In this presentation, we’re going to cover the patient preparation considerations for
the Barium Enema examination, outline the equipment and supplies needed to perform a
BE, preparation of the exam room, enema tip insertion distinguish some differences in
procedure between the single and double-contrast enema.
For patient prep, the large intestine must be completely emptied of all contents because
retained fecal matter can simulate small masses or false-positive readings radiographically.
A restricted diet and bowel cleansing regimen are standard for healthy patients. Preparation
for patients with severe diarrhea, gross bleeding, or obstruction is limited. Bowel cleansing
methods include complete intestinal cleansing kits, GI lavage preparations, and/or a cleansing
enema
BE apparatus consists of disposable soft plastic enema tips and enema bags are commercially
available in different sizes. Smaller enema tips may be necessary for patients with strictures,
fissures, inflamed hemorrhoids, or other anal abnormalities. Retention tips have balloon
cuff at end. The balloon is manually inflated with air after insertion to aid in retention
of enema. For safety, the balloon is inflated using fluoroscopy just before examination,
and should be supervised by a radiologist. There is potential for intestinal wall damage
if inserted or inflated improperly. A special tip is required for double-contrast to administer
the air, which can be instilled via sphygmomanometer bulb. We’ll be handling several types of
enema bags, balloons and other apparatus in lab. Enema bags have 3-quart (3000-mL) capacity,
and a filter prevents passage of unmixed lumps of barium. The tubing is approximately 6 feet
long with flow control clamp or clip. Smaller bags (500 mL) with short, large-diameter tubing
are available for double-contrast procedures. It’s best to follow manufacturer’s instructions
for barium suspension preparation.
High-density barium used for double-contrast. Temperature of suspension should be lower
than body temperature between 85° to 90° F, otherwise it can cause injury if too warm.
Higher temperatures are also uncomfortable for patient and decrease retention
Patient cooperation is key to success. Explain the patient’s role and examination required.
Instruct patient on ways to minimize discomfort during filling such as relax the abdomen,
take deep breaths, and communicate about cramping so that filling may be slowed or stopped.
It’s essential to allay fears and embarrassment. Encourage retention of barium and allow questions
and provide answers as within scope of practice or refer to physician. Make sure to provide
adequate draping for increased patient comfort. Be aware of patient’s strength, condition,
and age, and remember that the bowel prep may cause weakness. Elderly patients may require
extra care and attention. Call the patient’s attention to call button in restroom in case
assistance is needed. Respect patient privacy, but inquire frequently on patient’s condition.
Patient prep typically includes the following: Light evening meal prior to exam
Bowel-cleansing cathartics NPO after midnight
(8 hours minimum) No gum chewing
No smoking Enema morning of exam
Several factors should be considered for room preparation:
Fluoroscopy room setup Table horizontal
Cassettes available Contrast media prepared
Towels and linen available
A single-use, closed-system kit is typically used. Make sure cold versus room temperature
water is added. Mix well before use. Glucagon injection may be administered, and is optional
in case spasm occurs. Topical anesthetic may also be added to contrast media. Have your
enema tip prepared.
Special Supplies for Colostomy may be used. A colostomy postoperative kit and/or colostomy
tip may be required when introducing contrast into an ostomy. This may be used in combination
with a traditional kit, or it may be used independently. The protocol will vary per
patient and the radiologist should determine the routine for these specialized exams.
For Enema Tip Insertion, Instruct patient to turn onto left side. Roll them forward
35 to 40 degrees and rest on flexed right knee above and in front of left knee. This
is called the Sims’ position, and it relaxes abdominal muscles, decreases abdominal pressure,
and aids in relaxation of anal sphincter. Adjust IV pole height so that bag is no higher
than 24 inches (61 cm) above level of anus. Expose anal region only. Run barium into basin
to remove air from tubing. Lubricate enema tip. Instruct patient to take deep breaths.
Insert tip slowly, steadily, and gently during expiration of deep breath. Direct anteriorly
1 to 1½ inches (2.5 to 3.8 cm), then slightly superiorly. The total distance no more than
4 inches (10 cm). Never force insertion. Ask patient to assist if resistance is met and
if patient is capable
After tip is inserted, hold in place while patient turns to supine or prone position.
The retention cuff may be inflated at this time. Free the tubing of compression to ensure
free flow. For a Single-Contrast BE, introduce patient to radiologist. When the radiologist
requests, release clip to allow barium to flow. Flow is suspended periodically to reduce
cramping and defecation impulse.
Filling of the large intestine will be viewed on fluoroscope. The technologist controls
the rate of flow. Make sure you are able to pinch the tube to slow down or stop the rate
of flow if the barium travels outside the field of view of the fluoroscope. The tube
can be opened again once the field of view pans to the region the contrast is leading.
For single-contrast studies, the Radiologist instructs patient to rotate to visualize all
portions of bowel and takes spot radiographs, as needed. Subsequent overhead radiographs
will also be requested if needed. After all images acquired, remove enema tip and allow
as much barium as possible to drain back into the bag while the patient is on the exam table.
Deflate the retention balloon, and assist the patient to restroom. Instruct them to
expel as much barium as possible. Provide bedpan for weakened patients who are unable
to ambulate to the restroom. After patient has evacuated, another radiograph is taken
to check mucosa. If evacuation is inadequate, the patient may be given a hot beverage for
stimulation. Repeat postevacuation image, as requested. There are two methods for double-contrast
enemas… the Closed system method and the Welin method. The Closed system method does
not require removal and reinsertion of enema tip. Barium is introduced and removed via
bag position and air is introduced by bag insertion or manual compression of the sphygmomanometer
bulb. The patient remains on table for entire procedure. The Welin method is recommended
for early detection of small lesions. For this method, Barium is introduced to left
colic flexure, then the tip removed and patient evacuates. The tip is then reinserted, barium
is introduced to sigmoid, and air instilled. The patient’s position is altered to coat
mucosa, and spot radiographs taken as needed.