Barium Enema

A barium enema, or lower gastrointestinal (GI) examination, is an Xray 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.

In a 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. In some cases, the single-contrast study may be preferred for specific medical reasons or for older people who may not be able to tolerate the time-consuming and somewhat more uncomfortable double-contrast study. But if the results are not clear, a doublecontrast study may also be done. Why It Is Done A barium enema is done to:

Identify inflammation of the intestinal wall that occurs in inflammatory bowel diseases, such as ulcerative colitis or Crohn's

disease. A barium enema also may be used to monitor the progress of these diseases. Find problems with the structure of the large intestine, such as narrowed areas (strictures) or pockets or sacs (diverticula) in the intestinal wall. Help correct a condition called ileocolic intussusception , in which the end of a child's small intestine protrudes into the large intestine. Evaluate abdominal symptoms such as pain, blood in stool, or altered bowel habits. Evaluate other problems such as anemia or unexplained weight loss. How To Prepare Before a barium enema, tell your doctor if you:

Are or might be pregnant. Are allergic to latex. Latex products are commonly used to administer the contrast material. If you have a latex allergy, different products will be used. Know that you are allergic to barium. Have had an upper digestive barium test (upper GI or barium swallow) recently. Have had a colonoscopy or sigmoidoscopy recently. The preparation for a barium enema usually involves a very thorough cleansing of the large intestine, because the colon must be completely clear of stool and gas. Even a small amount of stool can affect the accuracy of the test.

For 1 to 3 days before the test, you will usually be on a clear liquid diet. On the day before the test:

You should drink very large amounts of noncarbonated clear liquids, unless your doctor has advised you not to. You will then take a combination of laxatives to empty your intestines. You may be asked to take a tap water enema to clean any remaining stool from your colon. On the day of the test, you may need to repeat the enema until the liquid that passes is free of any stool particles. Sometimes a rectal suppository or a commercially prepared enema, such as a Fleet enema, is used instead of a tap water enema.

Description
To begin a barium enema, the patient will lie with their back down on a tilting radiographic table in order to have x rays of the abdomen taken. After being assisted to a different position, a well-lubricated rectal tube is inserted through the anus. This tube allows the physician or assistant to slowly administer the barium into the intestine. While this filling process is closely monitored, it is important for the patient to keep the anus tightly contracted against the rectal tube to help maintain its position and prevent the barium from leaking. This step is emphasized to the patient due to the inaccuracy that may be caused if the barium leaks. A rectal balloon may also be inflated to help retain the barium. The table may be tilted or the patient moved to a different position to aid in the filling process. As the barium fills the intestine, x rays of the abdomen are taken to distinguish significant findings.There are many ways to perform a barium enema. One way is that shortly after filling, the rectal tube is removed and the patient expels as much of the barium as possible. Upon completing this, an additional x ray is taken, and a doublecontrast enema may follow. If this is done immediately, a thin film of barium will remain in the intestine, and air is then slowly injected to expand the bowel lumen. Sometimes no x rays will be taken until after the air is injected.

Preparation
In order to conduct the most accurate barium enema test, the patient must follow a prescribed diet and bowel preparation instructions prior to the test. This preparation commonly includes restricted intake of diary products and a liquid diet for 24 hours prior to the test, in addition to drinking large amounts of water or clear liquids 12-24 hours before the test. Patients may also be given laxatives, and asked to give themselves a cleansing enema. In addition to the prescribed diet and bowel preparation prior to the test, the patient can expect the following during a barium enema:

They will be well draped with a gown as they are secured to a tilting x-ray table. As the barium or air is injected into the intestine, they may experience cramping pains or the urge to defecate. The patient will be instructed to take slow, deep breaths through the mouth to ease any discomfort.

Aftercare
Patients should follow several steps immediately after undergoing a barium enema, including:

Drink plenty of fluids to help counteract the dehydrating effects of bowel preparation and the test. Take time to rest. A barium enema and the bowel preparation taken before it can be exhausting. A cleansing enema may be given to eliminate any remaining barium. Lightly colored stools will be prevalent for the next 24-72 hours following the test.

Risks
While a barium enema is considered a safe screening test used on a routine basis, it can cause complications in certain people. The following indications should be kept in mind before a barium enema is performed:

Those who have a rapid heart rate, severe ulcerative colitis, toxic megacolon, or a presumed perforation in the intestine should not undergo a barium enema. The test can be cautiously performed if the patient has a blocked intestine, ulcerative colitis, diverticulitis, or severe bloody diarrhea. Complications that may be caused by the test include perforation of the colon, water intoxication, barium granulomas (inflamed nodules), and allergic reaction. These are all very rare.

Normal results
When the patient undergoes a single-contrast enema, their intestine is steadily filled with barium to differentiate the colon's markings. A normal result displays uniform filling of the colon. As the barium is expelled, the intestinal walls collapse. A normal result on the x ray after defecation will show the intestinal lining as having a standard, feathery appearance. Accordingly, the double-contrast enema expands the intestine which is already lined with a thin layer of barium, but with air to display a detailed image of the mucosal pattern. Varying positions taken by the patient allow the barium to collect on the dependent walls of the intestine by way of gravity.

Abnormal results
A barium enema allows abnormalities to appear on an x ray that may aid in the diagnosis of several different conditions. Although most colon cancers occur in the rectosigmoid region, or upper part of the rectum and adjoining portion of the sigmoid colon, and are better detected with a different test called a proctosigmoidoscopy, an enema can identify other early signs of cancer. Identification of polyps, diverticulosis, inflammatory disease, such as diverticulitis and ulcerative colitis is attainable through a barium x ray. Structural changes in the intestine, gastroenteritis, and some cases of acuteappendicitis may also be apparent by viewing this x ray.

BOWEL PREP

Preparation
Bowel preparation for visualization of the colon is performed to ensure the procedure will be accurate and complete. There are several effective cleansing preparations including polyethylene glycol solution (Colyte), sodium phosphate solution (PhosphoSoda), magnesium citrate with bisacodyl tablets, and castor oil with bisacodyl tablets. One of these preparations should be administered starting at 4:00 p.m. the day before the procedure. Patients are usually asked to avoid solid foods for about 36 hours before diagnostic procedures. Such clear liquids as vegetable or beef broth, apple or white grape juice, soda pop or fruit-flavored gelatin are permitted, although some doctors ask patients to avoid redcolored beverages or gelatin flavors on the grounds that the red food coloring in these products may make bleeding more difficult to detect. In most cases, patients may continue to take other prescription medications at the usual times while they are restricted to clear liquids. It is a good idea, however, to check with the doctor beforehand.

Aftercare
Patients should have a friend or relative to drive them home after the procedure, as the combination of a period of dietary restriction, frequent bowel movements, and the procedure itself leaves most people feeling tired and slightly weak. Many doctors advise patients to postpone vigorous physical activity or work requiring mental concentration until the day after the procedure. Patients can resume eating solid foods as soon as they get home. Some patients may notice a small amount of blood on toilet tissue or underwear following a colonoscopy or other examination of the lower digestive tract. Spotting is not cause for concern; however, patients who have steady or heavy bleeding from the rectum should call their doctor as soon as possible.

Risks
The current standard of care dictates that patients receive antibiotic prophylaxis if they are at increased risk of developing an infection. High-risk patients include those with cardiac diseases or patients with prostheses. Bowel preparation can be stressful for some patients, particularly those with pre-existing nutritional problems associated with cancer treatment or malabsorption. In addition, many patients find the various oral solutions unpleasant to the taste and difficult to swallow for that reason. According to one British study, oral solutions flavored with lemon are more acceptable to patients than unflavored forms. Both Colyte and Phospho-Soda are available with flavoring added; patients may wish to ask their pharmacist for these specific products. Mild nausea, vomiting, stomach cramps, intestinal gas, dry mouth, and increased thirst are common side effects of these products. Some patients are helped by taking an electrolyte supplement along with oral sodium phosphate solution to lower the risk of dehydration. Some people may have severe allergic reactions to commonly used oral laxatives used for bowel preparation. Patients who develop hives, swelling of the face or hands, swelling or tingling in the throat or mouth, difficulty breathing, or tightness in the chest should call their doctor at once. This type of reaction is a medical emergency.

Normal results
Absence of anatomical changes or abnormalities in the intestines would result in normal diagnosis.

Abnormal results
Polyps can be treated with electrocautery. A biopsy is taken of any suspicious polyps and further analyzed. Sigmoidoscopy can detect masses, bleeding, and ulcerative disease.