• Single contrast barium enema uses barium to highlight your large intestine.
• Double contrast barium enema uses barium, but also delivers air into the colon to expand it. This allows for even better images.

DCBE is more sensitive than SCBE for detecting colorectal lesions. However, elderly and debilitated patients may be difficult to examine by the double-contrast method because of the need for more frequent movements with double contrast study. Also, detection of small colonic polyps under 1 cm in size is less crucial in elderly patients

Discuss the technique of barium enema?

• Bowel prep as for colonoscopy
• The patient lay down on back (or left lat position) on the x-ray table
• An enema tube is inserted in the rectum.
• Routine distention of the retention balloon at the tip of the enema tube is not necessary. Encouraging patients to retain the air and barium is usually sufficient. Retention balloons are inflated only in patients who are expelling air and barium from the anal canal and only after a normal distal rectum is demonstrated fluoroscopically.
• The enema tube is connected to a bag that holds the liquid barium sulphate (fine, white, odourless and non-toxic).
• The patient is turned in various positions to facilitate passage of the barium through the colon.
• A large enough volume of barium is required to coat the colon. If about one-third of the luminal diameter of distended colon is filled with barium, then enough barium has been instilled to coat the colon.
• Room air (or CO2) is gently and intermittently insufflated into the colon for DCBE
• For DCBE, the patient may be rolled 360° anywhere from one to four times, usually in partial turns. If a patient is elderly or feeble and has difficulty turning, the study should be converted to a SCBE examination. Most patients can accomplish two to three complete turns on the fluoroscopy table, which is sufficient for adequate colonic coating.
• The enema tube tip may be removed after an adequate amount of air and barium has reached the right side of the colon.
• A barium enema and the process of taking X-ray images of the bowel takes around 15 to 30 minutes to complete.

Discuss the efficacy of barium enema?
In experienced hands, the detection of cancer using DCBE techniques in symptomatic patients shows a sensitivity of 90.2% and specificity of 99.5% (Connolly et al 2002). Large polyp detection is also good with a sensitivity of 82.7% compared to colonoscopy which has detection rates of 89.9% (OTT 2000)
Discuss the complications of barium enema?
Bowel perforation 0.02-0.04% (Williams SR 1991)
Abdominal discomfort and bloating

Ref
Barium enema video
Williams SM 1991

• The contrast is administered at a controlled rate directly in the small bowel bypassing the regulatory action of pylorus.
• The entire small bowel is demonstrated in a distended state allowing better diagnosis. As a result of the dilatation, mild strictures, small sinus tracts and fistulas, and minimal extrinsic compressions can be visualized besides better delineation of skip lesions and the proximal and distal extent of diffuse diseases.
• Once the tube is in place, the examination can be completed in 15-30 minutes, thus reducing patient waiting time.

How is enteroclysis performed?

• Bowel prep is usually needed. This is to ensure that the right colon is empty and the barium can flow easily through the distal ileum and into the caecum.
• A tube is inserted through the nose to reach at least the fourth part of duodenum (this is done radiologically and prokinetic agents may be used to help propel the tube in small bowel)
• The barium suspension can be administered by hand from a syringe or by gravity flow from an enema bag.
• Enteroclysis may be:
  • the single-contrast method with a barium suspension alone,
  • the double-contrast method using an infusion of air, water, or methyl cellulose following the barium infusion to distend the small bowel. This improves sensitivity further.
• A flow rate of 75 ml/min seems ideal for most examinations, and small bowel transit will be accomplished in 5 – 10 minutes.
• During the infusion of the barium suspension, the examiner performs frequent, intermittent fluoroscopic examination of the small bowel.

Discuss the limitations of SBFT and enteroclysis?

• Barium examinations are not very sensitive and specific for small bowel diseases and result in a considerable number of false negative results.
• A barium examination may also overlook extramural complications such as fistulas, sinuses, and extra intestinal abscesses.
• Radiation exposure

• NPO for 6 hours before the examination
• The patient is asked to drink barium.
• The x-ray table is rotated in various positions to obtain adequate views
• It usually takes 10-20 minutes

Discuss the indications for barium swallow?
The primary indication is dysphagia. However an endoscopy is the preferred test
Discuss the barium swallow for achalasia?
Barium Swallow in achalasia shows:

• Dilated oesophagus that terminates in a beak-like narrowing caused by the persistently contracted LOS
• The diagnostic accuracy of barium swallow for achalasia is approximately 95 percent

Discuss the role of barium swallow as the first investigation in the diagnosis of dysphagia?
Patients with proximal dysphagia may have a pharyngeal pouch, post cricoid web etc which increase the risk of perforation on endoscopy. Barium swallow may be considered as an initial investigation for investigation of proximal dysphagia; however an endoscopy is safe as an initial test in experienced hands.
Discuss barium swallow for Schatzki ring?
Barium swallow is more sensitive than OGD. Endoscopy failed to show 1/3 of Schatzki rings demonstrated on barium swallow in one study. However, endoscopy is needed to confirm the diagnosis and exclude any other diagnosis once Schatzki ring is picked up on barium swallow.