Barium Enema Procedure Overview

Study Notes

Barium Enema

A procedure used to visualize the large intestine
Methods include double contrast and single contrast
Double contrast: used to visualize mucosal patterns
Single contrast: used for localizing obstructing lesions, assessing children, and reducing intussusceptions
Indications:
- Suspected large bowel pathology where colonoscopy may be preferred for tissue diagnosis.
- CT colonography is an alternative and has replaced barium enema where facilities and expertise exist
- If a tight stricture is present, only a small volume of barium is used to define the upper margin. This reduces the risk of barium impaction
Contraindications (Absolute):
- Toxic megacolon
- Pseudomembranous colitis
- Recent biopsy (rigid endoscope within 5 days, flexible endoscope within 24 hours)
Contraindications (Relative):
- Incomplete bowel preparation (can be returned later)
- Recent barium meal (7-10 days waiting period recommended)
- Patient frailty
Contrast Medium:
- Polibar 40% w/v 500 mL
- Air
Equipment:
- Disposable enema tube and pump
Patient Preparation:
- Low-residue diet for 3 days before the examination
- Fluids only the day before the examination
- Picolax (laxative) on the day before
- Diabetics first on the list on the day of the examination
Aftercare:
- Patients should not drive until Buscopan-induced vision blurring resolves (usually within 30 minutes)
- Bowel movements may be white for a few days after the procedure, but patients can eat normally and drink extra fluids to avoid barium impaction.
Antibiotic Prophylaxis:
- Not routinely required but essential for patients with specific risk factors for endocarditis:
  - Previous infective endocarditis
  - Acquired valvular heart disease (stenosis or regurgitation)
  - Valve replacement
  - Structural congenital heart disease
  - Hypertrophic cardiomyopathy

Complications (All Rare)

Cardiac arrhythmias: Induced by Buscopan or the procedure itself, this is the most common cause of death following a barium enema
Bowel perforation: Often related to rectal catheter balloon manipulation, this is the second most frequent cause of death after a barium enema
Transient bacteremia
Side effects from pharmacological agents
Intramural barium
Venous intravasation: Leading to barium pulmonary embolism (80% mortality rate)

The Instant Enema

Indications:
- Identifying or confirming the level of suspected large bowel obstruction, assessing the degree of narrowing
- Demonstrating the extent and severity of mucosal lesions in active ulcerative colitis
Contraindications:
- Toxic megacolon
- Rectal Biopsy (same contraindications as barium enema)
- Chronic ulcerative colitis: Optical colonoscopy preferred to detect dysplasia or neoplasia
- Crohn's colitis: Assessment unreliable

Contrast Medium (Instant Enema)

Water-soluble contrast (e.g., Urografin 150, Omnipaque)
Preliminary Image: Plain abdominal film to exclude toxic megacolon and perforation
Technique: Contrast medium run until it flows into obstructing lesion or dilated bowel loops; air insufflation unnecessary
Images: Obtained as needed, typically including prone, left lateral decubitus, and erect films

Air Enema

Rarely used
Indications: Demonstrating the extent of ulcerative colitis
Technique:
- Insert 14-16 F Foley catheter into rectum, inflate balloon (10-20 mL)
- Take preliminary AP film of abdomen
- Without patient movement, administer a relaxant (e.g., Buscopan), then inflate air (gentle puffs) into catheter lumen
- Take a follow-up AP film of abdomen