This document provides information on small bowel enema/enteroclysis procedure. It discusses the indications for the procedure including partial small bowel obstruction and Crohn's disease. It outlines the preparation process and describes how to position the Bilbao Dotter tube through the nose into the duodenum. The document discusses performing the procedure with single or double contrast and imaging techniques. Potential findings and complications are also summarized.

1. Dr.N.Suriyaprakash
JR,Dept of RD.

2.  Radiological study of small bowel from
jejunum to ileocaecal junction by intubation
of the jejunum and instillation of contrast
through the tube.
 a/k/a Small bowel enema

3.  Partial small bowel obstruction
 Crohns disease
 Suspected meckels diverticulum
 Malabsorption
 Tumours of small intestine
 Occult GIT bleeding
 Equivocal BMFT but strong clinical suspicion

4.  Complete colonic obstruction
 Suspected perforation
 Massive dilatation of small bowel
 Duodenal obstruction and gastrojejunostomy
 Paralytic ileus

5.  Liquid diet for full day and over night fasting
before the procedure.
 Dulcolax tablet in the evening preceding the
procedure.
 No rectal enema.
 NO drugs like tranquilisers , sedatives ,
antispasmodics or anticholinergic .

6. Bilbao Dotter Tube
 22 F polyethylene tube
 150 cm long
 Multiple side(8) holes at the tip
with or without end hole

7. Contrast medium
Single contrast enteroclysis : 20% w/v
suspension of barium sulphate is used
Double contrast enteroclysis : 200 to 250% w/v
suspension of barium sulphate is used

8.  Preliminary plain radiograph
Upright film
 Determine whether the patient is adequately
prepared or not
 Determining the best radiographic method
for evaluating the patient

9. Position of the patient
Upright
Supine or right lateral
Examination of Nasal cavity
Patients neck is hyperextended. Bilbao Dotter tube
without guide wire is introduced is inserted through
one of the nostrils and advanced with swallowing
action till it reaches the stomach.

10. Guide wire may be used to stiffen the tube to assist
advancement through the esophagus into the
stomach.
After 2/3rd of the tube is passed tip must be in
stomach.Under flouroscopic guidance the tube is
then advanced through antrum into pyloric canal.
Now with the guide wire 5cm proximal to the tube
tip,the tube is advanced till it reaches the duodenal
cap.

11. Advance the tip slowly keeping the guide wire 2-
3cm proximal to the pyloric sphincter . With each
advancement withdraw the guide wire .
At the end when the tube passes beyond the
duodenojejunal flexure . Guide wire will be in
pyloric canal.
Finally tube tip should be approximately 4-5cm
distal to Trietz ligament.

14.  Prolonged examination
 Incomplete distension of bowel
 Prolapse of small bowel into pelvis
 Faecal material in terminal ileum

15.  Performed in patients with high grade partial
small bowel obstruction with significantly dilatd
bowel loops.
 Avg amount of BaSO4 – 1 to 1.5 litres
 Avg time to reach ileocaecal junction – 15mins
 Stenotic lesions are best identified at head of
barium column.

16. Jejunal loops
Entire
small
bowel
Ileocaecal
junction
 10 x 12 film
 kV – 120 to 140

17. Normal small
bowel loops are
well distended
with folds in a
parellel
arrangement.

18.  150 to 500 ml of barium suspension (80 to
100ml/min) is injected till proximal ileum is
reached
 0.5% carboxymethyl cellulose is injected at
a rate of 75-120ml/min
 Ileocaecal spots taken when barium reaches
the junction and then again when double
contrast is in.
 Ileocaecal junction will be seen well in
double contrast immediately after the
patient defecates and spot films are taken.

19. Upper abdomen when
jejunum is seen
Ileocaecal
spots in single
and double
contrast
Entire
small
bowel
Complete filming in 20 –
25 mins
Erect filsms have no
additional information

20.  Preparation
Laxatives night before examination
NPO after 7pm the night before procedure
 Barium used : 50 to 70 % w/v barium sulphate
 Advantage : Better mucosal details
 Disadvantage :
 Difficult procedure
 Uncomfortable to patient
 Air may pass through minimal narrowing and it
may be missed

21. 150 to 200 ml of
barium (60ml/min)
When barium
reaches distal ileum
600 – 1000 ml of air
(100ml/min)
When air reaches
distal ileum
Antispasmodic is
given

23.  Quick.
 Tube may be left in place in patients with
obstruction for better decompression.
 Better delineation of small bowel than BMFT.
 Sinuses and fistulas are better demonstrated.
 Contrast administration is not influenced by
action of pyloric sphincter.

24.  Discomfort by placement of tube
 Rapid colonic emptying
 Operator dependent
 Failure to depict extra intestinal changes
 Nausea and vomitting due to inadequate
tube placement

25.  Warn patients about diarrhoea due to large
volume of fluid infused.
 Aspiration
 Perforation

27.  MC congenital structural abnormality of GIT –
Meckels diverticulum
 True diverticula
 Inflammation of Meckels diverticulum is
meckels diverticulitis

28. Small loops
extending from the
mesentric border
of jejunal loop

29.  IBD with widespread gastrointestinal
involvement with skip lesions.
 a/k/a regional enteritis
 Radiological features
 Aphthous ulcer
 Creeping fat sign
 Thickened folds due to edema
 String sign

30.  Target sign – Mucosal ulcer with surrounding
translucent mound of edema

31.  Thickened nodular folds in
terminal ileum
String sign

32.  T cell mediated autoimmune chronic gluten
intolerance
 Loss of villi in proximal small bowel
Radiographic features
 Small intestinal dilatation due to excess
fluids
 Dilution of contrast
 Moulage sign
 Jejunoileal fold pattern reversal
 Segmentation

34.  Affects esophagus , small bowel and colon.
 Spares stomach
 Atrophy of muscular layer and replacement
with fibrous tissue causing malabsorption.
Small
bowel
dilatation
Hide bound
appearance
Close
aproximation
of valvulae

35.  Rare disorder
 Caused by Tropheryma whipplei
 Small bowel (jejunum) is a classical location
– Intestinal lipodystrophy
Hallmark findings
 Nodules
 Markedly thickened bowel wall –
Picket fence thickening

36.  Gastrointestinal tumor of mesenchymal
origin arising from muscular layer of
intestinal wall
Solitary filling defect
in the jejunum.
Angles at the margin
is obtuse depicting the
intramural nature of the
tumor.
Normal mucosa/Bulls
eye lesion.

38.  Hybrid technique combining conventional
enteroclysis with that of abdominal CT.
 Can be combined with I V contrast study.
Helical scanning done 70 secs after
administration of I V contrast.
 Contrast media
Neutral
contrast
Positive
contrast
Water/ Methyl cellulose
IV contrast is usedwith neutral agents
Sodium diatrizoate/ Dilute barium
No IV contrast is used with positive agents

40.  Better detection of intraluminal , intramural
and extramural pathologies.
 Even small lesion can be detected.
 Measurement of bowel wall thickness
possible.
 Detection of enteric fistulous tract and
stenosis possible.

41. Enteroclysis performed under MRI
 Methyl cellulose in water as enteric coated
contrast agent with Gd-DTPA is preffered.