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Choice of contrast

Double contrast (barium and air)
- best mucosal detail
- The barium preparation depends on the study
- Avoid in perforation or obstruction

Baritop 100% w/v (i.e. or more correctly a mass of 100g barium sulfate in every 100 ml)
- Barium sulfate preparation
- Good for single contrast barium swallows and barium follow through

E-Z-HD 250% w/v
- Low viscosity, but high density barium sulfate preparation with variable particle size so that a thin layer of barium is deposited across all mucosal features and remains visible on the radiographs.
- Contains an anti-foaming agent to reduce bubbles
- Best for barium meals.(1)

Polibar as powder
- Barium sulfate for enema use
- Dilute to approx 115% w/v using the chart on the bag to determine the appropriate amount of warm water
- When ready to use, push the red ball into the bag

- Diatrizoate meglumine and diatrizoate sodium solution
- High osmolar contrast agent
- May cause pulmonary oedema if aspirated
- Safe in peritoneal cavity and mediastinum, but note the risk of aspiration
- Flavoured so not for i.v. use
- Non-particulate so mucosal detail is poor
- Hyperosmolar so fluid shift causes progressive dilution through the gastrointestinal tract – beware fluid shifts in children and patients who are dehydrated
- 370 mg iodine/ml

Urografin 150
- Similar to gastrografin
- Unflavoured
- Only for oral, rectal, urethral, or i.v. use
- The 146 mg iodine/ml preparation (Urografin 150) is suitable for urethrography and cystography (not CT).

Iohexol 300 mg iodine/ml (Omnipaque 300)
- Low osmolality contrast medium
- Non ionic
- For intravenous, intrathecal, intraarterial, oral, rectal or body cavity use
- Dilute with water (50:50) for cystography

Iodixanol 320 mg/ml (Visipaque 320)
- Non ionic
- Lower osmolality than iohexol
- Only for intravenous, intraarterial, oral, rectal or body cavity use

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The BNF should be to hand in the fluoroscopy room. Consult it frequently, especially if asked about interactions and in patients with any comorbidity. For example you would use Buscopan with caution in a patient with Down’s syndrome and not at all (as a radiologist) in a patient with myasthenia gravis. When using any drug to treat an adverse reaction, the BNF should be consulted. The names and doses are given here only to assist you in identifying the appropriate drug and are not indications to use the drug without first clarifying the indications, interactions, cautions and contraindications in an appropriate reference.

- Dopamine receptor antagonist
- Antiemetic and motility stimulant
- 20 mg orally
- May cause acute dystonic reaction (to treat, use procyclidine 5-10 mg i.v. or i.m.)

- Hyoscine butylbromide
- Antimuscarinic
- 20 mg i.v.
- May be repeated after 30 minutes, maximum 100 mg/day(1)
- Contraindicated in myasthenia gravis
- Caution with arrhythmias, closed-angle glaucoma

- Polypeptide hormone
- Contraindicated in phaeochromocytoma, caution in insulinoma
- 1 mg i.v.
- Less effective than buscopan(2), but still has an effect
- Expensive

For almost all of these procedures the tube is beneath the bed and the detector is above the bed. The reverse is true for paeds.

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Barium swallow

Gastrointestinal tract leak
High volume aspiration

Ensure the patient is not pregnant and can understand commands.
Use Baritop™ 100

To fully distend the stomach and assess reflux, use gas granules (Carbex). Mix the granules with a small amount of water and instruct the patient to drink the mixture then drink the lemon juice/citric acid.

Set to 4 frames/second.

Start with the patient standing side on to the x-ray beam to get a lateral view of the pharynx and upper oesophagus.

Cone in before taking an exposure or screening – use the light or guess. Don’t screen before you have coned in – with practice you can get it right routinely before your first screen.

Screen briefly to check you are aligned correctly. Correct alignment demonstrates the pharynx and oesophagus, but excludes most of the shoulders and base of skull (the shoulders are large and the base of skull is dense, so a higher dose is given to achieve what the machine thinks is an adequate exposure). If needed, put a filter in the air anterior to the patient’s neck. Instruct the patient to drink at an appropriate time and take images at 4 frames/second.

Figures 1,2,3 and 4 (above): Lateral pharynx and upper oesophagus seen at 4 frames/second during swallowing

Stop acquiring images as soon as the patient has swallowed.

Turn the patient to face the detector.

Open up the cones top to bottom slightly, cone in side to side and move the tube and detector down a little. Screen to check your position and then take images of the pharynx and upper oesophagus in the PA position still at 4 frames/second. Magnify the image for this series.

Figures 5, 6, 7 and 8 (above): PA views of the pharynx and upper oesophagus taken at 4 frames/second. This image could have been magnified and the vertical field of view reduced.

Change to single shot

Cone in to get a picture of the piriform fossae and valleculae. To get a good shot ask the patient to take a sip of barium and swallow it straight away. Then get them to puff their cheeks out or say “Eeeeeeeeeeeeeeeeeeeeeeeee”.

Figure 9 and 10 (above): Single shots in different patients of the hypopharynx demonstrating the piriform fossa (P) and valleculae (V). The median glosso-epiglotic fold is indicated by the arrowhead

Change to 2 frames/second.

Turn the patient to the right anterior oblique (RAO) position, move the tube and detector downwards, open up the cones top to bottom and cone in side to side. Screen to check that you have the oesophagus from the clavicles to the GOJ (sometimes you may need to take a separate, dedicated distal oesophageal series to include the GOJ). Take images at 2 frames/second as the patient swallows.

Figures 11, 12, 13, 14 and 15 (above): Alternate RAO projection images at 2 frames/second during swallowing.

Turn the patient to face the bed and lie them flat.

Change to single shots.

Get them to lift their right side slightly (RPO position) and screen a small bolus of barium all the way down – assess the peristalsis using one swallow only, do not use multiple swallows. Cone so that you can see the oesopahgus from at least clavicles to GOJ. Then instruct the patient to take as much barium in their mouth as possible – the more they take now, the fewer shots you will need and the less they will need to drink (tell them that). When they have as much as possible in their mouth, tell them to swallow and keep swallowing through the straws you have provided. Take a single shot or as many single shots as required to get full distension of the whole oesophagus in the RPO position. If the patient has done as instructed and have swallowed an enormous amount of barium, you often only need one shot and can tell them to stop drinking almost immediately.

Prone oesophagus
Figure 16 (above): A single shot of the oesophagus in the prone position when swallowing a large bolus of barium

Consider a bolus of solid food – white bread is best. Assess swallowing and hold up of the bolus.

Screen only from now on.

Turn the patient on to their back and assess for reflux. Cone in to the distal oesophagus and proximal stomach, but be prepared to open up the cones to see how far up it goes. If there is no reflux without provocation, try to provoke reflux with the following methods in this order: roll them towards you a little, drink water, and tilt them 5 degrees head down. Save a cine loop of any reflux you see. Finally take images of the stomach in the supine and left lateral position, including a little bit of proximal small bowel.

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Barium follow through

Use Baritop 100

20 mg metoclopramide orally

Explain the procedure to the patient and give the metoclopramide early on. Send the patient out to the waiting room with a full cup and the rest of the can of Baritop to drink (quickly). If you are in a rush, watch them drink the first cup – they will drink it more quickly with you encouraging them. However, it they drink it all too quickly, you will find, paradoxically, that it all sits in the stomach and goes nowhere. If they drink it too slowly you will be equally frustrated.

Call the patient back after 10 minutes, 30 minutes and 60 minutes to take prone radiographs of the progress of the barium. Ensure full coverage of the abdomen. Spot views of an abnormality may be useful, but not without the image of the whole abdomen. At Bart’s the patients will have the radiographs in another room whilst you get on with other examinations – do not forget to review each radiograph when it is done - the timings may need to be adjusted according to the rapidity of transit or you may need to screen to characterise abnormalities.

Figures 17, 18 and 19 (above): 10 minute, 30 minute and 60 minute radiographs showing progress of the barium through the small bowel.

If by 60 minutes the barium has not passed through to the terminal ileum, take steps to speed the process up – give another cup and a bit of dilute barium.

Take a short time to screen and look at the bowel peristalsis.

When barium has reached the colon, use the paddle to compress the right iliac fossa, move the bowel loops out of the way and take a shot of the terminal ileum. This can be done with the patient supine and, often, rolled a little away from you or prone and lying on the balloon (if the latter, be sure not to burst the balloon by overinflation – if the patient lifts themselves away from an overinflated balloon, it is at risk of bursting). Be firm (even a little rough) and change the position until you see the terminal ileum well.

Terminal ileum
Figure 20 (above): The terminal ileum

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Barium enema

- Perforation
- Pregnancy
- Toxic megacolon
- Pseudomembranous colitis
- Recent rectal biopsy
- Availability of colonoscopy or CT pneumocolon.

The patient should have had a bowel preparation regime prior to the procedure.

The patient should lie on the bed with their left side down and knees tucked up to their chest.

Mix the barium according to the instructions on the bag.

Give 20 mg Buscopan or 1 mg Glucagon. Contraindications to Buscopan are unstable cardiac disease/arrhythmia, myasthenia gravis or closed angle glaucoma.

Insert the rectal tube and let the barium flow in. Take an early filling shot (align the femoral heads to obtain a true lateral).

Early filling of the rectum
Figure 21 (above): A lateral, filling image of the rectum.

Turn the patient prone to watch until the barium reaches the hepatic flexure. At this point, drop the bag and allow the excess barium in the rectum to drain out. Once this is done clip the tubing and begin instilling the air.

Views (ask the patient to suspend respiration during each):
Right side up – rectum. Ensure good alignment by lining up both femoral heads.

Lateral rectum
Figure 22 (above): A lateral double contrast image of the rectum.

RAO – sigmoid
Prone Hampton’s view (angled cranially if under couch tube, caudally if over couch) – rectum
Standing supine – flexures (LAO helps open out the splenic flexure and RAO helps open out the hepatic flexure).

Figures 25 and 26 (above): Images of the hepatic and splenic flexures. The hepatic flexure has been opened out using an RAO position. The splenic flexure could be opened out a little more.

Lying supine – transverse colon, caecum (may help to be LAO, head down)

Figures 27 and 28 (above): Images of the caecum and transverse colon. The images of the caecum may be improved by using a head down tilt and compression to move the barium.

Lying on each side with a horizontal beam for decubitus images. You can’t just keep the patient in the same position and move the tube. You must move the patient to alter the position of the barium from one wall to the other.

Figures 29 and 30 (above): Examples of decubitus images. Note the dependent barium.

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Barium meal

Easier than you think! The only thing that your success depends upon is the speed at which the patient can drink the barium. If they struggle and drink slowly, you will find that the duodenum gets filled with barium before you have even got the patient to lie down.

Mix the E-Z-HD 250 with exactly 65 ml of water (follow the instructions on the container).

Start by giving the patient 2 sachets of gas granules with the corresponding lemon juice/citric acid. Advise the patient to swallow rather than burp.

Give Buscopan 20 mg i.v.

Take images as you would for the RAO part of the swallow, but just use single shots. When timed with swallowing, you will get excellent pictures of the oesophagus. You will not need to take many images. Concentrate on getting the patient to drink as quickly as possible. Two thirds of the can should do and will provide good coverage without obscuring too much of the anatomy.

Figure 31 (above): An RAO single shot image of the distal oesophagus and GOJ

Turn the patient to face the bed then lie them flat. Get them to make two full rotations to end up lying on their left hand side. This is your safe position – barium will not move that much from this position. Assess the coverage and distension and if either is unsatisfactory, take steps to correct it with more gas granules or a further roll to coat the stomach.

When you are ready get them to roll to RAO, supine and LAO positions (to assess the antrum and greater curve, antrum and body, and lesser curve). Take a shot at each position. If you need time to examine the images, put the patient back into the left side down position. Look especially at the lesser curve and make sure it has a good coating of barium. You may have to roll the patient again if coating is not satisfactory. Take spot views of the duodenal cap in these positions.

Figures 32, 33 and 34 (above): LAO, supine and RAO images of the stomach.

A left lateral view with or without the head slightly elevated will assess the fundus.

Figure 35 (above): A left lateral image of the fundus - a head up tilt, slightly altered projection or later image when barium has emptied from the oesophagus and cardiac area may have improved the image.

When you are ready get the patient to lie prone with their right side slightly up for as long as you dare (~30 s). Stand the patient up and take LAO, RAO and PA images (PA to assess the fundus, although assessment of the fundus at this point is less important than in the horizontal position).

Figures 36, 37 and 38 (above): LAO, PA and RAO spot images (cropped) of the duodenal cap.

Figure 39 (above): An erect PA image of the fundus.

A prone view of the duodenal cap is also useful. Although I mention this view at the end, take it where appropriate in the sequence above. If you are lucky, you are done. If not you, may have to lie the patient down again and acquire further images (all is not always lost if you have to do this).

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1. Montgomery DP, Clamp SE, De Dombal FT, et al. A comparison of barium sulphate preparations used for the double contrast barium meal. Clin Radiol. 1982;33(3):265–269.

2. Goei R, Nix M, Kessels AH, Ten Tusscher MP. Use of antispasmodic drugs in double contrast barium enema examination: glucagon or buscopan? Clin Radiol. 1995;50(8):553–557.

Further reading

1. Aitchison FA. A Guide to Radiological Procedures. 5th Revised edition. Saunders (W.B.) Co Ltd; 2009.