small bowel enema

1. ENTEROCLYSIS
(SMALL BOWEL ENEMA)
ANKIT KUMAR
BRIT

2. DEFINITION
:- It is a radiographical study of small bowel from
jejunum to the ileocecal junction by intubation of
the jejunum and instillation of contrast through the
tube.

3. ANATOMY

4. INDICATION
 Partial obstruction
 Chron’s disease
 Suspected merckels diverticulum
 Malabsorption
 Tumor / malignancy of small intestine
 Occult GIT bleed
 Equivocal BMFT but strong clinical suspicion

5. COTRAINDICATION
 Complete obstruction
 Perforation
 Massive dilation
 Duodenal obstruction (gasojejunostomy)
 Paralytic ileus
Equipment
 Bilboa – dottor tube
 22f polyethylene tube (180 cm long)
 Multiple side holes
 Teflon coated guide wire(reduce friction)

6. Bilboa – dottor tube Teflon coated guide wire
22f polyethylene tube

7. CONTRAST MEDIA
 Baso4 – alkaline
- It improves coating of valvulae connivents
1. For single contrast
- 20% w/v suspension of baso4
2.For double contrast
- High density low viscosity baso4 suspension
- 200 – 250 % w/v
 95% microbar dilute to 70 % to decrease the
viscosity
 10 gm CMC (carboxy methyl cellulose)+2 ltrs warm
water
 Mix and refridge overnight

8. PREPARATION
 Liquid diet (2-3 ltrs) for full day before examianation –
called overnight fasting
 2-4 dulcolax tablets in evening
 No rectal enema required –before the enema fluid may
reflux into the small bowel and create confusing small
bowel pattern when it mixes with Barium suspension
 Day before procedure – stop transquilisers ,sedative
and antispasmodics
 Anticholinergics and Ganlion blocking drugs cause
dialation of small bowel
 Narcotics affect mobility and appearance of folds of
the small bowel.

9. FOR INFANTS
- 4 Hours fasting
- Turn baby to right side – to enhance gastric emptying
- sedation
- Decrease peristalsis – Compensated by 3-5 ml of metaclopromide
CONTRAST DOSE
AGE DOSE
3-5 Months 200 ml
5-8 Months 300 ml
8-11 Months 400 ml
1-3 Months 500 ml

10. TECHNIQUE
 PLAIN FILM
- Adequately prepared and exclude
the presence of Barium from previous
exam
 UPRIGHT / ERECT FILM
- Used to determine the amount of
fluid present in stomach or bowel
loops
 Also observed in PLAIN FILM
- Free intraperitoneal air
- Displacement of bowel loop by
mass
- Calcification
- Abnormalities of bowel loop

11. PROCEDURE
 Patient sits upright on chair placed against the wall
 Those patient who cannot sit up ,then tube can be
placed with patient supine or rt. Lateral on fluroscopic
table
 2-3 cc of 2% xylocaine jelly –introduced into the nostril
 patient neck hyper- extended
 B.D tube (bilbao-dotter tube) without guide wire is
inserted through one of the nostril
 Advanced with the swallowing action of the patient till
the tip reaches the stomach
 5-7 cm of tube is passed in stomach then neck is flexed
 Guide wire used to stiffen the tube to assist
advancement through the oesophagus into the stomach

12. Cont.
 Patient to cough by observating under fluroscopy
 Under fluroscopic control the tube is then advanced
through the antrum of the stomach into the pyloric
canal
 Guide wire -5cm proximal to the tube tip, tube is
slowly advance till the tip enters the duodenal cap.
 Right side up – location of pyloric canal and duodenal
cup seen outline by air
 Right side down oblq.- Tube to reach pyloric canal by
gravity
 Tube tip enters the first part of duodenum ,advance
the tube slowly keeping the guide wire 2-3 cm
proximal to the PYLORIC SPHINCTER
 End – 4-5 cm distal to TRIETZ canal.

13. PROBLEMS
 Prolonged examination
 Incomplete distension of small bowel
 Prolapse of small bowel into pelvis
 Faecal material in the terminal ileum
 Reflux into duodenum and stomach

14. SINGLE CONTRAST ENTEROCLYSIS
 High grade partial small bowel obstruction
 Barium suspension – 20% w/v injected 75-120ml/min.
 No air goes during injecting
 1-1.5 litres of Baso4 injected without interrupted
 Average time to reach the ileocaecal junction-15 min.
 Use interrupted fluroscopy to follow the head of the
barium column
 Stenotic lesion – Best identifiable at the head of the
barium column
FILMING
 10 *12 spot film- jejunal loop
 Another for entire bowel loop
 Ileocaecal junction – with and without compression
 Filming done with high kvp technique (120-140 kv)

15. DOUBLE CONTRAST ENTEROCLYSIS
 150 -500 ML –Barium suspension injected at 80-100
ml/min. till the proximal ileum is reached
 Intermittent fluoroscopy
 0.5% supension of CMC injected at 75- 120 ml/min. using a
mechanical injector
FILMING
 Upper abdomen – Jejunum seen in double
contrast
 Full abdomen – Entire small bowel is in
double contrast
 Ileocaecal spot – In single and double
contrast

16. AIR DOUBLE CONTRAST
ENTEROCLYSIS
Preparation
 Laxative – before the night examination
 NPO after 7pm the night before the
examination

17. Procedure
ANTISPASMODIC (buscopan) agent is given
When AIR reaches distal ileum
600-1000 ml of AIR (100 ml/min)
When barium reaches distal ileum
150-200 ml of Barium (60ml/min)

18. ADVANTAGE
The mucosal detail seen is
superior
Aphthoid ulcer and minute
scar can be picked up easily

19. DISADVANTAGE
Difficult to reproduce
Uncomfortable to the patient
Air may pass through the minimal narrowing
and mild narrowing may be missed

20. COMPARISON
Methyl cellulose DC Enteroclysis Air DC Enteroclysis
1 Less information compared to air More clear detail
2 Simple procedure, can be done by
inexperienced radiologist
Operator dependent
3 Less time (20 minutes) More time

21. AFTER CARE
:- The patient should be warned that diarrhoea may occur
as a result of the large volume of fluid given. Patient can
take full diet following the procedure.
COMPLICATION
 Aspiration
 Perforation of the bowel

22. Anatomical differences between small bowel and large bowel
Small bowel Large bowel
Valvulae connventes Present Absent
Number of loops Many Few
Distribution of loops Central Peripheral
Haustra Absent Present
Diameter 3-5 cm 5 cm
Solid faeces Absent Present

23. CAPSULE ENDOSCOPY
Capsule endoscopy is a procedure used to
record internal images of the gastrointestinal
tract
Capsule Endoscopy involves swallowing a small
(the size of the large vitamin pill) capsule,
which contains a colour camera, battery, light
source and transmitter
It offers high diagnostic results in
IBD(inflammatory bowel disease) , Ulcers,
Polyp, Erosions

24. ADVANTAGE
 No radiation exposure
 Minimal patient discomfort
 Less operator dependent
DISADVANTAGE
 Inability to control the camera
 Biopsy can not be taken
 Capsule may not reach caecum in case of stricture hence
incomplete examination

25. ILEOSCOPY
 Ileoscopy is an endoscopic procedure that uses a tiny camera attached
to a scope to examine the lower portion of the small intestine (the
ileum).
 Endoscopy examination limited to distal ileum
ADVANTAGE
- Biopsy can be taken
DISADVANTAGE
- Inability to reach caecum
- Inability to intubate during colonoscopy