• This exam is done using the nasal route and a 12F Herlinger duodenal tube with an end hole and a curved stiff wire. One can use glide wires in different cases.  A 8F Enteriflex Feeding tube may also be used.
   
• Patients should receive instruction sheets explaining the procedure and some of them may require sedation. With the 8F Enteriflex tube, no sedation is required.  Do not hesitate to use Ativan sublingually or Valium IV since surgeons and gastroenterologists should be aware that radiologists often use sedation liberally.
   
• This exam is done using the nasal or the oral route.
   
• For intubations of the small bowel various small bowel enteroclysis tubes have been used (see the TUBES subsection - Equipment)
   
  • 12F Herlinger or 14F Maglinte duodenal tube;
    • With an end/side holes and a curved stiff wire.
    • These tubes are useful in the presence of small bowel obstruction for subsequent decompression
       
  • Smaller gauge catheters
    • Are being used more frequently
    • 8F Enteriflex Feeding
    • 8F Fredrick Miller tube feeding tube
    • Easy, fast intubations
       
• Patients Preparation:
   
  • Should receive instruction sheets explaining the procedure.
  • Colon cleansing (two Dulcolax tabs night before)
  • With the 8F catheters no sedation is required.
  • Some may require sedation.
    • Can use Ativan sublingually
    • Rarely Diazemuls IV is given if patient has had uncomfortable past experience.
       

Technique

• Spray the oropharnyx and nasal passages with Lidocaine spray and use Xylocaine gel on a Q-Tip to anaesthetize the nasal passage.
   
• Start an IV using a 22 gauge angiocatheter and give 10 mgm Maxeran IV (to facilitate intubation) and/or Valium.
   
• Refer to “Clinical Radiology of Small Bowel” by Dr. D. Maglinte and H. Herlinger regarding the technique and overcoming problems of intubation.
  
  Polibar (100% w/v) diluted to 80% w/v or 50% w/v is used
  For normal small bowel use between 250-500 cc of barium. For patients with an ileostomy or ileo-anal pouch use 120-180 cc of barium.
  
  Methylcellulose
  About 1.5-2 litres of 0.5% of methylcellulose.
   

Important Points

• Barium is pumped at 110 cc/min and methylcellulose is infused with a ‘dialysis’ pump at a rate between 75 and 140 cc/min.
   
• The tip of the Herlinger tube should always be in the proximal jejunum.
   
• Should use Reglan (Maxeran) to speed up intubation into the jejunum.

Radiographs

• All radiographs should be taken in both single and double contrast phases. All single and double contrast films are done on 105 mm spot films. At least one 14 x 14 prone and supine radiograph and spot 8 x 10 radiographs with compression of the terminal ileum are done. Selected spot 10 x 12 radiographs of the proximal, mid and distal small bowel in single and double contrast are also taken.
   
• A Trendelenberg position with compression of the pelvic loops can displace loops into the abdomen.
   
• Lateral view of pelvic loops is important to detect pelvic mets/radiation strictures or entero-rectal fistulas.
   
• Tube angulation (cephalad or caudal) may “displace” pelvic loops.

	Note the arrow pointing to the 8F Enteriflex tube.