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Barium Enema

= Colon in Loop
The routine examination of the colon

Technique :
• Single Contrast : barium suspension
• Double Contrast : barium susp.+ gas
Radiology Anatomy

Caecum - colon - rectum

Indication

Single contrast barium enema :

 Intussusceptions
 Diverticle dss/diverticulosis/diverticulitis
 Colonic polyps
 Colon and rectal carcinoma
 Crohn’s dss
 Hirschprungs dss
 Fatique / very old patient / serious illness
 Suspected pelvic metastasis
 Indication

Double contrast barium enema :

• Melena / bloody stool
• Chronic diarrhea
• Pain & abdominal discomfort
• IBD (inflamatory bowel dss)
• Diverticulosis
• Suspected colonic carcinoma
• Suspected colonic polyp / familial polyposis
• Family history of colonic ca / polyp
Contraindication

• Suspected bowel perforation

• Toxic megacolon
• After colonic biopsi
• After snare polypectomy
Complication

• Gas pain
• Colonic perforation or colonic ruptur
• Water intoxication
• Colonic intramural barium
• Rectal laserasion
• Bactery contamination
• Allergy / hipersensitivitas of barium or
glukagon/buscopan
Preparation

Patient preparation

Low residue diet

Increased fluid intake
Rectal or oral laxative (if needed)
Antispasmodic agent :
1. Glucagons : intravenous : 0,5 – 1 mg.
2. Buscopan (hyoscine N-butylbromide) : iv or
im : 1 ampul (20 mg/mL)
Contrast preparation

Barium sulphate suspension :

• Single contrast : 12% - 25% w/v
• Double contrast : 70% - 100 % w/v
Conventional digital fluoroscopy
Remote-control fluoroscopy
 4
1
Irigator preparation
Plastic irigator :
1. enema tip
2. enema tube
3. enema reservoir bag
4. retention balloon with its 3
inflator.

2
1

4
2
 Technique & positioning

A.
Left lateral position :
contrast filling
rectum and
rectosigmoid

B.
Left posterior
oblique (LPO):
contrast filling
sigmoid
C.
Left lateral with 15o
Trendelenberg position :
contrast flow to descendent
colon and lienalis flexure

D.
Clockwise to prone position:
contrast filling transversal
colon
E.
Clockwise to right lateral
with 15o Trendelenberg
position : contrast filling the
hepatic flexure

F.
From E, turn left to supine
position : contrast filling
hepatic flexure and
ascendant colon
G.
Turn to left posterior oblique
(LPO) to filling the
ascendants colon

H.
From G position, turn
clockwise to supine
position: contrast filling the
caecum
Recording / filming

• Plain abdominal photo

• Spot photo
• Overhead whole abdomen

Plain abdominal photo

Barium
Enema
Single
Contrast
Spot film : Single contrast

Rectum (left lateral) Sigmoid Lienalis flexure

Hepatic flexure Caecum

Whole abdomen : single contrast

Whole colon :
 overhead film

Overhead film
Barium
Enema
Double
Contrast
Spot film : double contrast

Rectum & sigmoid :

Lateral position Supine position Prone position

Spot film : double contrast

Distal descendant colon Proximal

Sigmoid :
descendant colon
posterior oblique
Spot film : double contrast

Lienalis flexure Transverse colon

(RPO) Erect position
Spot film : double contrast
Ascendant colon

Hepatic flexure

Erect position Erect position, LPO

Spot film : double contrast
caecum & terminal ileum
Caecum & appendix
Overhead film :
whole colon
Others position (if needed)

Right lateral decubitus (RLD)

- Redundant colon
- Decubitus to right side
(RLD)
- Horizontal ray
- Clearly evaluated :
lateral of descendant
and medial of
ascendant colon
 Others position (if needed)

Left lateral decubitus (LLD)

- Redundant colon
• Decubitus to left side
- Horizontal beam
• Clearly evaluated : lateral of
ascendant and medial of
descendant colon
 Single contrast vs Double contrast

SC DC

• Motility (+/-).
• Contour and mucosa (++)
• Difficult technique
 Motility study (++).
 Bowel contour (++),
mucosa (-)
 Simple technique.
False-positive findings :

1. Residual stool  may mimic a tumor.

2. The ileocecal valve  may mimic a cecal
tumor.
3. A submucosal mass (such as a lipoma or
benign mucosal adenoma)  may be
indistinguishable from a small polypoid
cancer.
4. Diverticulitis  Strictures and paracolic
collections may mimic a neoplasm.
 false-positive findings :

5. Extrinsic compression of the colon by an

adjacent tumor may mimic a primary colonic
tumor.
6. Strictures: Inflammatory bowel disease,
ischemic colitis, radiation colitis, and
tuberculous colitis may mimic a malignant
strictures.
False-negative findings :

1. Inadequate bowel preparation: Residual

stool may obscure a carcinoma.
2. Diverticulosis: severe sigmoid diverticulosis
 missed cancers is increased.
3. Small lesions: may be missed in a dense
pool of barium.
4. Errors of perception: can be reduced by a
second reading performed by a different
observer.
 Polyp

Bubble 
Pedunculated Polyp

Sessile Polyp

En profile view

En face view

En profile view

Mexican hat sign “sombrero”

Malignant polyp : villous type
 • Apple core sign
• Shoulder sign

Carcinoma colon : annular type

 Colonic diverticulitis

Colonic diverticulosis

Multiple additional shadow

 IBD : ulcerative colitis

Continuous ascendering lesion

Segmental colitis Pancolitis

IBD: Colitis Crohn’s
• Discontinuous lesion of the
bowel,
• Skip lesion sign.
 Colitis TB

Caecum 

 Terminal ileum

Rectal Ca.
• Barium enema lateral view.
• The lumen of the rectum is narrowed
severely by the circumferential mass
with mucosal destruction and the
overhanging edges or shouldering at the
tumor margins.
 Colonic polyp
Filling defect on single contrast Soft tissue mass on double contrast
 Extraluminal tumor

Ba enema : ileocaecal intussusceptions

(Coiled spring appearance)
Secondary tumor.

Metastases from breast

carcinoma