 Hello everyone and welcome to Indian radiologist once again. This week's video is a very unusual one, one on barium enema and why say unusual is because this study happens to be a thing from the past and we are just putting this video across to let you know what we used to do about 10, 20, 30 years ago and how irrelevant it has actually become. There are some centers still that would be doing this test but in most centers we have moved on to other modalities like ultrasound CT and MR to give us the diagnosis that we need. Another reason for barium enema is to disappear of course colonoscopies which are much more sensitive and much more accurate compared to barium enema. So still we are going to have a look at what we can see on barium enema studies. Thank you. So before we start talking about how to do this test we must know about the contraindications of this procedure. Hence it's always useful and very important to take a standing X-ray of the abdomen before you start this procedure. Why? Because you will rule out an acute perforation by seeing that there is no gas under the diaphragm. You should also not do this procedure when there is an acute fulminating colitis when there's been a recent rectal biopsy and also if there is dilated bowel loop seen like large bowel dilatation and you're suspecting toxic megacolon that's a very good reason not to do this test no matter how much the clinician forces you. So here we can see two images. One is on the left that shows us a complete small bowel obstruction which came with abdominal distension and was actually referred to us for a barium enema. Obviously it was declined and the patient went for CT and the image here on the right side where we can see a very enlarged dilated transverse colon cut off measures vary but usually anything more than six centimeters means that you cannot do this test. Do remember in case there's been a rectal biopsy or a suspected perforation and you do end up doing this test there's a very high chance of the barium leaking into the peritonal cavity and mortality rates for barium peritonitis are as high as 50%. So in the past we used to use dulcolex and dimole which was absolutely terrible and had very poor bowel cleansing and we used to really struggle to get the barium up to the terminal ilium and the IC junction. But now with the use of peg lac we have very good intestinal cleansing. So what we do in our institute is we do not use the entire sachet of peg lac we use half of this. You mix it in about a liter of water and make the patient start drinking this early in the morning around 6.37 usually defecation is initiated within about 30 to 45 minutes and the patient might have five to six loose tools and might get a little exhausted by the time his bowels get empty. So it's not a bad idea also for them to just maybe sip some lime juice or a cup of tea with some sugar so that they don't feel too dehydrated. Once they finish and they feel that the large bowel has cleared they can then come to the department. So the patient will lie down in a position to do a digital rectal examination and we pass a little tube connected to the barium can and the can's height for the enema of course should not be more than three feet and we slowly release it at a very slow speed if it is too fast there's a chance that that patient might release the barium on the table and be an absolute mess. So release it slowly into the rectum and initiate a comfortable conversation with the patient so that the patient is distracted and the barium continues to enter the large bowel as you feel on fluoroscopy on IITV that it has reached the rectum and is moving towards the splenic flexure you can turn the patient around and put the patient out right side down so that the barium from the splenic flexure can move downwards to the transverse colon up to the hepatic flexure and once that happens not a bad idea to make the patient supine and make head high so that the barium then moves towards the cecum. If the icy junction is lax you might also get barium entering the terminal limb. Once you see that you can start taking pictures of the single contrast study so the standard pictures would be on a 1417 you might take supine, a prone rectum lateral to see the pre-sacral space and of course both obliques right and left as soon as these set of images are taken and viewed you can ask the patient either to pass out the barium by removing the tube and sending him to the restroom or else you can actually get the barium can down and see that the barium comes back into the can which will of course later dispose. If you feel more than half or almost half of that barium that you had put inside has come out that's good enough because we do need some barium inside and now you will be passing air through a BP cuff instrument which is attached to the tube that is passed again into the anal canal and you start insufferating air keeping the patient calm not going too fast but just at enough speed to get good distention. You will take one check film once of the rectum or the descending colon to see that there is enough air seen and the entire colon should get distended right from the rectum to the cecum. This is almost the end of the procedure so now the patient should be told to keep the air in not to release the air and quickly again start taking pictures. See the colon on IITV look for narrowing strictures polyps diverticuli concentrate on that areas use compression images also to get a complete study. After having viewed the entire set of images you can ask the patient to now pass out whatever barium is was there inside and take a post evacuation film that ends the barium study. We will now look at the common pathologies that we see on this examination. So here's our first case we can see a single contrast on the left side and you can see that the entire colon has been nicely filled up with the barium however if you look carefully and we zoomed this image on the right side along the sigmoid colon you can see an almost out pouching this was in fact an old diverticular perforation and a barium enema was asked for in this patient and not only is that perforation important but you want to see the sigmoid colon sometimes on CT it might be little difficult to know whether it's just inflammatory changes because of diverticulitis or whether it's a tumor. So you will sometimes need a barium enema here and if you can see the images taken in an oblique position you can actually have a look at the mucosal irregularity you're seeing along the sigmoid colon as well as tiny diverticulitis but this irregularity is important because this tells us that we're dealing with the neoplastic lesion. And here is our next case again a double contrast study with the large ball completely opacified with the barium and the air that's the double contrast and what we can see is a short segment stricture seen in the mid-transverse colon you can almost see an apple-coring like effect with shouldering on either side and this happened to be again a neoplastic lesion. Iliocecl coccyx was seen so commonly in the 80s and 90s and early 2000s but we don't see it so commonly anymore and of course there are a couple of varieties you would see the ulcerative type as well as the hypertrophic type but this is the common picture that we see we see terminal isle stricture with the disease process involving the ic junction as we're seeing an enlarged cecum which has been pulled up because of fibrosis and you see terminal isle dilatation just proximal to the stricture this is ic coccyx and of course CT will show you concentric wall thickening usually with involvement of the ic junction but we will need histopath diagnosis almost always and more commonly abdominal coccyx is seen much better on ultrasound and CT in the form of abdominal nodes as well as omental thickening which can also be biopsy to give us a tissue diagnosis. And here is our next case this is of course a single contrast study as you can see and you can see a very subtle mucosal regulatory across the entire colon you can also observe the loss of hostile folds please understand that hostile folds may be absent in the descending colon but if you see absent hostile folds in the transverse colon as well as the ascending colon you do know that this is a disease process it's a classic case of ulcerative colitis you see this magnified view on the next image and you can see a classic mucosal irregularity we of course follow up ulcerative colitis not so much on barium enema but more with colonoscopy now we have another very uncommon disease which is usually tough to diagnose on barium enema but you can see here a little bizarre pattern areas of stricture formation areas of ulceration loss of hostile fold sometimes skip lesions so this is Crohn's disease and you can differentiate it from ulcerative colitis more often than not but ultrasound as well as CT scans especially when you are trying to diagnose fistula is much much more effective and sensitive rather than barium enemas and here's another beautiful case and you can see a filling defect which is seen on the single contrast study with a pedunculated lesion seen on double contrast study and this is a classic example of a pedunculated polyp you can catch these very easily on barium enema but of course CT colonography as well as regular colonoscopy is much much superior compared to barium enema and we come to our last case once again you can see a single contrast study in an lobally position again you can see a short segment irregular lesion which is actually a stricture which is formed because of a neoplastic growth in the wall of the sigmoid colon so these are the common conditions that you can see on barium enema you can catch neoplasms we can catch strictures you can see iliocecal cox and although you can catch these conditions quite accurately in today's imaging scenario they are just much much more better investigative tools available for us to diagnose without having the cumbersome barium enema procedure to be done so you have ultrasound you have CT and of course also MRI but these modalities with the newer sequences and dynamic imaging have actually pushed barium enema to the background and hence barium enemas are now only used in certain conditions in certain institutes and it is not an everyday procedure that used to be done almost 20 30 years ago