Transcript small bowel Barium follow-through Barium follow

Dr.Hadeel M.Al-Hialy
M.B.Ch.B. F.I.C.M.S
Barium follow-through
A barium follow-through procedure is a type
of medical imaging technique. It is used to evaluate
the presence of disease in a person's small intestine.
Examination
Barium follow through x-ray
The patient drinks a contrast medium containing barium sulfate. This contrast
medium appears white on x-rays, and shows the outline of the internal lining of
the bowel. X-ray images are taken as the contrast moves through the intestine,
commonly at 0 minutes, 20 minutes, 40 minutes and 90 minutes. This enables
the radiologist to assess the bowel as it becomes visible. The test is completed
when the Barium is visualised in the terminal ileum and Caecum, which marks the
beginning of the large bowel. This is one of the most common places for
pathology of the bowel to be found, therefore imaging of this structure is crucial.
The test length varies from patient to patient as bowel motility is highly variable.
The barium is non-toxic and passed out normally as a stool, although the appearance
may be paler than usual.
Pathology
The Barium follow-through test is used to diagnose conditions of the small bowel,
most commonly
Crohn's disease
Ulcerative colitis
Bowel cancer
causes of malabsorption include:
Celiac disease
some medications used to treat obesity
Certain types of cancer (lymphoma, pancreatic cancer, gastrinomas)
Certain types of surgery (gastrectomy with gastrojejunostomy,
surgical treatments for obesity, partial or complete removal of the ileum)
Chronic liver disease
Crohn's disease
Damage from radiation treatments
Parasite infection, including Giardia lamblia
Soy milk protein intolerance
Whipple's disease
Vitamin B12 malabsorption may be due to:
Pernicious anemia
Bowel resection
* Loss of normal feathery appearance of the small
bowel
* Flocculation & segmentation of the Ba
* Widening of the spaces between bowel loops
due to mucosal edema
*+/_ spiky appearance of the small bowel loops
Due to the overlap in clinical presentation of
Crohn's disease (CD) and ulcerative colitis (UC), imaging
often has a role to play in distinguishing the two.
Distinguishing features include:
bowel involved
CD : small bowel 70 - 80%, only 15 - 20% have only colonic
involvement
UC : rectal involvement 95%, with terminal ileum only
involved in pancolitis (backwash ileitis)
distribution
CD : skip lesions typical
UC : continuous disease from rectum up
gender
CD : no gender preference
UC : male predilection
Crohn's disease
is an idiopathic, chronic inflammatory process of
the gastrointestinal tract that can affect any
part of the tract from the mouth to the anus.
Individuals with this condition often experience
periods of symptomatic relapse and remission.
ages of 15 and 25 years of age, with no gender
predilection . There is a familial component and
incidence also varies with geographical
location..
Radiographic features
The characteristic of Crohn's disease is the
presence of skip lesions. The frequency with
which various parts of the gastrointestinal
tract are affected varies widely :
small bowel :
70 - 80 % + regional ileitis
small and large bowel : 50 % + regional ileitis
large bowel only : 15 - 20 %
X-Ray Manifestations
• Squaring of the folds-early manifestation from
obstructive lymphedema
• Apthous ulcers-small nodular filling defects (mound
of edema) with central ulceration
• Skip lesions-discontinuous involvement of the bowel
with intervening normal areas
• Cobblestoning-irregular, blanket-like appearance to
bowel wall caused by criss-crossing longitudinal and
transverse ulcers separated by areas of edema
• Pseudopolyps-islands of hyperplastic mucosa between
denuded areas of mucosa
• Filiform post-inflammatory polyps
• Pseudodiverticula-from bulging area of normal wall
opposite side of scarring from disease, usually on antimesenteric side
• String-sign-marked narrowing of terminal ileum
(usually) from a combination of edema, spasm and
(sometimes, but not always) fibrosis; frequently associated
with proximal dilatation
Location
Begins in rectum with retrograde
progression
o Rectosigmoid involved 95%;
continuous involvement of left colon
oTerminal ileum in 5-10% with
backwash ileitis
o
X-Ray Manifestations
Acute inflammatory stage
o
Spasm and irritability
o
Fine mucosal granularity earliest finding on air-contrast BE
o
Spiculated, serrated bowel margins from tiny, multiple ulcerations
o
Collar button ulcers
o
Thumb printing from edema of wall
o
Pseudopolyps
o
Widening of the pre-sacral space
o
o
Subacute stage
Coarser, more granular mucosa
Inflammatory polyps= frond-like lesions of inflamed mucosa
Chronic stage
o
Shortening of the colon-may be from spasm of longitudinal muscles or from
irreversible fibrosis (lead-pipe colon)
o
Loss of haustrations on left side of colon

Barium enema
examination
demonstrates loss of
haustral folds in the
entire descending
colon with small
ulcerations
suggested. The colon
has a "lead-pipe"
appearance.
The distribution and
appearance are
suggestive of
ulcerative colitis.
A barium enema, or lower gastrointestinal (GI)
examination, is an X-ray examination of the large
intestine (colon and rectum). The test is used to help diagnose
diseases and other problems that affect the large intestine. To
make the intestine visible on an X-ray picture, the colon is filled
with a contrast material containing barium. This is done by pouring
the contrast material through a tube inserted into the anus. The
barium blocks X-rays, causing the barium-filled colon to show up
clearly on the X-ray picture.
There are two types of barium enemas.
single-contrast study , the colon is filled with barium, which outlines
the intestine and reveals large abnormalities.
In a double-contrast or air-contrast study , the colon is first filled
with barium and then the barium is drained out, leaving only a thin
layer of barium on the wall of the colon. The colon is then filled
with air. This provides a detailed view of the inner surface of the
colon, making it easier to see narrowed areas
(strictures),diverticula, or inflammation.
Colorectal carcinoma (CRC) is the most
common cancer of the gastrointestinal
tract and the second most frequently
diagnosed malignancy in adults.
Clinical
o
Peak age 50-70 years
o
Weight loss
o
Blood in stool
o
Loss of appetite
o
Change in bowel habits
Location
o Rectum (15%), sigmoid (20%), descending colon (10%),
transverse colon (12%), ascending colon (8%), cecum
(8%)
o More common in right colon with advancing years
o More common in left colon with chronic ulcerative colitis
Imaging findings
o 90-95% rate of detection by BE
o Polypoid filling defect
o Annular constricting >>>>>
apple-core lesion
Out-pouchings of bowel result in blind-ended
diverticulae in communication with the
lumen of the bowel. These most commonly
occur within the sigmoid colon, although
them may be present throughout the bowel.
colonic diverticulosis : the presence of
multiple diverticulae within the bowel
colonic diverticulitis : infection of the
diverticulae, usually because the neck
becomes blocked
Autosomal dominant with high penetrance (80%)
• About 2/3 of affected people have a positive
family hx of colonic polyps or ca and about 1/3
are sporadic cases
• Colonic polyps are numerous and of all different
sizes
• They may be sessile or pedunculated
• Rectum and left colon are more commonly
affected than right side of colon
• Often, however, the entire colon is carpeted
with polyps
accounts for 1 percent of all cases of colorectal
cancer
Dome shape luency below the diaphragm with
straight air fluid level .
Pneumoperitoneum describes gas within
the peritoneal cavity, and is often the
consequences of many a critical illness.
Radiographic features
Plain film
Chest radiograph
An erect chest x-ray is probably the most
sensitive plain radiograph for the detection
of free intra peritoneal gas >>> crescent
shape of lucency unilateral or bilateral
Plain x ray SBO
dilated loops with air fluid level in erect
position
centrally placed
transverse lines (circular folds ) valvule
convent's
dilated bowel with gas
peripheral
haustra (not lines across bowel)
may have cut-off point
Inverted U-shaped appearance of distended
sigmoid loop
Largest and most dilated loops of bowel are
seen with volvulus
Loss of haustra
Coffee-bean sign à midline crease corresponding
to mesenteric root in a greatly distended
sigmoid
Sigmoid volvulus – bowel loop points to RUQ
Cecal volvulus – bowel loop points to LUQ
Bird’s-beak or bird-of-prey sign à seen on
barium enema as it encounters the volvulated
loop
Intussusceptions' occurs when one segment of
bowel is pulled into itself (or a neighboring
loop of bowel) by peristalsis.
It is an important cause of an acute
abdomen in children and merits timely
ultrasound examination and reduction to
preclude significant sequelae including bowel
necrosis.
Intussusception may also occur in the adult
population where it is usually caused by a
focal lesion acting as a lead point.
Abdominal plain film 
Abdominal x-rays may demonstrate an elongated soft
tissue mass (typically in the right upper quadrant in
children) with a bowel obstruction proximal to it.
Ultrasound
Ultrasound signs include
target sign (also known as the doughnut sign)
pseudo kidney sign
crescent in a doughnut sign
Fluoroscopy - contrast enema
A contrast enema remains the gold standard,
demonstrating the intussusceptions as an occluding
mass prolapsing into the lumen, giving the "coiled
spring” appearance .
narrowing of recto-sigmoid segment of
intestine
proximal dilatation of the colon
depicted transition zone on the contrast
enema is not accurate at determining the
transition between absent and present
ganglion cells.
The affected segment is of small calibre with
proximal dilatation. Fasciculation / sawtooth irregularity of the agangliotic segment
is frequently seen
Toxic megacolon (TM) is complication that can
be seen in both types of inflammatory bowel
disease, in infectious colitis, as well as in
some other types of colitis
Radiographic features
The colon (typically transverse colon) becomes
dilated to at least 6cm (usually greater).
There is additional loss of haustral markings,
with pseudopolyps often extending into the
lumen.
Thumbprinting from mucosal edema may be
present.