Chin J Radiol 2004; 29: 309-314
309
Barium Studies of the Small Intestine
J EN -H UEY C HIANG R HEUN -C HUAN L EE T SIU -S HAN T SENG Y I -Y OU C HIOU C HENG -Y EN C HANG
Department of Radiology, Taipei Veterans General Hospital
School of Medicine, National Yang-Ming University
The small bowel follow-through examination has
been applied in daily practice for a long period of
time. Despite the widespread use of endoscopy, CT
and MR imaging, barium meal examination remain
the primary diagnostic technique for evaluation of
patients suspected of having small bowel disease. To
investigate the diagnostic impact barium followthrough in the assessment of small bowel disease, we
prospectively compared examinations of barium
follow-through and dedicated fluoroscopic examination. Barium follow-through was carried out at
overhead X-ray machine room by radiological technologist. Dedicated fluoroscopic examination was
performed only by radiologist in fluoroscopic room.
The study showed no significant difference in diagnostic quality and examination time in either technique. Barium follow-through combined with fluoroscopic examination for the terminal ileum and
suspicious bowel segments not only improved the
examination quality but also result in saving much
time for the radiologists.
Key words: Intestines, radiography; Barium
follow-through; Dedicated fluoroscopic
examination; Radiological technologists;
Radiologists
The radiographic examination of the esophagus,
stomach and colon has been changed dramatically by
the introduction of upper GI endoscopy and
colonoscopy, however, little has been changed in the
small bowel examination. Ultrasound (US), computed
tomography (CT) and magnetic resonance imaging
(MRI) may be occasionally used but barium studies are
still the primary imaging method for the patient with
suspected small bowel disease [1]. Small bowel enema,
or enteroclysis, is used in many European countries for
evaluating small bowel disease; but in the United
States and our country, barium follow-through or conventional overhead small bowel follow-through
(overhead SBFT) remains the major radiographic
examination for diagnosing small bowel disease.
Current review of status of small bowel radiography
suggests that the barium follow-through should be
abandoned because the yield of information provided
by enteroclysis has higher negative predictive value
[2]. Owing to lack of enough radiologists in the
country, we tried to evaluate impact of the fluoroscopy-based small bowel follow-through (SBFT)
study or dedicated fluoroscopic examination on patient
management. The purpose of this study was to
determine the peroral small bowel single contrast
barium examination in respects of clinical indications
and radiographic results, diagnostic quantity and
quality, transit time of barium and assessment of small
bowel disease.
MATERIALS AND METHODS
Reprint requests to: Dr. Jen-Huey Chiang
Department of Radiology, Taipei Veterans General Hospital.
No 201, Sec. 2, Shih Pai Road, Taipei 112, Taiwan, R.O.C.
Between January 1 and December 31, 2003, a
total of 223 consecutive patients constituted the study
cohort in our department. They were put into control or
study groups randomly. The control group patients
underwent barium follow-through or conventional
overhead small bowel follow-through and the study
group patients underwent dedicated fluoroscopic
examination or fluoroscopic small bowel followthrough, respectively. Barium follow-through was
performed for 105 patients (60 men and 45 women;
age range, 16-88 years; mean age 56 years) and
310
Barium studies of the small intestine
dedicated fluoroscopic examination for 118 patients
(61 men and 47 women; age 18-89 years; mean age 55
years). Barium follow-through was mainly performed
by radiological technologists. Prior to the introduction
of oral contrast medium, a plain radiograph of the
abdomen was taken and then 500mL barium sulfate
suspension (50% wt/vol E-Z paque) (E-Z-EM, Inc,
Westbury, NY) was administered orally. The
overhead-based X-ray films were taken at 15-, 30-, 60, 90- and 120 minutes, respectively. The appearance of
barium in the cecum and ascending colon is an indication for fluoroscopy to demonstrate the terminal ileum,
crowded bowel loops and an abnormality of the small
bowel loops that had been demonstrated on overhead
films. The patients then were sent to the fluoroscopic
room. The fluoroscopic films were taken by radiologists in the fluoroscopic examination room. Dedicated
fluoroscopic examination or Fluoroscopic Small
Bowel Follow-Through was performed by radiologist
or supervised residents. Prior to the introduction of
oral contrast medium, a preliminary plain film radiograph of the abdomen was taken. The patients were
then directly sent to fluoroscopic room. The film
should be seen by the radiologist before starting the
examination. A cup of 500mL of 50% wt/vol E-Z
paque suspension was administrated orally in the
waiting area. The first small bowel fluoroscopic
session was done 15 minutes after ingestion of the
barium suspension. Different view spot films are taken
as needed. Subsequent fluoroscopic sessions follow at
20- to 30-minute intervals, as judged by radiologist.
Fluoroscopy and compression radiography should be
done at least three to four times during the course of
the examination until the colon is reached. Dedicated
fluoroscopic examinations were carried out and controlled by radiologists or supervised residents during
the whole course of procedure.
Clinical indications of small bowel examination
include (a) gastrointestinal bleeding with negative
finding on upper GI series and colon examination, (b)
anemia with unknown cause, (c) cramping abdominal
pain associated with abdominal distention, nausea or
vomiting, (d) abdominal pain, (e) large volume
diarrhea, (f) history of small bowel disease or (g)
suspected small bowel neoplasms. All studies were
clinically indicated for assessment of small bowel
lesions. Primary clinical indications of the study
cohort were recorded prior to X-ray examination. All
images were taken with digitalized X-ray unites and
were stored in PACS image system. Radiographic
reports were made by 4 gastrointestinal radiologists in
our department. For each subject, the small bowel film
quality, radiographic diagnosis from original radiolog-
Table 1. Clinical indications of small bowel examination
Indications
Number of patients
Barium
follow-through
Dedicated
fluoroscopy
34
26
20
11
5
1
5
3
0
25
30
19
15
5
105
118
Abdominal pain/distension
GI bleeding
Suspect bowel obstruction
Anemia
Vomiting / Nausea
Crohn’s disease
Suspect neoplasm
Diarrhea
Body weight loss
Total
11
9
4
Table 2. Quality of the examinations of small bowel
Barium follow-through
Dedicated fluoroscopy
(n = 118)
(n = 105)
Duodenum
Jejunum
Ileum
Terminal ileum
poor
fair
good
poor
fair
good
12
6
15
4
5
9
35
25
88
90
55
76
1
1
4
2
3
8
37
21
114
109
77
95
Table 3. Transit time of barium
Transit time
(minutes)
<60
61-120
121-180
181-240
>240
Total
Barium follow-through
(No. of patient)
Dedicated fluoroscopy
(No. of patient)
43
24
11
15
12
40
26
15
15
19
105
118
ical reports and clinical outcome were reviewed and
collected. With good technique and good examination
quality, all bowel loops must be separated from one
another and should be imaged when filled with
barium. Normality or pathology of the bowel segments
is ascertained and demonstrated clearly.
The human research committee of the institutional review board approved the study protocol.
RESULTS
Clinical indications for the small bowel examination were abdominal pain (60 cases), gastrointestinal
bleeding (56 cases), suspected small bowel obstruction
(39 cases), anemia of unknown cause (26 cases), postsurgical neoplasm evaluation or suspected abdominal
tumor growth (16 cases), large volume diarrhea (12
cases), vomiting (10 cases) and body weight loss (4
cases). Clinical indications for small bowel study for
Barium studies of the small intestine
each group of patients were shown in Table 1.
Radiographic film quality is shown in Table 2. Transit
time of barium is shown in Table 3. There is no significant difference in film quality and examination time
between the overhead small bowel follow-through and
dedicated fluoroscopic examination. There is no significant difference in the accuracy of either technique,
either.
One hundred eighty-seven examinations were
interpreted as normal radiographic findings with an
overall abnormalities rate of 16% (36 of 223 patients).
Peritoneal carcinomatosis with small bowel involvement was found in 14 patients who were known to
have abdominal dissemination or postsurgical evaluation for malignancy. Crohn’s disease was found in 5
patients with gastrointestinal bleeding or abdominal
pain. Two of them had history of the disease. Four
patients having gastrointestinal bleeding were found to
have a small polyp in jejunum or ileum. Three patients
showed smooth tumor mass in abdomen with intestinal
compression. Two of them had palpable abdominal
mass during physical examination. Partial intestinal
obstructions with proximal bowel dilatations were
present in 3 patients. Superior mesenteric artery
syndrome was found in 2 patients. Acute duodenal
ulcers were found in 2 patients. The normal studies
were generally found in patients with anemia, watery
Table 4. Positive reports of small bowel barium examination
according to indications
Indications
Barium follow-through Dedicated fluoroscopy
Abdominal pain
GI bleeding
Obstruction
Anemia
Nausea/Vomiting
Suspect neoplasm
Diarrhea
Weight loss
Total
0% (0/35)
15% (4/26)
50% (10/20)
0% (0/11)
20% (1/5)
20%(1/5)
0% (0/3)
28% (7/25)
23% (7/30)
21% (4/19)
0% (0/15)
20% (1/5)
27% (3/11)
0% (0/9)
0% (0/4)
16.2% (17/105)
18.6% (22/118)
311
diarrhea or body weight loss. Positive radiographic
reports according to clinical indications were shown in
Table 4. Correlation between clinical indications and
radiographic results were shown in Table 5.
DISCUSSION
The small bowel is a part of gastrointestinal tract
that extends form duodenum to terminal ileum. The
small bowel is a tube of unpredictable length with
range of length 4.88 to 7.85m (average 6.5m) [1, 2].
The small bowel is attached to the posterior abdominal
wall by a fan-shaped mesentery. The first part of
duodenum is intraperitoneal, with the remainder of the
duodenum is retroperitoneal as it runs inferiorly
around the pancreatic head and to the left of aorta and
then runs anteriorly to become intraperitoneal again.
The jejunum normally lies in the left upper abdomen
and periumbilical region, while the ileum occupied the
right lower abdomen and pelvis. The caliber of the
small intestine changes as the lumen fills and empties,
but when full, the jejunum usually has a caliber of less
than 3cm, and the ileum of less than 2.5cm [2].
Conventional radiological examinations are usually
under estimated because of loop superimposition and
considerable mobility within the abdomen [3].
Barium meal X-ray examination of upper gastrointestinal tract and barium enema for the colon
study are being performed less frequently in current
radiographic practice because of the common use of
upper GI endoscopy, colonoscopy and cross-sectional
abdominal imaging studies such as ultrasound,
computed tomography and MR imaging [4]. However,
barium meal follow-through examination of small
bowel series remains widely used in the United States
and many countries [5. 6] because of technical limitation of small bowel endoscopy.
One of the disadvantages of the barium meal
examination is that it is time consuming for the
patients, the radiologist and the radiology department.
Table 5. Correlation between clinical indications and radiographic results
Indications
Radiographic results (No. of patients)
Pain
Bleeding
Obstruction
Anemia
Vomiting
Neoplasm
Diarrhea
Weight loss
Total
N
60
56
39
26
10
16
12
4
223
DU
SMA
Adhesion
Malrotation
2
2
3
1
2
Crohn
3
2
Polyp
4
1
Malignancy
1
3
7
1
4
2
2
3
3
5
5
16
N: normal finding. DU: duodenal ulcer with demonstrated active ulcer crater. SMA: superior mesenteric artery syndrome. Crohn: Crohn’s disease.
312
Barium studies of the small intestine
An increase in amount of the volume of meal, 900 ml
of a diluted barium meal suspension, can improve
examination quality of the small intestine or opacification of the ileocecal region in less than one hour [7].
However, the barium follow-through or dedicated fluoroscopic examination can be difficult to perform for
the long-term bed-ridden or very ill patients. They
usually can not ingest adequate amount of barium
sulfate suspension in a very limited period of time,
and transit time is often prolonged and therefore
lowering examination quality. In such situations, the
small bowel film is often nondiagnostic or inconclusive. The thoughtful selection of patients by clinicians
for small bowel radiography is essential to make radiological evaluation cost effective.
We compared film quality and diagnostic efficacy
of barium follow-through from dedicated fluoroscopic
examination. We found that there was no significant
difference between two groups of examinations.
Barium follow-through X-ray films, with the patient
prone, were taken by X-ray technologists at intervals.
Technical requirement was low and film quality was
usually limited. All patients were finally undertaken to
a compression view of terminal ileum with a compression paddle in supine position performed by a radiologist. This procedure provided a significant improvement in diagnostic quality of the examination. In
contrast, when the whole procedure of dedicated fluoroscopic examination was performed by a radiologist,
abnormality or pathology of the small bowel segment
was usually ascertained. However, the dedicated fluoroscopic examination quality was more techniquedependant and the in charge residents should be very
interested in searching a critical result and be paying
high attention to both patients and procedures during
the whole course of examination in daily practice.
Examination quality was sometimes poor for ileum
located in pelvic cavity even in fluoroscopic examination due to overlapping of small bowel loops. The
double contrast images of the terminal ileum and
pelvic ileal loops obtained with the pneumocolon
might contribute to the better diagnostic quality of the
examination [8].
There is not much data in the literature on the
accuracy of the barium follow-through for detecting
abnormalities in the intestine, probably because of the
low incidence of small intestinal diseases. However,
there are a few number of studies suggesting that the
barium follow-through is not an accurate diagnostic
technique [9-12]. The reported positive findings on
small bowel examinations varied from 7-31% [13-15].
Our overall abnormal small bowel examination was
17.5%. The incidence of the disease of small intestine
is low and usually associated with non-specific
symptoms. The lower abnormal rate in the barium
follow-through may partially be due to patient
selection. Table 4 showed the relationship between
clinical indications for small bowel examination and
the report results. Low abnormal rate is noted in
patients with anemia, body weight loss, nausea,
vomiting, diarrhea or abdominal pain; in contrast, high
positive rate is identified in patients with chronic
intermittent gastrointestinal bleeding, a known history
of small bowel disease or Crohn’s disease. In our
study, of 56 patients with gastrointestinal bleeding, 11
patients (19.6%) were found to have small bowel
polyps, malignant tumors, acute duodenal ulcers or
Crohn’s disease. Out of 39 patients who were
examined for suspected bowel obstruction, bowel
neoplasms, obstruction or intestinal volvulus were
demonstrated in 14 (35.9%) patients. Preoperative
localization of gastrointestinal bleeding can be done
by using endoscopy, barium follow-through, small
bowel enema, 99mTc pertechnete scan, 99mTclabelled red cell scan and selective celiac and mesenteric angiography. Preoperative localization of gastrointestinal bleeding from obscure origin is usually
rather difficult. Unless preoperative investigations
showed the lesions in an anatomically fixed organ
such as the duodenum or colon, the lesions still had to
be identified at operation and therefore, intraoperative
localization procedures should be used more freely
[16]. Primary tumors, either benign or malignant
neoplasms, of the small bowel are rare. Most of our
patients found to have malignant tumor involving the
small bowel or mesentery had history of malignancy.
The major clinical impact of the radiological
results of barium meal small bowel examination on
patient management was to exclude a serious pathologic abnormality in patients with less specific
symptoms, such as abdominal pain, weight loss, or
miscellaneous symptoms [15]. The majority of
radiology departments performed barium followthrough examinations so far. Regardless of the practice
setting, these studies usually consist of a series of
overhead radiographs, with routine spot images of the
terminal ileum but not of the remaining small bowel.
This situation may need to be reassessed and all accessible small bowel loops be visualized at fluoroscopy
with representative radiographs to optimize the diagnostic yield of the examination [6]. Enteroclysis examinations (small bowel enemas) are being performed by
us only for a very few particular patients. The infrequent use of enteroclysis in our department may be
related to multiple factors, including, inadequate
training of radiologists in the technical aspects of ente-
Barium studies of the small intestine
roclysis, reluctance of some patients to undergo this
procedure and very time-consuming procedure.
In conclusion, the small bowel follow-through
study remains the primary diagnostic technique for the
patients suspected of having small bowel disease.
Barium follow-through carried out by technologists
combined with fluoroscopic examination by radiologist for the terminal ileum and suspected abnormal
areas can yield similar diagnostic results to the
dedicated fluoroscopic examination only by radiologists. Therefore, it may save much time for the radiologists.
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Barium studies of the small intestine