BARIUM ENEMA

• This consists of a series of x-ray films visualizing the colon. It is used to demonstrate the presence and location of polyps, tumours, and diverticula, and other anatomic abnormalities.
• Therapeutically it may be used to reduce non strangulated ileocolic intussusception in children.

Procedure and patient care

• Before
• Explain the procedure to the patient
• Encourage the patient to verbalize questions and fears
• Assist the patient with bowel preparation

Day before examination

• Give the patient clear liquids for lunch and supper(no diary products)
• Have the patient drink one glass of water or clear fluid every hour for 8-10 hours
• Administer a cathartic(10ounces)of magnesium citrate or x’prep(extract of senna fruit)at 2pm.
• In children lesser volumes may be used

Day before examination cont’d

• Administer three 5mg bisacodyl (dulcolax) tablets at 7pm
• Pediatric fleet enema the night before testing and repeated 3hours before testing may be adequate preparation for an infant
• Keep the patient NPO after midnight the day of the test

Day of examination

• Keep the patient NPO
• Administer a bisacodyl suppository at 6am and /or a cleansing enema
• Note that special preparations will be ordered for patients with an ileostomy or colostomy
• Determine whether the bowel is adequately cleansed, when the faecal return is similar to clear water, preparation is adequate

Day of examination cont’d

• Suggest that the patient take reading material to the x-ray department to occupy time while expelling the barium

During

• The test begins with placement of a balloon rectal catheter
• The balloon on the catheter is inflated tightly against the anal sphincter to hold the barium within the colon.
• The patient is asked to roll in the lateral,supine and prone positions.

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During cont’d

• The barium is dripped into the rectum by gravity. The colon of the young adult is not able to tolerate the volume and pressure of instillation of barium that an adult can, both should be reduced.
• The barium flow is monitored fluoroscopically
• The colon is thoroughly examined as the barium flow progresses through the large colon and into the terminal ileum

During cont’d

• The barium is drained out
• If an air-contrast barium enema has been ordered, air is insufflated into the large bowel
• The patient is asked to expel the barium and a post evacuation x-ray film is taken.
• The standard procedure for administering the barium through a colostomy is to instill the contrast medium through an irrigation cone placed in the stoma.

During cont’d

• When the x-ray series is completed, the barium is allowed to be expelled from the stoma. A gentle stream of clean water for irrigation is helpful in expelling residual barium
• Inform the patient that abdominal bloating and rectal pressure will occur during instillation of the barium.

After

• Ensure that the patient defaecates as much barium as possible
• Inform the patient that bowel movements will be white when all the barium has been expelled,the stool will return to normal colour
• Suggest the use of soothing ointments on the anal area to minimize any anorectal pain that may result from the test preparation

After cont’d

• Encourage ingestion of fluids to avoid dehydration caused by cathartics
• Encourage rest after the procedure . The cleansing regimen and the BE procedure may be exhausting
• Note that laxatives may be ordered to facilitate evacuation of the barium

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After

• Beware of dehydration and give electrolyte containing fluids.

Contraindications

• Patients suspected of a perforation of the colon ,in these patients diatrizoate(gastrogravin) a water soluble contrast medium is used
• Patients who are unable to coperate,this test requires the patient to hold the barium in the rectum and colon, this is especially difficult for elderly patients.

Contraindications cont’d

• Patients with mega colon ,barium may worsen the condition.

Barium swallow

• This is a more thorough examination of the oesophagus than that provided by most upper gastrointestinal series
• Defects in normal filling and narrowing of the barium column indicate tumour,strictures or extrinsic compression from extra esophageal tumours or an abnormally enlarged heart and great vessels.

Barium swallow cont’d

• In patients with oesophageal reflux, the radiologist may identify reflux of the barium from the stomach back into the oesophagus.
• Muscular abnormalities such as achalasia, as well as diffuse oesophageal spasm can be easily detected by a barium swallow
• A water-soluble x-ray contrast should be used.

Procedure and patient care

Before

• Explain the procedure to the patient,tell him no discomfort is associated
• Instruct the patient not to take anything by mouth for at least 8hours before the testing
• Usually the patient is kept NPO after midnight on the day of the test.

Before cont’d

• Assess the patient’s ability to swallow. If the patient tends to aspirate, inform the radiologist.
• Accompany the hospitalized patient to the x-ray department.

During

• The fasting patient is asked to swallow the contrast medium. Usually this is barium sulphate in a milk shake-like substance however ,if a perforated viscus is possible Gastrografin is used
• As the patient drinks the contrast through a straw, the x-ray table is tilted to the near-erect position

During cont’d

• The patient is asked to roll into various positions so that the entire oesophagus can be adequately visualised
• With fluoroscopy, the radiologist follows the barium column through the entire oesophagus

After

• Inform the patient of the need to evacuate all the barium, cathartics are recommended. Initially stools are white but should return to normal colour with complete evacuation

Contraindications

• Patients with evidence of bowel obstruction barium may create a stone-like impaction
• Patients with a perforated viscus
• Patients whose vital signs are unstable
• Patients who are unable to cooperate

ENDOSCOPIC PROCEDURES

UPPER GASTROINTESTINAL FIBEROSCOPY/ESOPHAGOGASTRO-DUODENOSCOPY(EGD)

• Fiberoscopy of the upper gastro intestinal tract allows for direct visualization of the oesophageal,gastric and duodenal mucosa through a lighted endoscope (gastroscope)

Endoscopic procedures cont’d

• This procedure is especially valuable when oesophageal,gastric or duodenal abnormalities and inflammatory, neoplastic or infectious processes are suspected
• Oesophageal and gastric contents can be collected for further analysis.
• Still or video photography taken through the scopes allows for documentation of findings.

Endoscopic procedures

• Upper gastrointestinal fiberoscopy also can be a therapeutic procedure when combined with other procedures
• Therapeutic endoscopy can be used to remove common bile duct stones, dilate strictures treat gastric bleeding and oesophageal varices

Patient preparation

• The patient is instructed to fast for 6-12hours before the examination
• The preparation includes spraying or gargling with a local anaesthetic,along with administering diazepam(valium) intravenously, just before the scope is introduced
• Atropine may be administered to reduce secretions

Patient preparation cont’d

• Glucagon may be given to relax smooth muscle
• The patient is positioned on the left side to facilitate saliva drainage and to provide easy access for the endoscope

procedure

• The gastroscope is lubricated with water soluble lubricant and then passed smoothly and slowly along the back of the mouth and down into the oesophagus
• The doctor views the gastric wall as well as the sphincters.
• The endoscope is then advanced into the duodenum for further examination

Procedure cont’d

• Biopsy forceps to obtain tissue specimen or cytology brushes to obtain cells for microscopy study can be passed
• The procedure generally takes about 30minutes
• During the EGD it is important to monitor and maintain the patient’s airway
• supplementary oxygen may be used if needed

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post procedure care

• After a gastroscopy the patient is instructed not to eat or drink until the gag reflex returns, in 1-2hrs to prevent aspiration of food or fluids into the lungs.
• Post gastroscopy assessment by the nurse includes observing for signs of perforation, such as pain,bleeding,unusual difficulty, swallowing and an elevated temperature.

Post procedure care cont’d

• Minor throat discomfort can be relieved with lozenges, saline gargles and oral analgesics after the gag reflex has returned. Patients who were sedated for the procedure are maintained on bed rest until they are fully alert.

Anoscopy ,Proctoscopy,and Sigmoidoscopy

• Procedures for the study of the lower portion of the colon make use of instruments that use small beams of light that allow the lumen of the lower bowel to be viewed directly. These can be rigid scopes or flexible fiberoptic scopes.
• The anoscope is a rigid scope used to examine the anal canal.

Anoscope ,protoscope,and sigmoidoscope cont’d

• Protoscopes and sigmoidoscopes are rigid scopes used to inspect the rectum and the sigmoid colon, respectively for evidence of ulceration, tumours, polyps or other pathologic processes.it is an important aspect of the cancer screening process.

Patient preparation

• These examinations require only limited bowel preparation. A warm tap water enema or Fleet’s enema is given until returns are clear.
• Dietary restrictions as well as sedation is not usually required.

Rigid scope procedures

• The patient assumes the knee-chest position at the edge of the bed or the examining table with the back inclined at about a 45 degrees angle.
• During a proctosigmoidoscopic examination,the patient is kept informed about the progress of the examination.

Rigid scope cont’d

• The patient is informed that the pressure exerted by the instrument will create the urge to have a bowel movements

Flexible scope procedures

• The patient is placed in a comfortable position on the left side with the right leg bent and placed anteriorly.
• Biopsies and polypectomies also can be performed during this procedure
• Rectal and sigmoidal polyps ,if present, may be removed with a wire snare.
• An electro coagulating current is then used to sever the polyp and prevent bleeding

Post procedure care

• The patient is monitored for rectal bleeding and signs of intestinal perforation such as fever, rectal drainage, abdominal distension and pain.

LIVER BIOPSY

• Liver biopsy is a safe ,simple and valuable method of diagnosing pathologic liver conditions.
• A specially designed needle is inserted through the abdominal wall and into the liver.
• A piece of liver tissue is removed for microscopic examination.

Liver biopsy cont’d

• Percutaneous liver biopsy is used in the diagnosis of various liver disorders such as cirrhosis, hepatitis, drug reaction ,granuloma and tumour

Indications

• Patients with:
• Unexplained hepatomegaly
• Persistently elevated liver enzymes
• Suspected primary or metastatic tumour
• Unexplained jaundice
• Suspected hepatitis
• Suspected infiltrative diseases

Liver biopsy cont’d

• The biopsy may be performed by a “blind” stick or directed with the use of a computed tomography(CT) or magnetic resonance imaging(MRI)scan.
• Directed scans are used if there is a specific area of the liver that is suspicious and from which tissue must be obtained eg metastatic tumour
• The “ blind stick” is used if the liver is diffusely involved

Contraindications

• Uncooperative patients who cannot remain still and hold their breath during sustained exhalation
• Patients with impaired hemostasis
• Patients with infections in the right pleural space or right upper quandrant,because the biopsy may spread the infection

Contraindications cont’d

• Patients with obstructive jaundice. In these patients, bile within the ducts is under pressure and may subsequently leak into the abdominal cavity after needle penetration.
• Patients with haemangioma. This is a very vascular tumour and bleeding after a biopsy may be severe

Procedure and patient care

• before
• Explain the procedure to the patient, many patients are apprehensive about it
• Obtain an informed consent
• Ensure that all coagulation tests are normal
• Instruct the patient to keep NPO after midnight on the day of the test
• Administer any sedative medications as ordered.

During

• The patient is placed in the supine or left lateral position
• The skin area used for puncture is anaesthetized locally
• The patient is asked to exhale and hold the exhalation. This causes the liver to descend and reduces the possibility of pneumothorax. Frequently the patient practices exhalation two or three times before insertion of the needle.

During cont’d

• During the patient’s sustained exhalation, the physician rapidly introduces the biopsy needle into the liver and obtains liver tissue

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• Several types of needles are available
• Occasionally the biopsy needle is inserted under CT guidance especially when tissue from a specific area of the liver is needed.

During cont’d

• The needle is withdrawn from the liver
• This test is performed by a physician in approximately 15minutes.

After

• Place the tissue sample into a specimen bottle containing formalin and send it to the pathology department.
• Apply a small dressing over the needle insertion site
• Place the patient on his left or right side for approximately 1-2hours. In this position, the liver capsule is compressed against the chest wall thereby decreasing the risk of haemorrhage and bile leak. Assess vital signs frequently for evidence of haemorrhage

Potential complications

• Haemorrhage caused by inadvertent puncture of a blood vessel within the liver
• Chemical peritonitis caused by inadvertent puncture of a bile duct, with subsequent leakage of bile into the abdominal cavity
• Pneumothorax caused by improper placement of the biopsy needle into the adjacent chest cavity

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Abnormal findings

• Benign tumour
• Malignant tumour
• Abscess
• Cyst
• Hepatitis
• Infiltrative diseases- cirrhosis, amyloidosis, hemochromatosis.