.
2. The patient should be warned that their bowel motions will be white for a few days after the examination and may be difficult to flush away.
3. The patient should be advised to eat and drink normally but with extra fluids to avoid barium impaction. Occasionally laxatives may also be required.
Complications
1. Leakage of barium from an unsuspected perforation
3. Conversion of a partial large bowel obstruction into a complete obstruction by the impaction of barium
4. Barium appendicitis, if barium impacts in the appendix (exceedingly rare)
N.B. It must be emphasized that there are many variations in technique, according to individual preference, and that the best way of becoming familiar with the sequence of positioning is actually to perform the procedure oneself.
Small bowel follow-through
Contrast medium
In general water-soluble small bowel contrast studies are avoided as contrast becomes diluted in small bowel fluid resulting in poor mucosal detail compared with barium. An exception is in adhesional small bowel obstruction where conservative investigation and ‘treatment’ with water-soluble contrast agents, frequently Gastrografin, may reduce the need for surgical intervention.1 In this case limited images are usually acquired at 1, 4 and 24 h, stopping once contrast is seen in the colon.
Preliminary image
Plain abdominal film is used if high-grade small bowel obstruction is thought possible.
Images
1. Prone PA images of the abdomen are taken every 15–20 min during the first hour, and subsequently every 20–30 min until the colon is reached. The prone position is used because the pressure on the abdomen helps to separate the loops of small bowel.
2. Each image should be reviewed and spot supine fluoroscopic views, using a compression device or pad if appropriate, may be considered.
3. Dedicated spot views of the terminal ileum are routinely acquired.
Additional images
1. To separate loops of small bowel:
(a) compression with fluoroscopy
(b) with X-ray tube angled into the pelvis
(c) obliques – in particular with the right side raised for terminal ileum views, or
(d) occasionally with the patient tilted head down.
(e) pneumocolon.2 Gaseous insufflation of the colon via a rectal tube after barium arrives in the caecum often results in good-quality double-contrast views of the terminal ileum.
2. Erect image – occasionally used to reveal any fluid levels caused by contrast medium retained within diverticula.
References
1. Catena, F, Di Saverio, S, Kelly, MD, et al. Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2011; 6:5.
2. Pickhardt, PJ. The peroral pneumocolon revisited: a valuable fluoroscopic and CT technique for ileocecal evaluation. Abdom Imaging. 2012; 37(3):313–325.
Small-bowel enema
Contrast medium
1. Single contrast: e.g. E-Z Paque 70% w/v diluted; or Baritop 100% w/v (one 300 ml can made up to 1500 ml with water).
2. 600 ml of 0.5% methylcellulose after 500 ml of 70% w/v barium.1
It may be difficult to obtain good distension and double-contrast effect of the distal small bowel and terminal ileum.
Equipment
A choice of tubes is available:
1. Bilbao-Dotter tube (Cook Ltd) with a guidewire (the tube is blind ending). Comes in various sizes and modifications including one variant with an inflatable balloon at the end to prevent reflux into the stomach.
2. Silk tube (E. Merck Ltd). This is a 10-F, 140-cm-long tube. It is made of polyurethane and the stylet and the internal lumen of the tube are coated with a water-activated lubricant to facilitate the smooth removal of the stylet after insertion.
Technique
1. The patient sits on the edge of the X-ray table. If a per-nasal approach is planned, the patency of the nasal passages is checked by asking the patient to sniff with one nostril occluded. The pharynx is anaesthetized with lidocaine spray or Xylocaine gel instilled into a nostril. The Silk tube should be passed with the guidewire pre-lubricated and fully within the tube, whereas for the Bilbao-Dotter tube the guidewire is introduced after the tube tip is in the stomach.
2. The tube is then passed through the nose or the mouth, and brief lateral screening of the neck may be helpful in negotiating the epiglottic region. The patient is asked to swallow with the neck flexed, as the tube is passed through the pharynx. The tube is then advanced into the gastric antrum.
3. The patient then lies down and the tube is passed into the duodenum. Various manoeuvres may be used alone, or in combination, to help this part of the procedure, which may be difficult:
(a) Lay the patient on his left side so that the gastric air bubble rises to the antrum, thus straightening out the stomach.
(b) Advance the tube whilst applying clockwise rotational motion (as viewed from the head of the patient looking towards the feet).
(c) Get the patient to sit up, to try to overcome the tendency of the tube to coil in the fundus of the stomach.
4. When the tip of the tube has been passed through the pylorus, the guidewire tip is maintained at the pylorus as the tube is passed over it along the duodenum to the level of the ligament of Treitz. The tube is ideally passed beyond the duodenojejunal flexure to diminish the risk of aspiration due to reflux of barium into the stomach.
5. Barium is then run in, ideally with a controllable mechanical pump, or by gravity. Initially start at 50 ml min−1 and, with regular initial screening, aim to ‘chase’ the leading edge of the barium distally to maintain an unbroken column of contrast within the small bowel. The infusion can usually be increased rapidly to 100 ml min−1 depending on the progress of the barium through the bowel. If methylcellulose is used, it is infused continuously, after an initial bolus of 500 ml of barium, until the barium has reached the colon.
