Small bowel study.

1. v. Siva prakash
Bsc.MIT 3nd year
Saveetha medical college
Chennai.

2.  The study called because it is performed following
barium meal.....
 For evaluating patients with suspected small bowel
abnormalities
 Small bowel – ileocaecal junction
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3. SMALL INTESTINE
 Is the longest part of
alimentary canal
 Extends from pylorus of stomach
ileocecal junction
 Length = 6 m
 Diameter = 4 – 2.5 cm.
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4.  Site :it occupies all
abdominal regions except
epigastic and
hypochondriac
region normally
 Fixation :it is stabilized by
mesentery
 Mesentery = peritoneal
fold attaching small
intestine to posterior body
wall
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5.  Anatomical
subdivisions :
 a) Duodenum
 b) Jejunum
 c) Ileum
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6. Duodenum:
 C-shaped tube
 25 cm long & width 3.75-4
cm
 Joins stomach to jejunum
 The first & shortest part of
small intestine
 The widest & most fixed part
 Curves around the head of
 pancreas
 Begins at pylorus on right
side & ends at
duodenojejunal junction on
left side
 Partially retroperitoneal
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7.  Duodenum is divided into
four parts :
a) First (superior) part
b) Second (descending) part
c) Third (horizontal) part
d) Forth (ascending) part
 First part of duodenum
 It is 5 cm long
 Lies antiero-lateral to body
of L1 vertebrae
 Most movable part
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8. Duodenum
 Second part:
 It is 8 to 10 cm long
 Descends along right sides
of L1 through L3 vertebrae
 Third part :
 It is 10 cm long
 Crosses L3 vertebra
 Fourth part of
duodenum Ascending
 It is 2.5 cm long
 Begins at left of L3 & rises
superiorly as far as superior
border of L2 and continues
with jejunum 8SIVA PRAKASH

9. JEJUNUM & ILEUM
 Jejunum begins at
duodenojejunal flexure
(L2) & ileum ends at
ileocecalJunction.
 Jejunum & ileum = 6 to 7
m
long (jejunum 2/5, ileum
3/5)
 Coils of jejunum & ileum
are suspended by
mesentery from posterior
abdominal wall & freely
movable.
 Most jejunum lies in
leftupper quadrant & most
ileum lies in right lower
quadrant
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10.  Wall of small intestine is made of the following layers :
 a) Serosa coat
 b) Muscular coat
 c) Submucosa coat
 d) Mucosa coat
 Serosa: made of peritoneum
 Muscularis: made of smooth muscle fibers arranged in
outer longitudinal & inner circular layers
 Submucosa : contains loose CT & large venous plexuses
(submucosa of duodenum contains duodenal or Brunner’s
glands)
 Mucosa composed of a layer of epithelium, lamina propria
& muscularis mucosa (Plicae circulares numerous in
jejunum, Peyer’spatches present in ileum)
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12. Barium Techniques
 Indirect
 Small bowel follow
through....
 Dedicated small bowel
follow through...
 Peroral pneumocolon.....
 Retrograde small bowel
....
 Direct
 Enteroclysis...
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13. Indication
 Abdominal pain and diarrhoea
 Small bowel obstruction
 Crohn’s disease
 Nasogastric tube/failed intubation
 Malabsorption
 Anaemia/gastrointestinal bleeding
 Abdominal mass
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14. Contraindications
 Colonic obstruction
 Suspected perforation
 Paralytic ileus
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15. Contrast media
 Medium density barium suspension (50-60%w/v)
 Suspending agent to prevent flocculation and
maintain stability
 High density barium(200-250%) may produce an
appearance of fold thickening and clumping of small
bowel
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16.  Acid Baso4 suspension may produce spasm, enlarged
folds and dilatation of duodenum & jejunum
 Alkaline Baso4 suspension improves coating of
valvulae and improves diagnostic accuracy
 It is usually mixture of any flavour
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17. Why barium usedIt is an insoluble material
It is high atomic no:56
It is high density,
It provides a positive contrast in x-ray
It is radiopaque material
Is not absorbed or metabolized
Is eliminated intact from the body
Alkaline BaSO4 suspension improve coating valvulae
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18. Why iodine is not used
 Is water soluble
 Diminish blood volume
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19. Preparation
 Purgative- Dulcolax 2tab HS (not in suspected
obstruction, acute crohn’s exacerbation, ileostomy)
 Low roughage high fluid intake diet 48hrs prior
 No food/fluid should be taken for 12hrs before
investigation
 No antispasmodics, codeine, tranquilizers 24-48hrs
prior
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20. Barium follow-through examination
 This is performed following a barium meal
examination of the esophagus, stomach and
duodenum
 150ml 250%w/v—200ml 20-25%--250ml40-45%
 As the barium column progresses through the small
intestine large radiographs of the abdomen are taken
at intervals
 First one is taken with the patient supine about 15
minutes after the barium meal and shows the proximal
jejunum
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21.  The remaining radiographs are normally taken at half
hourly intervals with the patient prone.
 When the barium column reaches the caecum spot
views of the terminal ileum are taken
 It takes from 2 to 6 hours for the head of the barium
column to reach the caecum
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22. Dedicated small bowel follow
through
 Single contrast technique
 Barium 50-60% 600-900ml
 Drink as rapidly as possible
 To right lateral position 15-20mins
 Then prone filming done every 15-20min until
ileocaecal junction opacification noted
 To demonstrate ileocaecal junction supine right is best
as ileum enters caecum posteromedially
 Always empty the bladderprior to these spot films
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23. Single contrast technique
Positioning Purpose
First Right side down
dependent
To aid gastric
emptying
Second Prone To separate
bowel loops
Third Right side up To visualize IC
junction
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24.  Periodic fluoroscopic examination and compression
spot films are recommended
 4 spot films for ileocaecal junction should be taken
with variable degree of compression
 Compression over bowel loops to avoid overlap thereby
prevents efffacemen of mucosa and small lesions may
not be missed
 The abnormality must be shown in 2 spot films taken
at different times to confirm persistence of lesion
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25. Overlap of contrast filled bowel loops in pelvis Overcome by
 Table head down
 30 degree caudal angled view of pelvis
 Emptying urinary bladder prior to filming ileal loops
Peristalsis can be increased by
 Metoclopromide, Neostigmine , Cholecystokinin, glucagon
 20-40ml sodium/meglumine diatrizoate or gastrograffin to
barium increases transit time
Cold water-
barium more palatable ,speeds gastric emptying
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26. Interpretation
Jejunum Ileum
Constitutes proximal
2/5th of small intestine
3/5th
Position Upper left and
periumblical region
Lower right hypogastric
and pelvic region
Max. diameter 4 cm 3 cm
Number of folds 4-7 per cm 3-5 per cm
Pattern Feathery mucosa Less feathery or maybe
absent
Fold thickness 1.5-2mm bowel wall depth 1-1.5mm
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27. BA Meal follow through:
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29. The pattern of the mucosal lining of the first part of the duodenum is different
from the other parts. longitudinal pattern of the mucosa of the first part of the
duodenum forming what is known as the duodenal cap This pattern is very
similar to that of thepylorus of the stomach This pattern changes to a
more flecked appearence in the distal duodenum
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31. Reflux examination
 Barium and air refluxed through the ileocaecal valve during
a barium enema examination give good views the terminal
ileum. Replaced by enteroclysis
 The radiographs should be studied carefully and spot views
of the distal ileum is taken if necessary
 All of the small intestine can be examined by refluxing
barium from the colon into the terminal ileum – the
complete reflux examination
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32. doublecontrast barium enema examination
(with reflux
into terminal ileum) shows carcinoid tumor
in terminal ileum
Doublecontrast barium enema
examination (with reflux
into terminal ileum) shows lipoma
as smooth, ovoid, submucosal
mass in distal ileum 33SIVA PRAKASH

33. Peroral Pneumocolon examination
 Excellent view of the terminal ileum and caecum can
be obtained by giving barium orally and when the
head of the barium column has reached the ascending
colon introducing air per rectum and refluxed in to
distal ileum
 Glucagon can be used to relax ileocaecal valve
 This procedure shows Crohn’s disease and carcinoma
of the caecum particularly well
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34. Per oral pneumocolon
examination
Indications contraindicatns
 Terminal ileum porly
visualized on routine
compresion spot films .
 Clinical suspicon of Crohn
disease with normal
apearance of terminal ileum
 abnormal apearance of
terminal ileum on routine
compresion spot films
 history ileocolic
anastomosis.
 Recent colonic or rectal
biopsy
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36. Advantages Disadvantages
 Easily performed
 No catheterisation
 Physiologic transit time
can be assessed
 Overlapping of barium
filled bowel loops in
pelvis
 Poor distension
 Partial or intermittent
bowel obstruction
 Operator dependant
 Time consuming
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37. Complicaions
 Leakage of barium form unsuspected perforation
 Aspiration
 Impacted barium converts partial obstruction in to
complete obstrction
 Barium appendicitis impaction at appx
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