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Technical Innovation |
1
Department of Radiology, Children's Hospital Medical Center, 3333 Burnet Ave.,
Cincinnati, OH 45229-3039.
2
Present address: Austin Radiological Association, 6101 W. Courtyard Dr., Bldg.
5, Austin, TX 78730.
Received June 3, 1999;
accepted after revision May 15, 2000.
Address correspondence to L. L. Barr.
Introduction
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The child is given a clear liquid diet beginning at noon on the day before the test. The child is also administered one dose of magnesium citrate (Table 1) the evening before the test. Ideally, the examination is scheduled early in the morning so the child will not have to go to school hungry. When the child arrives, the technologist inquires about the color and consistency of the last bowel movement. A scout film is performed if the last bowel movement was not liquid and clear or yellow. If the patient is not adequately prepared, he or she is rescheduled for the next day and instructed in detail about preparation.
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Next, the technologist explains to the patient that the purpose of the test is to coat the colon with barium and fill it with air by inserting into the rectum a tiny tube that is smaller than the patient's normal bowel movement. After the air is administered, the patient is turned in various directions to coat the colon with the barium.
With the patient in the left lateral position, the technologist or radiologist inserts the lubricated rectal tube using a standard enema bag system (Super XL Enema Bag System; E-Z-EM, Westbury, NY). After the tip is inserted, the balloon is not inflated. The buttocks are taped with three pieces of cloth adhesive tape approximately 2.54 cm wide and 20 cm long. The tape is positioned as a sling around the rectal tube, with two pieces of tape in the shape of the letter U and one as an inverted U.
The patient is placed in the prone position and the table tilted 5-10° in the Trendelenburg position. Barium sulfate suspension (HD 85; Lafayette Pharmaceuticals (Canada), Lafayette, IN) is instilled slowly to and not past the splenic flexure. The child is instructed to let the radiologist know if he or she feels any cramping. If the patient experiences cramping during the administration of the barium or air, the instillation is stopped until the cramping ceases. After the appropriate volume of barium sulfate has been introduced, the barium tube is clamped and the table is brought to a horizontal position. Clamping the distal end of the tubing with both the plastic clamp that comes with the tubing set and an extra hemostat prevents excess barium from flowing into the rectum.
The patient is turned to the left lateral position and air is pumped slowly into the colon. One pump consists of a slow full squeeze on a regular sphygmomanometer bulb. The number of pumps administered per position is based on age, as described in Table 2. Pumps appropriate for the child's age are administered in the following six-position sequence: left lateral position, left anterior oblique position, right anterior oblique position, right lateral position, and supine position.
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Brief fluoroscopy is used to ensure that barium and air have reached the cecum. Then the patient is asked to rotate clockwise to the prone position, and the table is elevated 68-80° to the reverse Trendelenburg position. The rectum is drained of excess barium and four more pumps of air are introduced. Then the enema tip is removed. Early removal of the enema tip is key to patient satisfaction because removal decreases the sensation of impending defecation.
The table is returned to the horizontal position and the child is asked to lie in the left lateral position. A spot film of the lateral rectum is obtained. The child then rotates counterclockwise to the left posterior oblique position for a spot film of the sigmoid colon. Next, the child rotates counterclockwise to the supine position for an anteroposterior spot film of the rectum. A soft compression paddle and lead glove are used to obtain a spot film of the cecum and terminal ileum. Reflux into the terminal ileum or appendix is necessary to ensure the entire colon has been visualized. If this has not yet occurred, the spot films of the cecum are delayed until later in the examination. The table is raised to the vertical position, and the child turns to the right posterior oblique position for spotting of the splenic flexure. The child assumes the left posterior oblique position for spotting of the hepatic flexure.
Next, the table is returned to the horizontal position and the following overhead films are obtained: anteroposterior and posteroanterior abdominal films, right lateral and left lateral decubitus films of the abdomen, a prone cross-table lateral view of the rectum, and a posteroanterior view of the rectum. The radiologist checks each radiograph as it emerges from the processor to expedite repeating films if necessary. This step hastens the end of the examination by allowing the patient to evacuate as soon as possible and the room to be cleaned for the next patient.
If reflux into the terminal ileum or appendix did not occur earlier, it is at this point that the cecum is spotted. The child is then allowed to evacuate the barium. A film after evacuation is necessary only if areas of the colon were previously obscured by barium or if there has not been reflux into the terminal ileum or cecum. If the sigmoid colon is redundant, the film of the abdomen after evacuation may be obtained in the left posterior oblique position with cranial X-ray tube angulation of 15°.
The method described here was introduced 10 years ago to replace a double contrast technique in which a caulking gun was used to instill thick barium and a Foley catheter was used to instill air. This method has been highly successful in a department in which 30 double contrast enemas are performed each year. The method has been taught to radiology residents, pediatric radiology fellows, and practicing pediatric radiologists.
Fluoroscopy time averages 80 sec and is less than 2 min in all cases. Using this technique, we have had no incidents of nondiagnostic quality examinations, nor have we found it necessary to use glucagon or carbon dioxide to decrease discomfort. Patient satisfaction is high, most likely because the examinations are scheduled early in the day, the enema tip is removed early, and glucagon is not injected before the examination.
Children often enjoy seeing one of the radiographs before they leave the department and learning the results, if possible. Parents enjoy being told that the examination was of high diagnostic quality. Technologists appreciate a set routine for what can be a stressful examination for the patient.
In conclusion, the method described for the performance of double contrast barium enema in children has been successful in both hospital and outpatient settings for 10 years. Adoption of a departmental standard for examination performance provides a pleasant experience for everyone.
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