Saskatoon Medical Imaging/Saskatoon Women's Imaging

Fluoroscopy Services provided:
Barium Enema
Esophagography (see upper gi tract radiography)
Small bowel examination (see upper gi tract radiography)
Upper GI tract radiography

What is a Barium Enema (Lower Gastrointestinal (GI) Tract Radiography)

This is an x-ray evaluation of the large intestine, also known as the colon. The major zones of the colon, the right or ascending colon, the transverse colon, the left or descending colon and the rectum are all assessed. The appendix, if present, may be seen, as well as a portion of the small intestine.

The tissues of the lower GI tract are similar in density, so a contrast material is needed to provide exquisite detail of the inside of the colon. Liquid barium, a dense, non-absorbable suspension, is introduced into the colon through a tube inserted into the rectum to act as the contrast material. Air is also introduced into the bowel as well.  The barium coats the inside of the colon filled with air producing sharp, well-defined images.

The radiological images for this procedure are created by using a small amount of x-rays to acquire images on x-ray film. In addition. fluoroscopy, a special type of x-ray that creates video type images are also acquired. Fluoroscopy is used to obtain optimal images of the colon with the patient in a variety of positions during a barium enema examination.  Fluoroscopy is also used to monitor the distribution of barium and air in the colon during the procedure.  Both the static x-ray films and the fluoroscopy are very useful elements of the examination of the colon and rectum. 

How should I prepare for the Barium Enema?

You should tell your doctor about any allergies you might have to medications, and about any recent illnesses or other medical conditions, especially if you have had any radiation treatment in the past for cancer of the prostate, uterus or rectum.  It is especially important to let your doctor know if you have had a recent sigmoidoscopy or colonoscopy prior to having a barium enema.

Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant.

SMI Barium Enema Preparation Instructions

1. No solid foods or dairy products for 48 hours prior to the barium enema.

Drink clear fluids, at least 8 glasses of water/day.

2. Diet before barium enema

a)  Light breakfast and lunch 2 days before your test. 

b)  Black coffee or tea - No creamer of any sort (powder or flavored)

c)  Any kind of soft drink or iced tea.

d)  Jell-O, popsicles, freezies.

e)  Any clear fruit juice (apple, cranberry, raspberry, prune, or grape)

f)  You may supplement the above with Ensure, 1 - 2 cans/day.

Absolutely NO:

a)  Dairy products of any kind.

b)  Juices with pulp.

c)  Vegetable juice (tomato, V-8, Clamato, or carrot)

2.  Bowel Cleansing

a)  X-Prep laxative:  2 DAYS before examination take 1/2 bottle at 1:00 PM and then take the remaining 1/2 bottle at 4:00 PM.

b)  X-Prep laxative:  1 DAY before examination take 1/2 bottle at 1:00 PM and then take the remaining 1/2 bottle at 4:00 PM.

Note: Fleet Oral laxative may be substituted for X-Prep if so desired.

Once you arrive at the imaging center, you will be asked to change into a gown before your examination. You will also be asked to remove jewelry, eyeglasses, or any metal objects that could obscure the images.

What does the x-ray equipment look like?

The equipment used for most lower GI examinations consists of a large, flat table. The table tips end-to-end allowing the radiologist to have you in a head up or a head down position during the exam.  A moveable apparatus extends over the table and when activated by the radiologist acquires the fluoroscopy video images that are transmitted to a television monitor in the fluoroscopy room. Multiple static x-ray images are also obtained by the radiologist and technologist for later review.  The mechanism to obtain the x-ray images is all contained in the fluoroscopy table.

Fluoroscopy Table Horizontal	Fluoroscopy Table Upright
Fluoroscopy Table Head-down	Radiologist Performing Barium Enema

How is the Barium Enema procedure performed?

A lower GI radiological examination is often done on an outpatient basis. The radiologist or technologist will discuss details of the examination and can review rare contraindications (circumstances that need special consideration). The patient is positioned on the table, and a preliminary film may be obtained to check for adequacy of the bowel preparation.

The radiologist or technologist will then insert a small plastic tube into the rectum. A mixture of barium and water is passed into the patient's colon through the tube in the rectum. To help the barium thoroughly coat the lining of the colon, air or carbon dioxide gas may also be injected through the tube. In some circumstances, the radiologist or referring physician may prefer a water and iodine solution rather than barium to opacify the colon. Following complete coverage of the colon with barium, a series of x-ray images are captured.

Sometimes spasm of the colon prevents a good examination. The radiologist may give you an injection of Buscopan or Glucagon to relax the colon to obtain the best quality images possible.

The patient may be repositioned frequently during the barium enema to enable the radiologist or technologist to capture views of their colon from several angles. The repositioning also helps to spread the barium evenly throughout the large bowel.  During the study, the radiologist will monitor the delivery of barium and take or request special views or close-ups.

Once the x-ray images are completed, most of the barium is drawn back into a bag, and the patient is directed to the washroom to expel the remaining barium and air. In some cases, the technologist may then take additional images to help the doctor see how well the colon has cleared. The patient is then released.

A lower GI study typically takes 30 to 60 minutes.

What will I experience during the procedure?

As the barium fills your colon, you will feel the need to empty your bowel. You may feel abdominal pressure, and minor cramping. These are common sensations, and most people tolerate the mild discomfort easily. The tip of the plastic enema tube in the rectum is specially designed to help you hold in the barium. If you are having trouble, let the technologist know.

During the imaging process, you will be asked to turn from side to side, and to hold several different positions. At times, pressure may be applied to your abdomen. The x-ray table may be turned into an upright or head-down position.

You are able to return to a normal diet and activities immediately after the exam. Your bowel movements may appear white for a day or so, as your body clears the barium liquid from your system. You will be encouraged to drink additional water for 24 hours after the examination. After a barium enema, some people experience constipation. If you do not have a bowel movement for more than two days after your exam, or are unable to pass gas rectally, call your doctor promptly. Your doctor will prescribe the right solution for you.

What are the current recommendations for the Barium Enema?

A physician may request a lower GI examination to look for diverticula (small outpouchings of the bowel wall), benign tumors (polyps, for example), cancer, or signs of certain other intestinal illnesses. The procedure is frequently performed on individuals suffering from chronic diarrhea, blood in stools, constipation, irritable bowel syndrome, unexplained weight loss, a change in bowel habits, or to detect a source of suspected blood loss. Images of the bowel and colon are also used to diagnose inflammatory bowel disease, a group of disorders that includes Crohn's disease and ulcerative colitis.

Screening programs for colon carcinoma are not very common but they do exist.

What are the benefits vs. risks?

Benefits

• With the use of the barium contrast material, lower GI imaging provides valuable, detailed information to assist physicians in diagnosing and treating conditions from diverticular disease, inflammation, polyps, and cancer.
• The barium enema is a minimally invasive, with very rare complications.
• You may return to normal activity following the examination.
• The imaging process is fast and well-tolerated.
• This test may provide enough information to avoid more invasive procedures, such as colonoscopy, or may show polyps or other conditions that may lead to colonoscopy for further investigation.

Risks

• In rare cases, the barium suspension could leak through an undetected perforation (hole) in the lower GI tract, producing inflammation in surrounding tissues.
• Perforation of the rectum is more likely if the bowel is fragile such as after previous irradiation treatment for pelvic cancer. In this situation, the radiologist will modify the technique to increase the safety level.
• Even more rarely, the barium can cause an obstruction in the gastrointestinal tract, called barium impaction.
• The effective radiation dose from this procedure is about 4 mSv, which is about the same as the average person receives from background radiation in 16 months.  Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant.

What are the limitations of the Barium Enema?

A barium enema is usually not indicated for someone who is in extreme abdominal pain or had a recent colonic biopsy by surgery or colonoscopy. If perforation of the colon is suspected, the enema should not be performed with barium but can be performed with a water based iodinated solution. X-ray imaging is not usually indicated for pregnant women.

Sample Images

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Esophagography

This is a component of the Upper gi-series. The radiologist images the esophagus (the passage between the mouth and the stomach). If done alone, in the absence of images of other structures it is simply called an esophagram or esophagography.

Small Bowel Examination (follow through)

This examination is a continuation of the upper gi-series. It involves the acquisition of delayed x-ray images that evaluate the passage of the swallowed barium through the small intestine. The Radiologist supervising the exam may take additional images during the test.

What is Upper Gastrointestinal (GI) Tract Radiography?

Also called an upper gastrointestinal (GI) series or simply an upper GI, upper gastrointestinal tract radiography is an x-ray examination of the esophagus, stomach and the first part of the small intestine. This procedure is called a barium swallow, or esophagram, when only the pharynx and esophagus are evaluated. In order for the anatomy of these structures to be seen on radiographs, the upper gastrointestinal tract must be coated with a contrast material called barium, an substance that appears white on radiographs. The barium is given in the form of a thick fluid drink. Additionally, patients are often asked to swallow baking-soda crystals to create gas in the stomach and further improve the images; this procedure is called an air-contrast or double-contrast upper GI.

Initially, the radiologist monitors the flow of barium into the upper gastrointestinal tract on a fluoroscope, a device that projects radiographic video-like images onto a monitor. Standard x-ray images are also obtained demonstrating the air-filled gastrointestinal tract coated with barium.

How should I prepare for the procedure?

Your doctor will give you detailed instructions on how to prepare for your upper GI imaging. The quality of the images obtained during this procedure can be degraded if the stomach is not empty of food and fluid. Therefore, you will likely be asked not to eat or drink anything (including orally administered medications) after midnight on the morning of the examination. Nor should you chew gum or smoke after this time as these activities can cause increased stomach secretions, which may degrade the quality of the images.

SMI Upper GI Imaging Preparation Instructions

Stomach must be empty.  Do Not eat or drink anything for at least 14 hours prior to the examination.

Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant.

Before the procedure begins, you will be asked to remove all jewelry and also may be asked to wear a special gown without metal fasteners.

What does the x-ray equipment look like?

You will be positioned on an x-ray table that has the capability of tipping up to reside in a vertical orientation.  Commonly, you will begin the examination in the standing position and later on the table will lie flat for most of the other images.  The table can also be tipped head down for some of the images acquired.  The table has a film cassette holder built into it and the x-ray source arises from an apparatus suspended over the table.

How is the procedure performed?

Upper GI imaging can be performed in a radiology office or a medical center's radiology department as an outpatient procedure. It is usually scheduled in the morning to reduce the time individuals must remain fasting.

A radiologic technologist or nurse will position you next to the radiographic machinery. You may be asked to swallow baking-soda crystals (sometimes called fizzies or gas pills), which will create gas in your stomach. Then, you will be asked to drink a cup of liquid barium, which has the consistency of a milkshake, however, it will be at room temperature.

The radiologist will note the passage of barium into your esophagus and stomach on the fluoroscopic monitor. Once the upper gastrointestinal tract is adequately coated with the barium, still radiographs are obtained.

The examination is usually completed within 15 - 20 minutes.

What will I experience during the procedure?

The liquid barium has a chalky taste, although the taste can be masked somewhat by added flavors such as strawberry or chocolate. If you receive gas producing crystals, you may feel the need to belch. However, the radiologist or technologist will tell you to hold the gas in as its presence in the stomach enhances the detail in the radiographic images.

Initially, you will be standing up, then lying down, as the radiologist obtains pictures of your esophagus and stomach. You will be asked to hold your breath to prevent blurring of the still images. Also, periodically you will be asked to move into different positions while standing, and to roll into different positions while lying on the examining table. In some medical centers, the technologist can minimize patient movement by automatically tilting the examining table. These actions assure that the barium is coating all parts of the esophagus and stomach. As the procedure continues, the technologist or the radiologist may want you to drink more barium.

During this procedure, you may hear the mechanical noises of the radiographic apparatus moving into place. Once the examination is complete, you will be asked to wait. At this time, the radiologist will preliminarily examine the images to be sure they contain the necessary information for a careful evaluation later. If the radiographs are acceptable, you can dress and leave the examining area. Occasionally, repeat imaging may be necessary.

After the examination, you can resume a regular diet and take orally administered medications unless told otherwise by your doctor. The barium may color stools gray or white for 48 to 72 hours after the procedure. Sometimes the barium can cause temporary constipation, which is usually treated by an over-the-counter laxative.

What are some of the current recommendations for the procedure?

An upper GI procedure is done to observe digestive function or to detect abnormalities such as ulcers, tumors or inflammation of the esophagus, stomach and proximal small intestine. Patients who undergo this procedure are usually those who have difficulty swallowing, are complaining of chest and abdominal pain or reflux (a backward flow of partially digested food and digestive juices), or have unexplained vomiting, severe indigestion, or blood in the stool (indicating internal bleeding).

What are the benefits vs. risks?

Benefits

• Upper gastrointestinal tract radiography is safe, non-invasive test and the results usually lead to an accurate analysis of the esophagus, stomach, and duodenum. 
• Exposure to radiation is kept to a minimum. Special care is taken during x-ray examinations to ensure maximum safety for the patient by shielding the abdomen and pelvis with a lead apron, with the exception of those examinations in which the abdomen and pelvis are being imaged.

Risks

• Some patients may be allergic to the flavoring added to some brands of barium. If you have experienced allergic reactions after eating chocolate, certain berries or citrus fruit, be sure to tell your doctor or the technologist before the procedure. 
• There is a slight chance that some barium could be retained, leading to a blockage of the digestive system. Therefore, patients who have an obstruction in the gastrointestinal tract should not undergo this examination. 
• The effective radiation dose from this procedure is about 2 mSv, which is about the same as the average person receives from background radiation in eight months.

What are the limitations of Upper Gastrointestinal (GI) Tract Radiography?

The examination is limited to providing information about the surface lining of the GI Tract and possibly provided some information about the structures lying immediately beneath the surface lining.  However, it provides very little information about the structures deep to the surface lining.  Computed tomography (CT) and ultrasound are more adapted to providing information about these regions.

Sometimes the abnormalities depicted by GI tract radiography are very subtle and the detection of these finding depends upon the quality of the x-ray equipment and the experience of the technologist and the radiologist.

Sample Image

Upper Gi-series, showing stomach and some small intestine

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