Downloaded from www.ajronline.org by 109.83.212.96 on 10/14/15 from IP address 109.83.212.96. Copyright ARRS. For personal use only; all rights reserved

279

Technical

Double-Contrast Colon David

W. Gelfand1

and

Enema:

David

A Simplified

and

Methods

After a brief history to

the

patient,

an air

is obtained tip

and the examination

is inserted

in the

rectum,

is explained

and

the

patient

receives an IV injection of 0.5 mg of glucagon. The injection relaxes the colon and makes the examination more comfortable, but it is not mandatory. Handles are fixed near the head of the table for the patient to grasp, and the patient is placed in the prone 15-20#{176} Trendelenburg position.

Under

fluoroscopic

control,

barium

suspension

(Liquid

Poli-

bar Plus, E-Z Em Co., Westbury, NY) is allowed to flow around the splenic flexure and into the distal transverse colon. With the patient remaining

in the prone

administered

with

Trendelenburg

a bulb-type

patient, the table is elevated, drained of barium suspension. position,

and again without

of air are administered. adequate

barium

position,

air pump

suspension

(Fig.

30 pumps

1A).

of air are

Without

moving

the

and the rectum and distal colon are The table is brought to the horizontal

moving

the patient,

Fluoroscopy has

a second

30 pumps

is used briefly to determine reached

the

transverse

colon

that and

that distension of the entire colon has been achieved. The tip is removed, and radiography of the distal colon and rectum is started. At this point, it is only necessary that the first rotation of the patient Received 1

August

Both authors:

AJR 154:279-280,

3, 1 989; accepted Department February

after revision

of Radiology,

for Filling the

Ott

J.

Among the useful attributes of a routine for filling the colon during a double-contrast enema are simplicity and ease of compliance by the patient. In this technical note, we present what we think is an unusually simple and undemanding method. The procedure requires minimal fluoroscopy and no movement of the patient while the colon is being filled. The method is sufficiently simple that it is easily learned by firstyear residents and radiologic technologists.

Materials

Method

Note

September

Bowman

1990 0361-803X/90/1542-0279

21

Gray School

,

be onto the right side, which ensures that sufficient sion is transferred

from the transverse

colon

barium suspen-

into the ascending

[1].

Discussion

This procedure for filling the colon with barium and air for a double-contrast enema was designed to provide maximal ease for the patient and simplicity of performance. It has been used in approximately 1 0,000 examinations performed over the past 1 3 years and has been tested thoroughly. A minority of these examinations were performed with conventional equipment; most were performed with remote control fluoroscopy. The method is learned easily by first-year radiology residents and by technologists experienced in gastrointestinal radiology [2].

A major

advantage

of the procedure

is that the patient

remains prone until radiography has been started. The table is placed first in the 1 5-20#{176}Trendelenburg position, then upright, and then horizontal, but the patient’s position is not changed with respect to the table. The procedure depends on the effects of gravity and the anatomy of the colon. With the patient in the prone Trendelenburg position, the mid-transverse colon is the most dependent segment of the colon. After injection of barium suspension and then air, a considerable fraction of the barium comes to rest in the transverse colon (Fig. 1 A). The transverse colon is also dependent when the patient is upright, and most

1989.

of Medicine, Winston-Salem,

© American

Roentgen

colon

(Figs. 1 B and 1C). This procedure can be used with radiographic sequences designed for conventional or remote control equipment

Ray Society

NC 271 03. Address reprint requests to D. W. Gelfand.

Downloaded from www.ajronline.org by 109.83.212.96 on 10/14/15 from IP address 109.83.212.96. Copyright ARRS. For personal use only; all rights reserved

280

A

GELFAND

AND

OTT

AJR:154,

B

February

1990

C

Fig. 1.-A, Large film of colon obtained after filling with barium suspension and 30 pumps of air while patient was in prone 15#{176} Trendelenberg position. Transverse colon is most dependent and has filled with barium suspension. B, Spot film of rectum and sigmoid colon obtained in left supine oblique position after removal of enema tip. Turning patient onto right side to reach this position has transferred barium from transverse colon into ascending colon and cecum (arrow). C, Left supine oblique view of colon obtained after spot filming shows adequate filling and coating of right colon.

of the barium remains there while the distal colon is being drained. When the patient is returned to the horizontal position and the second 30 pumps of air are insufflated, the barium suspension in the transverse colon either remains there or is displaced partially into the ascending colon. To complete the transfer of barium from the transverse colon into the ascending colon and cecum after the enema tip has been removed, it is only necessary to turn the patient onto the right side and then onto the back during initial filming of the rectum and sigmoid colon (Figs. 1 B and 1 C). The total of 60 pumps of air will distend the average colon when this method is used. The number of pumps is reduced to 50 pumps (25 plus 25) for smaller patients. However, patients who have a large colon should receive 60 pumps first. Additional air can then be insufflated as needed to achieve distension. With this procedure, air almost always precedes the barium suspension into the cecum. However, this does not produce an “air lock” and should not be of concern. Most of the barium suspension is in the transverse colon when filling has been completed, so turning the patient on the right side transfers barium into the right colon (Fig. 1 C), resulting in afairly uniform distribution of barium suspension among the major segments of the colon. Although this procedure has been designed for simplicity, it is not performed without fluoroscopy as was the “7 pump” method of Miller and Maghinte [3]. The brief periods of fluo-

roscopy allow greater control over the distribution of barium suspension and air than can be achieved with any blindly performed routine. The method thus accommodates itself to patients with colons of different capacity. Also, the fluoroscopist is alerted to any variant anatomy, such as surgical resection or nonrotation, which may require modification of the procedure. As a result, failure to distribute the barium suspension and air adequately within the colon is rare. Such failures are usually associated with a very tortuous colon or with an inexperienced fluoroscopist. The contribution of this procedure to the overall accuracy ofthe subsequent double-contrast enema has been confirmed by radiologic-endoscopic correlation studies [4]. Despite the simplicity of the procedure, the resulting examinations are at least as accurate as those in which more complicated methods of filling the colon are used. REFERENCES 1 . Gelfand DW. Gastrointestinal

radiology.

New

York:

Churchill

Livingstone,

1984:95-104 2. Campbell

JA, Leiberman

with technician

M, Miller RE, Dreesen

performance

of gastrointestinal

RH, Hoover

C. Experience Radiology

examinations.

1969;92:65-73 3. Miller RE, Maglinte DDT. Barium pneumocolon: technologist performed “7 pump” method. AJR 1982;139: 1230-1232 4. Ott DJ, Gelfand DW, Chen YM, Munitz HA. Single-contrast vs. doublecontrast barium enema in the detection of colonic polyps. AJR 1986; 146:993-996