4. Is the longest part of
alimentary canal
Extends from pylorus of stomach to
ileocecal junction
Length = 3 m in a living person
& 6.5 m in a cadaver
(loss of muscle tone)
Diameter = 4 cm in gastroduodenal jn
& 2.5 cm at i-c junction.
Small bowel represents 75% of the length
& 90 % of mucosal surface of intestinal tract.
5. 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
6. Anatomical subdivisions :
a) Duodenum
b) Jejunum
c) Ileum
Duodenum = C-shaped tube
which is attached to the
Stomach.
Jejunum = is the coiled
Midportion.
Ileum = the final
section,which leads into the
large intestine.
7. Embryology:
Duodenum: above and including ampulla of vater is
developed from foregut.
Rest from midgut
Jejunum and ileum (except terminal portion) pre-arterial
segment of midgut loop.
The terminal portion of the ileum is derived from the post-arterial
segment proximal to the caecal bud.
Endoderm gives rise to mucosal lining of small bowel rest
of the layers are derived from splanchanic laayer of lateral
plate mesoderm.
8.
9.
10. 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
11. 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 anterolateral to body of
L1 vertebrae
Most movable part
12. 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
13. ANATOMICAL RELATIONS
FIRST PART-
PERITONEAL RELATIONS:
2.5cms movable and
attached to lesser and greater
omentum. Next 2.5cms is
fixed and retroperitoneal.
VISCERAL RELATIONS:
Anteriorly: Quadrate lobe of
liver andGB
Posteriorly: Gastroduodenal
A, bile duct and PV
Superiorly: floor of Epiploic
foramen.
Inferiorly: Head and neck of
pancreas.
14. SECOND PART-
PERITONEAL RELATIONS:
retroperitoneal & fixed.
VISCERAL RELATIONS:
Anteriorly: Rt lobe of liver,
transverse colon
root of transverse mesocolon
Posteriorly: Anterior surface
of rt kidney, rt renal vessels,
rt edge of IVC,rt psoas
Medially: Head of pancreas
and bile duct.
Laterally: Rt colic flexure
15. THIRD PART-
PERITONEAL
RELATIONS:
retroperitoneal & fixed.
VISCERAL RELATIONS:
Anteriorly: Superior
mesenteric vessels
Posteriorly: Rt ureter, rt
psoas major, rt testicular
or ovarian vessels, IVC
abdominal aorta.
Superiorly: Head of
pancreas.
Inferiorly: Coils of
jejunum.
16. FOURTH PART-
PERITONEAL RELATIONS:
retro-peritoneal & mobile.
VISCERAL RELATIONS:
Anteriorly: Transverse colon &
mesocolon, lesser sac &
stomach.
Posteriorly: Lt sympathetic
chain, lt psoas, lt renal vessels, lt
testicular veins & inferior
mesenteric vein.
To the right: attachment of
upper part of root of mesentry.
To the left: Left kidney & ureter.
Superiorly: Body of pancreas.
17. Ligament of trietz
Suspensory ligament of duodenum
Fibromuscular band arising from rt crus of diaphragm
close to oesophageal opening and attaches to
posterior surface of D-J Flexure
Upper 1/3- striated muscle
Middle 1/3- elastic tissue
Lower 1/3- smooth muscle
19. smooth muscle lining of 1st
part of duodenum is
longitudinal
plicae circularis
(circular folds) of 2nd part
of duodenum
Major duodenal papilla is a
small rounded elevation at
site where bile duct & main
pancreatic duct pierce
medial wall of 2nd part of
duodenum
20. 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
21.
22.
23.
24. 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)
25.
26. Intestinal crypt epithelium
Secretory cells that
produce intestinal juice
Enteroendocrine cells
Intraepithelial
lymphocytes (IELs):
Release cytokines that kill
infected cells
Paneth cells:Secrete
antimicrobial agents
(defensins and lysozyme)
Stem cells
27. Duodenum
Arterial supply: Upper half
is supplied by superior
pancreaticoduodenal(gatro-duodenal)
Lower half is supplied by
inferior
pancreaticoduodenal(SMA)
Venous drainage
Superior
pancreaticoduodenal vein
drains into portal vein
inferior vein joins superior
mesenteric vein.
28. Blood supply:
Ileum and Jejunum
Arterial supply: Branches of superior mesenteric artery
Intestinal branches arise from left side of the artery & run
in mesentery to reach the gut (gastrointestinal tract)
They anastomose with one another to form as series of
arcades
Lowest part of ileum is supplied by ileocolic artery
Venous drainage
Veins correspond to branches of superior mesenteric artery
& drain into superior mesentery vein
29.
30. Lymphatic drainage:
Duodenum:
Lymph vessels follows arteries & drain upward via
pancreaticoduodenal nodes to gastroduodenal nodes
& then to celiac nodes .
Downward via pancreaticoduodenal nodes to superior
mesenteric nodes around origin of superior mesentery
artery
Jejunum & Ileum: Lymph vessels pass through many
intermediate mesenteric nodes & finally reach
superior mesenteric nodes (situated around origin of
mesenteric artery)
31.
32. Nerve Supply:
Duodenum:
Nerves are derived from sympathetic (T6-T9)&
parasympathetic (vagus) nerves from celiac & superior
mesenteric plexuses
Jejunum & Ileum:
Nerves are derived from sympathetic &
parasympathetic (vagus) nerves from superior
mesenteric plexus
33. Mesentary:
Broad fan shaped fold of peritoneum that suspends
jejunum and ileum from posterior abdominal wall
Conveys nutrition and innervation
Consists of 2 layers derived from greater sac
Root- 15cms long extends from left side of L1 vertebrae
at duodenojejunal junction to Rt Sacro-iliac joint at
ileo-caecal junction.
Free border separates to enclose jejunum n ileum
34.
35. Need for imaging
• Small bowel diseases presents with non specific
symptoms.
• Small bowel represents 75% of the length & 90 % of
mucosal surface of intestinal tract.
• Diagnostic tests which can provide documentation of
structural abnormality or normality.
• Limited role of enteroscopy of small bowel has
retained barium examination of small bowel as
primary investigation for its mucosa.
36. Plain abdominal Radiograph:
Most commom indication suspected bowel obstruction
/Perforation .
Views
Supine
Erect
Lateral dorsal decubitus
Antero-posterior or posteroanterior left lat decubitus
Erect PA chest
38. NORMAL GAS PATTERN
Stomach
- always
Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 2.5-3 cm
Larger bowel
- in rectum or sigmoid colon - always
39.
40. Fluid levels:
3 to 5 fluid levels < 2.5 cm in length may be seen
particularly in the right lower quadrant.
More than 2 fluid levels in dilated small bowel
more than 2.5 cm caliber are abnormal and
usually indicate paralytic ileus or intestinal
obstruction
41. NORMAL FLUID LEVELS
Stomach
- always (except supine film)
Small bowel
- 2 or 3 levels possible
Large bowel
- none normally
42.
43.
44.
45.
46.
47.
48.
49. Usg-small bowel:
Both standard (2.5–6 MHz) abdominal convex probe
and high resolution (7.5–14 Mhz) probe are used
All parts of small bowel—duodenum, jejunum and
ileum are accessible to TUS examination.
Isosmotic polyethylene glycol (PEG) solution 1000 mL
is required for small intestine contrast sonography
(SICUS) enteroclysis or hydrosonography of SB.
50. GUT SIGNATURE
The sonographic layers
appear alternately echogenic
and hypoechoic
the first, third, and fifth
layers are echogenic,
the second and fourth layers
are hypoechoic.
muscular components of the
gut wall—the muscularis
mucosa and the muscularis
propria—constitute the
hypoechoic layers on
sonography
51. The quality of the scan and the resolution of the transducer
determine the degree of layer differentiation
Normal intestinal wall thickness is generally ≤ 3 mm (using mild
compression) ranging from small diameters in the jejunum,
ileum
5mm is considered upper limit for non-distended bowel
Physiological contraction of the intestine leading to a thickened
wall segment may cause misinterpretation, therefore bowel
motions have to be taken into account before measurements are
performed
In addition to wall thickening, echomorphology (integrity of
wall architecture) and surrounding structures have also to be
considered in the interpretation of the intestinal wall diameter.
52. Normal small bowel:
Transverse view of pars
horizontalis duodeni
between aorta and SMA.
53. Normal small bowel: Longitudinal view of jejunum in left mesogastrium—with numerous
valvulae conniventes.
Longitudinal section of terminal ileum (TI) in the left iliac fossa
54. Valvulae conniventes (plicae circulares) of the small bowel. These are more easily
seen when there is fluid in the lumen of the bowel
55.
56. Sonographic appearance
of an inflamed colon
segment in Crohn’s
disease. Characteristic
appearance: thickened
wall diameter (almost 1
cm), partial loss of wall
stratification, prominent
submucosal layer,
narrowed lumen and
mesenteric fat
hypertrophy.
57. Small Intestine Contrast Ultrasonography
(SICUS) or Hydrosonography. TUS with using oral
contrast solution (iso-osmolar nonabsorbable polyethylene glycol solution
(PEG). The amount of PEG solution used in different studies varies between
200 and 2000 mL.
On average, the entire small intestine could be visualized on ultrasonography
by about 45 min after the ingestion of 600 mL or less of contrast solution
without any side effects .
SICUS improves TUS resolution by separating of SB walls and eliminating
bowel gas.
Compared with conventional sonography luminal filling can improve
visualisation of bowel walls and fold pattern but extends time of examination
(vary between 30–40 min).
In the study of Pallotta et al. SICUS is proved superior to that of standard TUS
in detecting the presence, number, extension, and sites of small bowel lesion
58. Color Flow (Power) Doppler—CFD. It is used to estimate
presence, density or absence of vascular signals in
thickened segments of bowel wall, in intraluminal or
extraluminal pathological structures and for imaging flow
in big abdominal vessels—SMA, coeliac trunk, portal vein.
CFD is part of standard abdominal and bowel sonography.
2cm after the SMA branches off from the aorta, and as it
runs parallel to the aorta
Triplex Scanning or Color Assisted Duplex Scanning (TUS
+ CFD + PWD). Enables evaluation of SMA/CA flow and
intramural flow in thickened bowel segments
59. Readily detected color
Doppler flow and a
resistive index less than
0.6 wereconsistent with
inflammation
Cross-sectional images of ileum proximal to an obstructing lesion. The lumen is
distended with fluid. The wall is slightly thick. ON Color Doppler image
marked hyperemia of the gut wall as a reflection of its inflammation
60.
61. Non-invasiveness and lack of radiation, makes TUS is a
relatively good alternative to CT or MRI enterography,
particularly in young patients and pregnant women.
In the duodenum and terminal ileum, TUS can detect
the most of benign and malignant tumors.
TUS is easily available , noninvasive, and low-cost
diagnostic procedure.
significant limitations (obesity, meteorism)
In the hands of experienced examiner offers reliable
tool for SB diseases examination.
62. Barium Techniques
Barium studies classified into indirect and direct
techniques.
Indirect techniques examine the SI with barium that
has passed through the upper GIT or colon before
entering the SI and include the
follow through examination/dedicated follow throgh
complete reflux examination (retrograde exam.)
peroral pneumocolon examination of the ileocaecal
region
63. Direct technique
Enteroclysis (small bowel enema) involve introducing
barium or other contrast agents directly through a tube
into the distal duodenum, proximal jejunum, or the
more distal SI
64. Indications Contraidications
Patients who have low
suspicion of small bowel
disease – abdominal pain
and diarrhea
Suspected complete or
near complete small
bowel obstruction
Crohn’s diease
Patients eho refuse for
placement of nasojejunal
tube/bilbao catheter
Colonic obstruction
Suspected perforation
Paralytic ileus
65. 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
Acid Baso4 suspension may produce spasm,enlarged
folds and dilatation of duodenum & jejunum
Alkaline Baso4 suspension improves coating of
valvulae and improves diagnostic accuracy
66. Entrobar is a raspberry flavored barium sulfate suspension. It is a
contrast medium developed for use in enteroclysis and follow-through
x-ray examinations of the small intestine.
The product contains 50% w/v barium sulfate USP, suspending
and dispersing agents, simethicone, citric acid, potassium
sorbate, flavoring, sodium citrate, saccharin sodium and water.
Barium sulfate has the empirical formula of BaSO4.
Barium sulfate is an insoluble material which, because of its
density, provides a positive contrast during x-ray examination.
Barium sulfate is an inert radiopaque material which is not
absorbed or metabolized and is eliminated intact from the body
in a manner similar to other non-absorbed inorganic materials.
Excretion rate is a function of gastrointestinal transit time.
67. Preparation
Purgative-Dulcolax 2tab HS (not in suspected
obstruction,acute crohns 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
68. 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
69. 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
70. 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
71. 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
72. 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
73. 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
Peristalisis can be increased by metoclopromide
neostigmine cck glucagon
20-40ml sodium/meglumine ditriazoate or gastrograffin to
barium increases transit time
Cold water- inc palatibility speeds gastric emptying
74. Interpretation
Jejunum Ileum
Constitutes proximal
2/5ths of small intestine
3/5ths
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
77. 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
78.
79. 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
80. 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
81. 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
82. 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
83.
84. 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
85. Complicaions
Leakage of barium form unsuspected perforation
Aspiration
Impacted barium converts partial obstruction in to
complete obstrction
Barium appendicitis impaction at appx
90. Bilbao dotter tube
Bilbao Dotter tube is (22 F
polyethylene tube which is
150 cms long with a guide
wire which is 5 cms shorter
than the tube, with
multiple side holes which
are 8 in number without an
end hole
guide wire is teflon coated
to reduce friction).
Latest modified
catheters(10F-14F)
children 7F caths are used
91.
92. Maglintos Balloon enteroclysis
catheter
Modification of the 1 4 French Bilbao duodenal tube
Made of radiopaque polyvinyl chloride
1 60 cm - length, inner diameter -0.1 1 0 mm and an outer diameter of 0.1 70
mm (1 3 French).
Six side holes measuring 0.70 inches (1 8 mm) in diameter are located distal to
the latex balloon.
This closed-end catheter has a weighted tip 5 cm distal to the balloon, attached
proximal to the last row of side holes .
Balloon lumen measures 0.030 inches (0.76 mm) and is provided with a one-way
check valve attached adjacent to the open end of the catheter.
About 12-15 ml of air gauged fluoroscopically is injected once the
catheter tip is in the desired position.
A 1 80-cm-long, Teflon-coated, stainless-steel, braided torque guide wire
0.065 inches (1 .7 mm) in outer diameter is provided with a straight tip to act as
a stiffener and angled tip fordirectional or torque control.
93. Advantages
material does not have to be held up by normal pyloric
activity
Quicker
increase in distention of lumen
Disease that reduce this distention –easily identified
95. Contrast medium
Single – 20% w/v suspension of micropulverised barium
with added suspending agent in alkaline medium
Double – high density low viscosity 200 – 250%
Ba + methylcellulose
Ba + air – air double contrast EC
adv : mucosal detail superior to any other examination
10gms of carboxymethylcellulose added to 2litres of warm
water. Refrigerate mixture overnite and shake well before
use
96.
97. Why methylcellulose?
Commonly used as bulk laxative and suspending agent
Non irritating to bowel mucosal lining
Unable to be absorbed
No toxic effects on body
Natural tendancy to retain water in lumen promotes
peristalisis and prevents luminal collapse.
Propels barium to distal ileum and colon
Low diffusivity with compatiable ba suspension and thus
preserves an interface between dense barium coating of
mucosa and luminal water density
Promotes evaccuation by laxative effect
98. Patient preparation
Non-residue liquid diet(a day prior)
NPO(after midnight)
Medication – reduce motility (a day prior)
Laxative – magnesium citrate/bisacodyl(CI-partial
obst)
Asc col and terminal ileum clear from stool
Drugs –
antich, ganglion blocking – diltn-mimic sprue
Narcotics
For infants, 4 hrs fasting ,sedation.
99. Contrast dose :
Age dose
3-5 mnths- 200ml
5-8 mnths- 300ml
8-11 mnths- 400ml
1-3 yrs- 500ml
Children
And adults- 1-1.5 litres
100. Inflation of baloon
15 to 20 ml
Beyond lig of Treitz
Reflux into stomach –
distention, nausea
101. Infusion of Barium 70 to 75 ccs/min
Infusion of methyl cellulose 70 to 120 ccs/min
important that ba advance in an uninterrupted column
and w/o causing focal distention of lumen.
102. Technique:
Preliminary plain radiographs of the abdomen:
To determine wether the patient is adequately
prepared and to exclude the presence of barium
from previous examinations.
Free intraperitoneal air, displacement of bowel loops
by mass, calcification and abnormality of bowel
loops other than distension.
103. Procedure:
Patient sits upright on a chair placed against the wall so not
to move away from the advanced tube. Alternatively, in a
patient who cannot sit up, the tube can be placed with the
patient supine or right lateral on the fluoroscopy table.
2-3 cc 2% xylocaine jelly is intorducd into the nostril
through which the tube to be placed after ensuring no
nasal blockage, with patients neck hyperextended.
The Bilbao-dotter tube without the guide wire is inserted
through one of the nostrils and advanced with the
swallowing action of the patient till the tip reaches
stomach.
About 5-7 cms of the tube is passed in stomach and then
neck is flexed.
Guide wire may be used to stiffen the tube to assist
advancement through the esophagus into the stomach.
104. Further it is advanced through the antrum into pyloric
canal, now with guidewire 5cms proximal to tube tip,
the tube is advanced till the tube enters duodenal cap,
which may be facilitated by turning the patient supine
with right side up so that the location of pyloric canal
and duodenal cap can be seen outlined by air.
With further advancement the tube tip is placed at the
duodenojejunal flexure with tip of guide wire in
pyloric canal.
Finally the tube tip should be 4-5 cms distal to the
ligament of treitz. Such a placement prevents reflux of
barium and CMC into proximal parts of duodenum.
105. If stomach is collapsed or has very little gas, injectin
100-150 ml of air will help the above manipulation.
If stomach is overdistended with gas, aspirate out air
to reduce distension
If residual fluid in stomach,should be aspirated
prior to manipulation
While advancing the tube it will tend to hold up at
the following places due to acute angulation of the
intestine, junction of 1st- 2nd part
duodenum;junction of 2nd-3rd parts of
duodenum;duodenojejunal flexure
106.
107.
108. Problems:
Prolonged examination time: it is due to improper flow
rates. Too high infusion rates should not be used. To
restore peristalisis , inj.metoclopromide 10 mg IV is useful
Incomplete distension of small bowel: due to slow infusion
rates, or due to excessive dose or response of
metoclopromide. Increasing the rate of flow of contrast
will solve the problem
Prolapse of small bowel into pelvis: few loops may dip into
the pelvis, angled compression allows lifting of pelvic
segments . If caecum obscures pelvic ileum, patient is
turned prone and the table is tilted head down. This allows
caecum to empty and terminal ileum becomes visible.
Fecal material in terminal ileum: due to incompetent
ileocaecal valve or in patients who are chronic laxative
users, infusion of adequate amount of methylcellulose will
push debris into the colon
109. Reflux into the duodenum and stomach: this is due to
too fast infusion rate or small bowel obstruction.
Incidence can be reduced by the use of ballon
enteroclysis catheter. In patients with obstruction,
preliminary decompression of stomach and proximal
jejunum decreases reflux.
110. Single contrast enteroclysis:
This is performed in patient with a high grade partial
small bowel obstruction.
Barium suspension 20%w/v is injected at the rate of 75-
120 ml/min
An average of 1-1.5 lts of barium suspension in injected
without any interruption
Average time taken to reach the ileo-caecal junction is
about 15 mins.
Interrupted fluoroscopy is used to follow the head of the
barium column
Stenotic lesions are best identifiable at the head of the
column
111. Filming:
One film for the jejunal loops, another film is taken for
the entire small bowel.
Spot films are taken with or without compression where
ever necessary
Spots of the ileocecal junction are done
All filming is done with high kVp technique(120-140 kV)
112. Double contrast enteroclysis:
150-500 ml barium suspension(200-250% w/v) is
injected at a rate of 80-100 ml/min, till the proximal
ileum is reached.
After this , 0.5 %suspension of CMC is injected at a rate
of 75-120ml/min.
Ileocaecal spot film should be taken initially when the
barium column reaches the IC junction and again when
the IC junction is in double contrast.
113. Filming:
Upper abdomen when jejunum is seen in double
contrast
Full abdomen when entire small bowel is in double
contrast
Ileocaecal junction spots in single and double contrast
filming has to be completed within 20-25 mins for good
double contrast effect
Erect films donot give any additional information of
small bowel study
115. Normal enteroclysis demonstrating catheter in first jejunal loop and well
distended jejunum and proximal ileum with normal pattern of valvulae
conniventes
116. Normal small bowel:
Fold shape: The folds are less pronounced or possible absent in the
ileum. The folds run fairly straight and parallel, joining the bowel wall
in the form of rounded corners. At times in the ileum, the folds may
crowd together on the concave side of a bowel loop, creating a
triangular fold pattern.
117. Fold thickness: The folds are normally 1.8 mm thick in the jejunum,
and 1.5 mm thick in the ileum. When the thickness exceeds 2.5 mm in
the jejunum or 2.0 in the ileum, it is considered a pathologic finding.
118. Number of folds: 4 to 7 folds per inch are normal for the
proximal jejunum and 2 to 5 folds per inch is normal for the
distal ileum
119. Fold Height. The height of the folds is 3 to 7 mm in the jejunum and
1.5 to 3.5 mm in the ileum. the height of the folds may vary
considerably within the same segment of the bowel, thus the
visualization of the entire segment for the height of the folds is must
120. Lumen Diameter: There is a gradual decrease in lumen diameter from
the jejunum into the ileum. The upper jejunum averages from 3.0 cm to
4.0 cm, 2.5 cm to 3.5 in the lower jejunum, and 2.0 cm to 2.8 cm in the
ileum. Abnormal diameters are anything that exceeds 4.5 cm in the
upper jejunum, 4.0 cm in the distal jejunum, and 3.0 in the ileum.
121. Wall Thickness: When two adjacent loops are
found to be parallel over a distance of at least 4 cm,
with abdominal compression, the distance
between the two represents the combined wall
thickness. Half of this measurement is the
thickness of a single loop. The wall thickness is the
same throughout the small bowel. A wall thickness
greater than 4 mm is considered abnormal.
122. Air double contrast enteroclysis:
150-200ml Barium @ 60ml/min
Intermittent fluoroscopy to visualise barium reaching
terminal ileum.
Inject 200ml of air @ 100ml/min initially
A total of 600-1000ml air is necessary
Antispasmodic iv/im when air reaches distal ileum
Mucosal details superior
Minimal narrowing is missed as air passes through
Uncomfortable for patient
123. Comparision:
Methylcellulose DC
enteroclysis
1.Less information
2.Simple procedure
3.Less time(20-30 mins)
Air double contrast
enteroclysis
More clear detail
Operator dependent
Relatively longer time
124. ADVANTAGES OF ENTEROCLYSIS
Contrast material is administered at a desired rate and
not influenced action of pyloric sphincter
Direct infusion at a rate that produces hypotonia,
completely dilates the small intestine and therefore
the fold patterns and mucosal abnormality can be
easily assessed.
Because the distensibility if bowel lumen is challenged
by enteroclysis, the bowel proximal to stenosis dilates
thus facilitating recognition of even a minimal
narrowing.
125. Sinuses and fistulous tracts can be demonstrated
by enteroclysis
Can be completed in less time
Enteroclysis tube may be left in place in patients
with obstruction to achieve better decompression
Enteroclysis permits better delineation of the
small bowel than that achieved by BMFT,
segmentation and flocculation can be avoided.
126. Disadvantages
Placement of the nasoenteric tube causes discomfort
which can be minimised by sedation
Extrapyramidal symptoms of metaclopramide can be
made to subside by giving atropine or benadryl
Nausea and vomiting due to inadequate tube
placement proximal to ligament of treitz.
Treatment: aspiration of contents by withdrawing
the tube into the stomach
Diarrhoea if large amount of fluid is given
127. Rapid colonic emptying
Use of barium as primary contrast
Operator dependent
Failure to depict extraintestinal changes
After care:
The patient should be warned that diarrhoea may occur as a
result of the large volume of fluid given
Complications:
Aspiration
Perforation of bowel
129. CT Enterography
non-invasive technique for diagnosis of small bowel
disorders.
Advantages
evaluates the entire thickness of the bowel wall
offers information about the surrounding mesentery
the mesenteric vasculature and the perienteric fat
useful in the assessment of the solid organs and
provides global overview of the abdomen
130. non-invasive technique for diagnosis of small bowel
disorders.
Adequate luminal distension is necessary as collapsed
bowel loops may mimic pathology. CT enterography
utilizes two types of contrast:
neutral oral contrast agents
these have attenuation similar to that of water e.g. water, PEG
electrolyte solution, methyl cellulose
intravenous contrast is used with neutral agents
these agents allow better assessment of mucosal
enhancement, mural thickness as well as mesenteric
vasculature, this is important especially in the evaluation
of Crohn's disease
131. positive contrast agents
such as a dilute (1%) barium solutions
they are not routinely used in CT enterogrpahy
pathologic mural enhancement and intestinal
hemorrhage are obscured by positive contrast agents
mainly used to detect lower grades of small bowel
obstruction and internal fistula
132. procedure
Abstain from all food and drink 4-6 hours before the exam.
Patients drink about 1.5- 2 L of oral contrast over 40-60
minutes.
Administration of intravenous contrast injection at a rate 4
ml/sec.
CT scanning is ideally performed on a multi-detector
computed tomography (MDCT) scanner about 45-65
seconds after contrast material injection in a single
(venous) phase or dual (arterial & venous) phases for the
evaluation of mesenteric vasculature or GI tract bleeding.
Data interpretation with the use of axial and coronal
reformatted images for proper evaluati
133.
134.
135. MR Enterography
Technique
patients should abstain from all food and drinks for 4-6 h
prior to the study
patients drink about 1-1.5 L of a 2.5% mannitol solution at
regular intervals over a period of approximately 40 min
prior to the study
this solution acts as a hyperosmolar agent which draw fluid
into the bowel & (biphasic) appears as low signal intensity on
T1-weighted images and high signal intensity on T2-weighted
images
scanning is ideally performed on a 1.5-T MRI scanner, using
a phased array surface coil, either in the supine or prone
position
136. MR ENTEROGRAPHY
MR protocol
comprehensive MR examination of the small bowel usually
requires axial and coronal both T1 and T2 weighted images
high-resolution ultra-fast sequences such as true fast
imaging with steady-state precession (true FISP) and
HASTE sequences with and without fat suppression are
usually used
fat-suppressed three-dimensional (3D) T1-weighted
breath-hold gradient-echo images of the abdomen and
pelvis before and after intravenous gadolinium-based
contrast material administration
137. CT Enteroclysis
Computed tomographic (CT) enteroclysis is a hybrid
technique that combines the methods of fluoroscopic
intubation-infusion small-bowel examinations with that of
abdominal CT
CT enteroclysis can be performed by using positive enteral
contrast material without intravenous contrast material
and neutral enteral contrast material with intravenous
contrast material.
CT enteroclysis has been shown to be superior to other
imaging tests such as peroral small-bowel examinations,
conventional CT, and barium enteroclysis, except in the
demonstration of early apthous ulcers of Crohn disease.
138. Technique:
Patient positioning:
Head first, supine with arms extended above the
level of head.
Topogram position/ landmark:
Anteroposterior ; level of nipples to 3 cms below the
inferior border of the symphysis pubis
Mode of scanning: helical with single breath hold
technique.
139. Scan orientation: craniocaudal
Starting location- 1cm above the highest point of the dome
of diaphragm
End location- base of the bladder.
Gantry tilt-nil
Field of view-just fitting the abdominal wall
Contrast administration- intravenous monphasic and
enteral via the nasoenteral tube
Enteric contrast:paraffin solution or polymethyl cellulose at
a rate of 40-50 ml/ min
IV contrast-60-100 ml
140. Rate of contrast injection:2-3ml/sec
Scan delay-40-50 sec
Slice thickness in reconstruction-3-5 mm
Slice interval in reconstruction-1.5-2.5mm
Reconstruction algorithm- medium smooth
3D reconstructions-MPR,MIP,VRT
141. Patient is kept on overnight fasting before the
examination.
Antigas and cathartics are given for bowel cleansing
Lots of fluids are prescribed to counteract the cathartic
effects of the study( when high osmotic substance like
mannitol/paraffin/polymethylcellulose are used).
The enteral contrast material is administered via the
nasoenteric tube with its tip placed at the
duodenojejunal flexure.
142. CT enteroclysis utilises mainly two types of contrast :
neutral contrast media
these have attenuation similar to that of water e.g. water,
methyl cellulose
intravenous contrast is used with neutral agents
these agents allow better assessment of mucosal
enhancement, mural thickness as well as mesenteric
vasculature
better used in unexplained subacute gastrointestinal bleeding
due to vascular malformation and assessment of
inflammatory activity and complications of small
bowel Crohn’s disease
143. positive enteral contrast material
e.g. (4 to 15% water-soluble (sodium diatrizoate)
solution or a dilute (1%) barium solution)
no intravenous contrast is used with these agents
mainly used to detect lower grades of small bowel
obstruction and internal fistula
144. procedure
Conscious sedation (optional, according to patient's preference)
Introduction of the 12 to 14-F enteroclysis tube (under
fluoroscopy or through duodenoscope). The tube tip is usually
placed distal to the ligament of Treitz .
Contrast is administered either on the fluoroscopy table or after
transferring the the patient to the CT unit for commencement of
the CT scan (usually 1.5-2L of oral contrast).
In the CT unit, the position of the enteroclysis tube is checked in
the topogram.
In case negative oral contrast will be used, intravenous contrast
injection will be given (approximately 100-150ml).
After completing the scan, the tube is withdrawn gradually to the
stomach and any extra contrast volume is suctioned.
146. Coronal reformation of CT enteroclysis image obtained with dilute 0.1% barium sulfate
in 50-year-old patient with mild active Crohn disease shows similar findings. The barium
sulfate has slightly higher attenuation (30–50 HU) than water (0–20 HU) and a barely
visible speckled appearance, probably since it is a suspension of several ingredients,
including gum, sorbitol, and barium sulfate.
147.
148. MR Enteroclysis
Magnetic resonance (MR) enteroclysis is an emerging
technique to diagnose small-bowel disease.
Potential benefits of MR enteroclysis include direct
acquisition of coronal plane images and high intrinsic soft-tissue
contrast resolution, as well as the absence of
exposure to ionizing radiation.
An additional benefit of MR enteroclysis when compared
with small-bowel follow-through, small-bowel enteroclysis,
video capsule endoscopy, is the ability to depict
extraintestinal involvement.
sensitivity and specificity of MR enteroclysis in the
diagnosis of small-bowel neoplasms to be 0.86 and 0.98,
respectively.
149. PROCEDURE:
After placement of a nasoduodenal tube under
fluoroscopy the small bowel is distended with
1000-3000 ml of methyl cellulose and water
solution using an electric infusion pump, located
outside the scanner room at an infusion rate of
800-200ml/min
As per the protocol which consists of MR
fluoroscopy using thick slab 50mm coronal
HASTE with fat saturation, starting at the
beginning of infusion and repeated every 8
seconds during normal breathing.
This allows for the study of contrast passage speed,
luminal distension, peristalisis and retrograde
filling of stomach.
150. Subsequently, every 5 mins, depending on the
degree of distension observed from the HASTE
images, coronal and axial TRUFISP sequences with
fat saturation are performed with a slice thickness
of 5mm to study morphologic changes.
Finally with maximum distension, multislice
HASTE images with fat saturation and
unenhanced and enhanced(0.1mmol/kg gado)
coronal and axial FLASH 2D images with fat
saturation are obtained 60 sec after contrast
injection is made
151. Name of MR sequence by various
vendors
SIEMENS GE PHILIPS HITACHI TOSHIBA
HASTE SINGLE SHOT
FSE
SINGLE SHOT
TSE
SINGLE SHOT
FSE
FACE
FISP GRASS T1 FFE RF SPOILED
SARGE, RSSG
FAST FE
FLASH SPGR FFE REPHASED
SARGE
SSFP
TRUE FISP FIESTA BALANCED
FFE
BALANCED
SARG/ BASG
TRUE SSFP
Haste is fast/turbo spin echo rest are gradient echo sequences
152. Haste sequence is T2 weighted FSE sequence –
provides motion free images
Normal bowel wall-hypointense
Pathology-Hyperintense
Endoluminal negative contrast –low signal intensity
So bowel wall pathology is easily made out
Limitation-poor depiction of mesentary
(due to k-space filtering effects)
153. 3D Flash aequence: T 1 weighted image
Bowel wall- hypointense
Mesenteric fat-hyperintense
Any bowel wall pathology is easily made out and also
wen combined with fat saturation luminal pathology is
easily made out
Most suitable images for virtual endoscopy by volume
rendering method
High contrast to noise ratio
154. TRUFISP: contrast depends on T2/T1 ratio
Bowel wall-intermediate signal
Fluid :High signal intensity
Fast acquisition time- less motion related artifacts
No intraluminal flow voids
Able to demonstrate mesentary due to good contrast
between bright peritoneal fat and dark small blood vessels
and lymphnodes
Single shot tse sequence with heavily T2 weighting is used to
check position of placement of catheter
155. Fast imaging with steady-state precession of MR enteroclysis. Adequate luminal
distension throughout the jejunum and ileum is seen.
157. True FISP (a) and HASTE (b) coronal MR images show homogeneous opacification of the
lumen. The HASTE image
was acquired after administration of an antiperistaltic drug to avoid intraluminal flow voids.
Thickening of the valvulae conniventes (plicae circulares) appears on both images (arrow).
trufi haste
159. Drawbacks:
1.Susceptibility weighted artefacts from air bubbles in
the small bowel due to infusion or air while performing
the procedure,specially in FISP sequence.
2.Motion artefacts
3.Artefacts from previous surgeries
160. CT enteroclysis
Risk of radiation and relatively
nephrotoxic contrast agents
More accurate
higher sensitivity and
interobserver agreement for
imaging signs of small-bowel
disease
The sensitivity of CT
enteroclysis for bowel wall
thickening, abnormal bowel wall
enhancement, and adenopathy
was 89%, 79%, and 64%,
respectively
The interobserver agreement for
these signs varied between 0.52
and 0.65 for CT enteroclysis
MR enteroclysis
Magnetic resonance (MR)
enteroclysis has the
advantage of a lack of
radiation exposure and safe
contrast agents
less accurate than CT
enteroclysis
Relatively less sensitive
For the same signs, the
sensitivity of MR enteroclysis
was 60%, 56%, and 14%,
respectively
between 0.15 and 0.48 for
MR enteroclysis.
161. PET-CT
PET-CT is not first choice, but can be useful if findings
on CT or MR are equivocal or to look for metastatic
disease.
