BARIUM IMAGING

DR. ROOPAK KUMAR PANDA

1ST YEAR RESIDENT,
DEPT. OF RADIODIAGNOSIS
MKCG MCH, BERHAMPUR
 WHAT IS BARIUM?
Barium is a soft, metallic element, normally present in nature as
• Barium carbonate (BaCO3)
• Barium sulphate (BaSO4)

WHY BARIUM SULPHATE IS USED AS A CONTRAST

MEDIA?
• Radiopaque
• Non absorbable/ non toxic
• Insoluble in water & lipid
• Inert to tissues
• Can be used for double contrast study as it coats the mucosa in
thin layer thus allows introduction of 2nd contrast agent without
significant degradation
 PREPARATION
• Barium sulphate is obtained from mines & the
impurities are removed by chemical precipitation
• Mined barium sulphate is reduced to barium
sulphide(soluble)
• Barium sulphide + sodium carbonatebarium
carbonate (poisonous)
• Barium carbonate + sulphuric acid insoluble
barium sulphate
• Average particle size = 0.3-12 micrometre
 DILUTION
• WEIGHT BY WEIGHT- W/W SUSPENSION
e.g. 30% w/w suspension = 30 gm BaSO4+70gm
water
• WEIGHT BY VOLUME - W/V SUSPENSION
e.g. 30% w/v suspension = 30gm BaSO4 added
to water to make 100ml suspension
 MIXING
• High speed & high shear mixer is used to
ensure mixing of BaSO4 particles & evenly
mixing of particles into suspension
• Suspension should be mixed for atleast 15 min
to ensure stability
 BARIUM FORMULATIONS
• MICROBAR PASTE
High viscosity & high density ; used for pharynx & oesophagus

• MICROBAR SUSPENSION
Moderate viscosity & density; used for stomach, small
intestine & oesophagus

• MICROBAR HIGH DENSITY SUSPENSION

High density & low viscosity; used for double contrast study
of oesophagus, stomach & duodenum
 COMMERCIALLY AVAILABLE BARIUM
SULPHATE
PASTE :-
• Can be made into suspension by adding water
• Mainly designed for studies of oesophagus &
rectum
• Most pastes are thick containing >100% BaSO4 w/v
POWDER :-
• Made into suspension by adding water
• 81-98% w/w - upper GIT
• 92-99% w/w - colon
SUSPENSIONS :-
• Most widely used preparation
• Contain 13 to 210% BaSO4 w/v
• Low density suspensions for GIT CT (0.1 to 5%
BaSO4 w/v)
 CHARACTERISTICS
• SETTLING
Carboxy methyl cellulose added to prevent
settling; rate of settling should be <1/10 @ the
end of 3 hrs
• DENSITY
achieved by using required weight of BaSO4
• STABILITY
By adding suspending agents like gum acacia,
carboxy methyl cellulose
• FLOCCULATION
antacids like sodium citrate, magnesium hydroxide
are used to neutralize gastric acid to prevent
flocculation
• PRESERVATIVES
sodium metabisulphate is used to prevent fungal
growth
• ANTIFOAMING AGENTS
methyl polysiloxone added to prevent formation of
air bubbles which mimic polyps
• COLOURING AGENT
Erythrocin

• SWEETENING AGENT
Saccharine or fruit essences
 PROPERTIES OF AN IDEAL BARIUM
PREPARATION
• high density for optimum study
• stable suspension which doesn’t settle
• shouldn’t flocculate with secretions
• low melting characteristics
• should give good & stable mucosal coating
 ADVERSE EFFECTS
• Chemical peritonitis
• Extravasation into bronchial tree, urinary tract &
other body cavities
• Barium inspissation in colonic obstruction
forming hard stones
• Intravascular embolism
• Barium encephalopathy
• Long standing barium deposits are carcinogenic
 BARIUM STUDIES
• Barium swallow
• Barium meal
• Barium meal follow through
• Enteroclysis
• Barium enema
 BARIUM SWALLOW
• It is a dedicated test of pharynx & oesophagus
• It may be performed as a single or double
contrast study
• It is useful to evaluate the entire pathway
from lips to fundus of the stomach
 Patient preparation in barium swallow

Overnight fasting, avoid smoking/chewing gums

to decrease the secretions in oral cavity &
pharynx
 Indications of barium swallow
• Dysphagia
• GERD
• Assessment of hiatus hernia
• Generalized epigastric pain
• Globus hystericus
• Persistent vomiting
• Assessment of fistula
• Inability to pass the endoscope in upper GI
endoscopy
 Contraindications of barium swallow
• Suspected perforation.
• Post-op assessment for leak.
Water soluble contrast agent to be used

Complications of barium swallow

• Leakage of barium from an unsuspected perforation.
• Aspiration.
 Procedure of barium swallow
Evaluation of pharynx
• Scout film is taken to r/o any fb, abscess or fistula
• The examination is performed in upright lateral position
after swallowing high density barium
• Right lateral view should be obtained initially to r/o any
aspiration or penetration, then frontal view is taken
• For optimal evaluation, dynamic video fluoroscopy
should simultaneously be done
• Spots are obtained quickly during suspended respiration
& under phonation to distend the hypopharynx
 Evaluation of oesophagus
Single contrast
– Multiple mouthfuls of 80% w/v barium
suspension are given
– Films are taken in erect position- RAO, frontal &
lateral views when the oesophagus is well
distended
Double contrast
– High density low viscosity barium is used
– Patient swallows 15-20 ml barium
– The effervescent powder is given with another
mouthful of barium
– Films are taken in RAO, frontal & lateral views
 Views of barium swallow
• On the frontal
view, piriform
fossae are
outlined by
barium and base
of tongue &
epiglottis appear
as filling defects
in the midline
• The cervical
oesophagus lies
on the ventral
surface of the
cervical spine
On the lateral view, the
base of tongue,
vallecula & epiglottis
are seen from the side.
A posterior indentation
caused by contraction
of cricopharyngeus
indicates the
commencement of
cervical oesophagus
The thoracic
oesophagus is
best
demonstrated in
the right anterior
oblique view
 BARIUM MEAL (for oesophagus, stomach & 1st part of bowel)
Patient Preparation

• Nil orally for 6 hrs

• No smoking as it may interfere with
coating of mucosa
Indications of barium meal
• Failed upper GI endoscopy
• Dyspepsia
• Weight loss
• Upper abdominal mass
• GI h’ge (or unexplained iron deficiency anaemia)
• Partial obstruction
• Assessment of site of perforation(essential to use a
water soluble contrast media e.g. gastrografin or
LOCM)
Contraindications of barium meal
• Complete large bowel obstruction
 Procedure of barium meal
Single contrast method
 Low density barium suspension is used(80-100% w/v)
 Water soluble contrast media are indicated when gastro-
duodenal perforation is suspected
Conventional single contrast study
• Done at 80-90 kV
• In erect position fluoroscopy is done to see diaphragm to
detect any pathology. Stomach & intestine are seen for air
fluid levels
• 10-15ml of 80-100% w/v barium is given & oesophagus is
visualized under fluoroscopy
• The table is made horizontal & pt is asked to lie down & rotate
in clockwise direction (viewing from foot end of pt). A good
coating of stomach is thus obtained & radiography is done to
show the mucosal relief
• The pt is kept supine & 100-250 ml barium is
given. Then the standard views are taken
• Disadvantage of conventional single contrast
study is that small mucosal lesions like polyps or
early carcinoma may not be demonstrated
High kv technique
• 30% w/v barium sulphate is used
• Radiography done at 120-130 kV
• This permits the visualization through the
barium column so that lesions won’t be
drowned by low density barium
Double contrast method
 High density, low viscosity (250% w/v) barium suspension is
used as it produces best mucosal coating & hence detail
• Pt swallows a gas producing agent & then drinks 100-150 ml
of barium while lying on the left side, supported by elbow.
This position prevents the barium from reaching the
duodenum too quickly & obscuring the greater curve of
stomach
• Pt then lies supine & slightly on the right side, to bring the
barium up against the gastro-oesophageal junction. This
manoeuvre is screened to check for reflux, which may be
revealed by asking the pt to cough or to swallow water in this
position. The significance of reflux produced by tipping the
pt’s head down is debatable as this is not a physiological
position. If reflux is seen, spot films are taken to record the
level to which it ascends
• An i.v inj of smooth muscle relaxant is given
(buscopan 20mg or glucagon 0.3mg)
• The pt then rolls on to the right side & then
quickly over in a complete circle to finish in
RAO position. This rolling is done to coat the
gastric mucosa with barium. Good coating has
been achieved if the area gastricae in the
antrum are visible
 Aftercare
• The pt should be warned that his bowel
motions will be white for few days & may be
difficult to flush away
• The pt should be advised to eat & drink
normally to avoid barium impaction. Laxatives
may be taken if required
• The pt must not leave the dept. until any
blurring of vision produced by buscopan has
resolved
 Complications of barium meal
• Leakage of barium from an unsuspected
perforation
• Aspiration of stomach contents due to
buscopan
• A partial large bowel obstruction may get
converted into a complete obstruction by
impaction of barium
• Barium appendicitis, if barium impacts in the
appendix(very rare)
 BARIUM MEAL FOLLOW THROUGH
(for small intestine)
Patient preparation
Metoclorpramide 20mg orally may be given before or
during the examination
Indications
• Diarrhoea
• Anaemia/ GI bleeding
• Partial obstruction
• Malabsorption
• Abdominal mass
 Contraindications
• Complete obstruction
• Suspected perforation
Procedure
• 100% w/v 300ml barium given at 10-15 min intervals. Some
radiologists give the full 300ml at once.
• The transit time through the small bowel has been shown
to be reduced by adding 10ml of gastrograffin to the barium
• 3-4ml/kg is a suitable volume in children
• If barium is contraindicated, non ionic water soluble
solutions are satisfactory alternative
• The aim is to deliver a single column of barium into
the small bowel. This is achieved by laying the pt on
the right side after ingesting the barium.
Metoclopramide enhances the rate of gastric
emptying. If the transit time through small bowel is
slow, an osmotic water soluble contrast agent is
added.
• If a follow through examination is combined with a
barium meal, glucagon is better than buscopan for
the duodenal cap view as it has a short duration of
action & doesn’t interfere with the small bowel
transit time
• Prone PA films of the abdomen are taken every 15-20 min
during the first hour & then every 20-30 min until the colon is
reached. The prone position is used as the pressure on the
abdomen helps to separate the small bowel loops
• Spot films of the terminal ileum are taken in supine position
using a compression pad
• Additional films
 To separate the small bowel loops
1. Compression with fluoroscopy
2. Obliques
3. With x-ray tube angled into the pelvis
4. With pt’s head tilted down
 to demonstrate any diverticula- erect film- this position will
reveal any fluid levels caused by contrast medium retained
within the diverticula
Aftercare & complications
same as barium meal
 ENTEROCLYSIS
• Radiological study of small bowel from jejunum to
ileocaecal junction by intubation of jejunum &
instillation of contrast through the tube
Patient preparation
• Liquid diet for a full day before examination &
overnight fasting
• 2-4 tab of dulcolax in the previous evening
• No rectal enema
• 4 hr fasting, sedation for infants
 Indications of enteroclysis
• Partial small bowel obstruction
• Crhon’s disease (to know its extent)
• Suspected meckel’s diverticulum
• Malabsorption
• Tumors of small intestine
• Occult GI bleeding
 Contraindications of enteroclysis
• Complete colonic obstruction
• Suspected perforation
• Massive small bowel dilatation
• Duodenal obstruction & gastrojejunostomy
• Paralytic ileus
Complications of enteroclysis
• Aspiration
• Bowel perforation
 Procedure of enteroclysis
• Pt sits with the chair to the wall/supine/right lateral
• 2-3 cc of 2% xylocaine jelly into nostril
• ensure no nasal block/mass
• Neck hyperextended
• Bilbao-Dotter tube without guide wire introduced into nostril, advanced
with swallowing action till it reaches stomach
• Barium introduced directly into the small intestine, challenges its
distensibility making it easier to identify morphological abnormalities
• 800-1200ml of 20% w/v barium introduced using a pump @ 75ml/min
• Tip of the catheter placed at DJ flexure or preferably 5-10cmdistally into
jejunum
• Neck flexed, guide wire 5cm proximal to tube tip. Tube
advanced into duodenal cap
• Pt turns supine with rt side up. Tube advanced with guide
wire 2-3cm proximal to DJ flexure. Tube should be 4-5cm
distal to treitz ligament

Single contrast
• done in pts with high grade partial small bowel obstruction
• Barium suspension 20% w/v injected @75-120m/min
• Avg time to reach ileocaecal junction is 15min
• Follow head of barium column on fluoroscopy
• One spot film for jejunal loops & one for entire small bowel
• With high kvp technique (120-140 kv)
 Double contrast
• 150-500ml of high density barium injected @80-100ml/min
• Head of barium column is visualized under fluoroscopy
• 0.5% suspension of carboxy methyl cellulose injected @75-
120ml/min
• IC junction films are taken when head of barium column
reaches there or even after the pt defecates
• Air contrast shows detailed mucosal changes like small ulcers
• Intestine is not distended, barium is not diluted
• Sinuses, fistulae & stenosis may be overlooked
• CMC is used because- it propels barium, distends small bowel,
has low diffusibility with barium, promotes evacuation of
barium, double contrast is achieved
 CMC DOUBLE CONTRAST AIR DOUBLE CONTRAST
• Less information • More detail
• Simple procedure • Operator dependent
• less time • More time
 Filming in enteroclysis
• Upper abdomen- when jejunum is seen in
double contrast
• Full abdomen- when entire small bowel is in
double contrast
• Ileocaecal spots in single & double contrast
• Spot films as required
• Filming should be completed within 20-25 min
for good double contrast
 BARIUM ENEMA
• Radiographic study of large bowel by
administration of contrast through rectum
Preparation
• Tablet dulcolax.. 2 tab HS for 2days
• Tap water enema previous night & 7am on the
day of examination
• Low residue diet for 2 days
• Empty stomach on the day of examination
 Indications Contraindications
• Rectal bleeding • Colitis
• h/o carcinoma or polyp • Recent rectal biopsy
• Family h/o colorectal • Paralytic ileus
carcinoma • Toxic megacolon
• Evaluation of • Difficulty in passing the
sinus/fistula tube
• Reduction of
intussuception
• Severe diverticulosis,
polyposis
• obstruction
Procedure of barium enema
 Double contrast technique
• 75-95% high density barium is used. Thin enough to
flow quickly through the colon & to wash feces &
mucus into the barium pool. Thick enough to coat the
colon without flocculating
• Barium is instilled to the mid transverse colon while
the pt lies in prone position. The pt must be turned to
the left anterior oblique or trendelenburg’s position to
aid barium passage
• Once the barium column reaches the mid transverse
colon level, the enema bag is lowered to remove
barium from the rectum leaving only a thin layer of
barium on the wall of the colon
• Colon is then filled with air to provide a
detailed view of inner surface of colon, making
it easier to see strictures, diverticula or
inflammation
• The colon can be distended with CO2 rather
than room air as CO2 is rapidly reabsorbed
from the colon, which results in less
discomfort during & after the examination
Single contrast barium enema
Double contrast barium enema
Thank you