Double Contrast Barium Enema
 Digital Technique & No Overhead Film Technique

In this ‘No Overhead Film Technique’, the entire study is imaged by the Radiologist if the fluoroscopy room used does not have overhead film capability.  Images are taken by the radiologist to cover the entire colon.

Principles of this technique:

  • The entire colon to be imaged in double contrast phase.

  • There must be at least a minimum of two images per segment of the colon.

  • The referring physician, especially gastroenterologists and GI surgeons, require ‘Overhead survey views” of the entire colon to get a better perspective of the colonic anatomy and of the disease segments.

  • Therefore DO NOT ONLY take magnified views (12, 9 or 6” FOV) views of the colon.

  • Where necessary, give antispasmodics when there is colonic spasm. (See the Medication section for dosage and contraindications)

This technique consists of four phases:

  1. The Rectal Tube Placement Phase

  2. The Colon Filling Phase

  3. The Colon Insufflation Phase

  4. The Imaging Phase

The Rectal Tube Placement Phase
Perform a limited rectal examination:
  • To ensure no rectal lesion
  • To facilitate easy and comfortable placement of rectal tube
  • Use 2 % Xylocaine gel
  • Gentle hyperventilation and Valsalva maneuver will assist in quick tube placement
Inflating the rectal balloon:

Using fluoroscopy:

  • Inflate balloon gently with supplied air insufflators.
  • Maximum inflation should be 80ccs of air (one puff)
  • Do not over inflate

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The Colon Filling Phase with Barium
Left Lateral Position:

With the barium bag about 3 feet above the table top, let barium gently flow into the rectum & sigmoid colon. You can place patient in slight Trendelenburg position.
Prone position:

Once the barium has reached the mid-transverse colon, the patient is turned PRONE. Let the barium bag down on the floor with the tube open. Ask the patient to ‘bear down’ (i.e. push the barium out into the bag). This will advance the transverse colon barium into the right colon, and clear the rectal and sigmoid of barium.

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The Colon Insufflation Phase
Right Lateral Position:

The colon is then distended with either air or carbon dioxide using a CO2 pump.
Upright Position:

Once barium reaches the ascending colon, bring the patient UPRIGHT to push barium into the cecum.
CO2 Infusion:

Continue infusion throughout these maneuvers until the colon is well distended.

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The Imaging Phase
Upright Position:
Drain the barium from rectum by opening the barium bag. Re-clamp the tube and wiith the entire colon well distended in double contrast take the following views ALL on 9” FOV.
Rectum (Lateral View):

Turn the patient in the left lateral position.  Use 9" FOV.

 
Splenic Flexure:

Turn the patient to their right for the Right Posterior Oblique view of the splenic flexure (9" FOV).
 

 
Hepatic Flexure:

Turn the patient to their left for the Left Posterior Oblique view of the hepatic flexure (9" FOV).

 

 
Supine Position:
Then bring the table and patient down in supine position and take the following views. Keep infusing the carbon dioxide if there is absorption or poor distension. Images are taken on 9” , 12 and/or 16 “ FOV (as prescribed below).
 
Lateral Rectum:

Turn the patient to Left Lateral Decubitus position and take a lateral view of the rectum with the balloon deflated. Use 9” FOV.
Left Posterior Oblique Sigmoid Views:

Turn the patient in LPO position and take multiple views with a straight or angled tube to get the best view of the sigmoid colon. Use 9” FOV.
Supine Colon Survey View:

With the patient in supine position, take a ‘colonic survey’ view using 16” FOV.
Transverse Colon View:

Using 9” FOV take at least 3 views of the transverse colon. One may have to oblique the patient or angle the tube to open the transverse colon, especially if it is redundant.

 
Right Posterior Oblique Position:
Turn the patient in right lateral decubitus position to let the air rise to the left colon. Then after a few minutes, turn the patient in RPO and take the following views of the LEFT colon.
Lateral Rectum:

Take lateral view of rectum with balloon deflated. Use 9” FOV
Right Posterior Oblique Sigmoid Views:

Turn the patient in RPO position and take multiple views with a straight or angled tube to get the best view of the sigmoid colon. Use 9” FOV.
Descending Colon:

Using 12 or 16 “ FOV take a survey view of the left colon including the splenic flexure.

 
Left Posterior Oblique Position:
Turn the patient in left lateral decubitus position and with a slight Trendelenburg to let the air rise to the right colon. Then after a few minutes, turn the patient in LPO and take the following views of the RIGHT colon.
Right Colon Survey View:

Take an image using 16” FOV to get a survey view of the right colon.

Hepatic Flexure:

Using 9” FOV take views of the hepatic flexure.
Ascending Colon:

Using 9” FOV take views of the ascending colon.
Cecum:

Place the patient supine and take a view of the cecum and terminal ileum using 9” FOV.

Tips for Cecum Views:
You may have to place the patient prone, right or left lateral and slight Trendelenburg to drain the barium out of cecum in order to get double contrast views.

 
Upright Final Images
Bring the patient upright and take the following views using both 9” and 16” FOV.
Colon Survey View:

Using 16” FOV take the following views:

- UPRIGHT view of the entire colon
- LPO view of the RIGHT colon
- RPO view of the LEFT colon
Splenic Flexure:

Turn the patient to their right for a Right Posterior Oblique view of the splenic flexure (9” FOV) .
Hepatic Flexure:

Turn patient to their left for Left Posterior Oblique views of the hepatic flexure (9”FOV).
Rectum (Lateral View):

Turn the patient in Left Lateral position. Use 9” FOV. DEFLATE the balloon to get the entire rectum in double contrast.

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