QUIZ 1 MIDTERM 15 ITEMS

Problem solving A patient with a clinical history

of hiatal hernia comes to the radiology department. Which procedure should be performed on this patient to rule out this condition? (5pts)

Problem solving What projection if the

radiograph of the stomach demonstrates the fundus if filled with contrast media and the body and duodenal bulb is filled with air with the lesser curvature en face is best visualized seen. Why? (5pts)

11.- 12. Two Types of Ileus

13. – 15 Division of the small intestine

PASS YOUR PAPERS

LARGE INTESTINE/BARIUM

ENEMA

ANATOMY REVIEW OF THE LARGE

INTESTINE

LARGE INTESTINE

It begins in right iliac region when it joins the ileum of the small intestine.

The length is approximately 5 ft. (152cm) long and is greater in diameter than the small bowel.

Functions The large intestine takes about 32 hours

to finish up the remaining processes of the digestive system.

The large intestine simply absorbs vitamins that are created by the bacteria inhabiting the colon. It also absorbs water and compacts feces, and stores faecal matter in the rectum until eliminated through the anus

Location It starts in the right iliac region of the pelvis,

just at or below the right waist, where it is joined to the bottom end of the small intestine.

From here it continues up the abdomen, then across the width of the abdominal cavity, and then it turns down, continuing to its endpoint at the anus.

Large Intestine Anatomy CECUM  COLON  RECTUM ANUS                                 

Cecum The cecum or caecum (from the Latin

caecus meaning blind) is a pouch, connecting the ileum with the ascending colon of the large intestine.

It is separated from the ileum by the ileocecal valve (ICV) or Bauhin's valve, and is considered to be the beginning of the large intestine.

Ascending colon The ascending colon, on the

right side of the abdomen, is about 25 cm long

It is the part of the colon from the cecum to the hepatic flexure (the turn of the colon by the liver).

Transverse colon The transverse colon is the part of

the colon from the hepatic flexure to the splenic flexure (the turn of the colon by the spleen).

The transverse colon is encased in peritoneum, and is therefore mobile (unlike the parts of the colon immediately before and after it).

Descending colon The descending colon is the part

of the colon from the splenic flexure to the beginning of the sigmoid colon.

The function of the descending colon in the digestive system is to store food that will be emptied into the rectum.

Sigmoid colon The sigmoid colon is the part of the

large intestine after the descending colon and before the rectum. The name sigmoid means S-shaped

The walls of the sigmoid colon are muscular, and contract to increase the pressure inside the colon, causing the stool to move into the rectum.

*Rectum and Anal Canal* Rectal Ampulla Anus Anal canal

Rectum The rectum (from the Latin rectum

intestinum, meaning straight intestine) is the final straight portion of the large intestine and terminating in the anus. The human rectum is about 12 cm long

Its caliber is similar to that of the sigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla.

Colon subdivision Ascending Transverse Descending Sigmoid

BARIUM ENEMA

Barium Enema (BE or Lower GI series) It is a Radiographic study of

the large intestine. Purpose:

to study Radiographically the form and function of the large intestine, as well as to detect any abnormal conditions.

Clinical indications Colitis Diverticulosis Neoplasm Volvulus Intussusceptions Appendicitis

Colitis Inflammation of the colon Image – thickening of mucosal wall

and loss of haustral markingsDiverticulum

outpouching of the mucosal wall resulting from herniation of the inner wall of the colon.

Image – jagged or sawtooth appearance of the mucosa

Neoplasm tumors in large intestine. Image - narrowness or tapering of

lumen “apple core” or “napkin-ring” lesions

Volvulus twisting of a portion of the intestine

on its own mesentery. Image – corkscrew in appearance

with air-filled distended region of the intestine

Intussusceptionstelescoping of one part of the

bowel into another.Image – mushroom-shaped

dilation at the distal aspect of the intussusception with little or no gass passing beyond it.

Colitis

DiverticulaeApple core

Volvulus “coffe bean”

Intussusceptions

Preparation of the Patient The final objective is that the

section of alimentary canal to be examined must be empty.

2 – classes of Cathartics (laxative) Irritant cathartic – castor oil Saline cathartic – magnesium

citrate or sulfate

Contraindications to Cathartics

Gross bleeding Severe diarrhea Obstruction Inflammatory lesions

(appendicitis)

Contrast Media High – density Barium Sulfate

It is excellent for use in double-contrast studies of the alimentary tract in which uniform coating of the lumen is required.

Air contrastCarbon dioxide may also be used

because it is more rapidly absorbed than nitrogen of air when evacuation.

Mixture of Barium suspensions

12 % - 25% weight / volume – Single contrast

75% - 95% weight / volume – Double contrast

Barium Containers Closed system type

enema Open system type

enema

Close system type

Enema Tips 3 – common enema

tipsPlastic disposableRectal retentionAir contrast retention

Enema tips

Enema tips insertion  Sims position – relaxes the abdominal muscles and decreases pressure within the abdomen.

Sims Position

Summary of Enema tip insertion1. Describe the tip insertion to pt. 2. Place pt in sims position. (pt

should lie on the left side, with the right leg flexed at the knee and hip

3. Shake and inspect the enema container to provide good mixture. Allow the barium to flow through the tubing and from tip to remove any air in the system

4. Wearing gloves, coat enema tip with water-soluble lubricant.(KY jelly or any sterile lubricant)

5. On expiration, direct enema tip toward the umbilicus proximally 1 to 1.5 inches

6. After initial insertion, advance up superiorly and slightly anteriorly. Do not force enema tip.

7. Tape tubing in place to prevent slippage. Do not inflate unless directed by radiologist

8. Ensure IV pole/enema bag is no more than 24 inches (60cm) above the table. Ensure tubing stopcock is in the closed position and no barium flows into the pt.

Procedures 3 – Types of Examinations

of ColonSingle – contrast Ba. EnemaDouble – contrast Ba. Enema

Defecogram

Single Contrast Barium Enema

Double Contrast Ba. Enema

Defecogram

Cont…Single – contrast

utilizes only a positive contrast medium.

Double – contrastDifference is that in an examination there is both air and barium.

2  - APPROACHES OF DOUBLE-CONTRAST

ADMINISTERING

Two-stage procedure described “by Welin”

A.  In which the entire colon is filled with a barium suspension.

B. Patient evacuates the barium and immediately returns to the fluoroscopic table for injection of air or other gaseous contrast into the colon.

Single-stage double contrast examination The barium and the air

are instilled in a single procedure as compared to the two-stage which reduces time and radiation to patient.

7 – pump method (by Miller)1) 7 pumps, left lateral position2) 7 pumps, LAO position(left PA-

oblique)3) 7 pumps, prone position4) 7 pumps, RAO position5) 7 pumps, right lateral position6) 7 pumps, RPO position7) +7 pumps, supine position

“PRIOR TO ANY SPECIAL PROCEDURE A SCOUT

FILM SHOULD BE TAKEN FIRST.”

POSITIONING AND FILMING

10 – Routine Sequence of Radiographs1) AP – Rectosigmoid area2) Left lateral – Rectum 3) AP/PA – Full Barium whole

abdomen4) AP/PA – Double Contrast

study5) Left & Right Oblique –

Flexures

Cont…6) Left Lateral Decubitus – Air

Filled Colon7) Right Lateral Decubitus – Air

Filled Colon8) Pt. In Prone W/ Cross Table

Projection – Rectosigmoid Area

9) Angle Prone – Rectosigmoid Area

10)Post Evacuation