Progressreport Barium examination thesmallintestine

Gut, 1981, 22, 682-694

Progress report

Barium examination of the small intestine

Radiological studies showing the small intestine were first performed at thebeginning of this century. In 1901 Cannon observed radiographically thestomach and small intestine of animals after they had ingested food mixedwith bismuth subnitrate.' Rieder2 observed the small intestine in humansubjects when he performed his bismuth meal examination. The smallintestine was also visualised radiographically by Hulst using bismuth sub-nitrate.3 Little attention was given to the radiological investigation of thesmall intestine with contrast medium until papers by Morse and Cole in19274 and Pesquera in 1929.5 Since then barium studies have become well-established in the diagnosis of diseases of the small intestine. This report is areview of the different techniques available for examining the small intestinewith barium-their development, advantages, and shortcomings.

Indirect techniques

FOLLOW-THROUGH OF ORAL BARIUM

The anatomy of the small intestine as shown on the barium follow-throughwas described by Cole and his colleagues.46 A moderately thick paste using227 ml (8 oz) barium mixed with 142 ml (5 oz) water was given. Thisconsistency of contrast medium was chosen so that it would pass out of thestomach at a fairly rapid and uniform rate and be of sufficient consistency topass evenly, and preferably very slowly, through the small intestine. Largefilms were taken, mostly in the prone position, one half hour after the uppergastrointestinal tract examination and then at two, four, and six hours. Thetime interval was varied according to the rate of gastric emptying.The importance of carrying out a special study of the jejunum and ileum

with barium was emphasised in 1936 by Golden7 and also by Pendergrassand his colleagues.8 Golden perfected the barium follow-through technique.He pointed out that the small intestine could be the source of the trouble inpatients with diarrhoea and deserved a radiological study if the large intestinewere found to be normal.' At that time he recommended that 57 ml (2 oz) ofbarium sulphate mixed with water should be given on an empty stomach firstthing in the morning. With the patient prone, films were taken at half-hourlyintervals, sometimes quarter-hourly, until barium reached the ascendingcolon or until adequate information concerning the small intestine wasobtained. Films were taken routinely after five, six, nine, and 24 hours.Fluoroscopic observations of the intestinal movements, mobility and ten-derness, were made two or three times during the examination. He notedthat the opaque material began to pass through the ileocaecal valve one-and-a-half to four hours after ingestion in normal individuals.

In later years he recommended a large amount of barium, (113 g; 4 oz)pure barium sulphate suspended in 114 or 142 ml (4 or 5 oz) of normal salinesolution or the equivalent quantity of a non-flocculating barium suspended in

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water.9 He stated that the non-flocculating preparations were better for thedemonstration of organic disease. The importance of using a non-flocculatingbarium suspension for showing the maximum mucosal detail of the smallintestine was first recognised by Ardran and his colleagues. 'The barium follow-through examination of the small intestine has a big

disadvantage in that it is time-consuming for the patient, the radiologist, andthe radiology department. A number of suggestions have been made forincreasing the speed of barium through the small intestine. Weintraub andWilliams" found that a marked decrease in the transit time of the contrastmedium through the small intestine was obtained when the barium-salinemixture was followed by ice-cold normal saline. The mucosal pattern wasmore clearly delineated and there was more complete filling of the entiresmall intestine than with the hourly film technique, they claimed. Theyfound that 90% of examinations were completed in one hour.

Metoclopramide has proved to be an effective agent for increasing thespeed of oral barium through the small intestine. A dose of 20 mg may begiven intravenously2' 3 after examination of the oesophagus and stomachwith barium. Kreel'4 gave the same dose of metoclopramide orally 5-10minutes before barium meal and follow-through examinations. Metoclop-ramide promotes gastric emptying and accelerates the transit of bariumthrough the small intestine thus allowing the routine follow-through to beundertaken with the minimum of extra films and radiation. Apart from anincrease in the number of contracted segments there was no detectabledifference in the pattern of the small intestine or its calibre. 14Adding Gastrografin to the barium also reduces the transit time taken for

barium to pass through the small intestine.' Other pharmacological agentshave been suggested such as neostigmine,'6 glucagon,'7 cholecystokinin,'8'9and ceruletide.202 However, the advantage of decreasing the transit time isoffset by diminished anatomical detail, particularly in the terminal ileum.2'

Preliminary cleansing of the colon, combined with the use of 284 ml(10 oz) or more of oral barium suspension and placing the patient in the rightlateral recumbent position was suggested by Nice.2223 He stated that thistechnique produced rapid uniform filling of the small intestine resulting in anexcellent diagnostic pattern.The barium follow-through is the most widely used procedure for examin-

ing the small intestine with contrast medium. A barium meal examinationfollowed by a conventional follow-through examination of the small intestinewas recommended by Laws and Pitman.24 They also advocated an examina-tion of the small intestine using duodenal or jejunal intubation in certainselected cases, notably when an anatomical lesion of the intestine wassuspected and had not been satisfactorily demonstrated by conventionalmeans. They stated, however, that in some cases the barium enema was thebest way of demonstrating chronic strictures of the lower ileum.A number of reports show that the barium follow-through is not accurate

for assessing the small intestine in Crohn's disease. In a review of 100patients with regional enteritis seen over a period of26 years examined by thebarium follow-through, Meyers and his colleagues25 stated that it was notuncommon for the radiologist to fail to find the lesion after it had beendemonstrated on the operating table. The results of the National CooperativeCrohn's Disease Study in the United States have recently been published.26The follow-through and single contrast barium enema gave inadequate

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radiographic definition ofone or more segments and prevented evaluation ofthat segment in a surprisingly high number of instances. Evaluation of theextent and depth of the disease was unsatisfactory and it seemed likely thatmucosal irregularity was undetected. As a result the data concerning thenature and extent of Crohn's disease were treated with caution. The poorquality of the radiographic examination was likely to result in under-estimation of the extent of ileal involvement. Better visualisation of theileum was obtained with barium refluxed into the terminal ileum duringbarium enema examinations. The barium studies were from 14 Universityhospital centres and probably reflect the average level of radiographictechnique currently practised.The only merits of the barium follow-through are that it is simple to

perform and causes no discomfort to the patient.

ORAL DOUBLE CONTRASTIt is possible to obtain double contrast views of the small intestine after theoral administration of barium. Pajewski and his colleagues in 197027 injected60 mg propantheline (Probanthine) intramuscularly and passed a flexibletube to the stomach about 40 minutes after a barium meal. Air pumped intothe stomach passed through the duodenum and as a result distended theloops of small intestine. The oral barium coated the walls of the intestine anddouble contrast views were obtained. Later they changed their techniqueand used a duodenal tube to introduce the barium and air.28A method for performing double contrast examinations of the small

intestine without intubation has been described.29 Oral barium followed bycapsules that effervesce in the small intestine were prescribed and hypotoniawas produced by propantheline (Probanthine) or glucagon. Successfuldouble-contrast examinations of the small intestine were obtained in 90 outof 130 patients and the average transit time of the contrast medium throughthe small intestine was 78 minutes.

COMPLETE REFLUX EXAMINATIONThe terminal ileum can be examined by refluxing barium through theileocaecal valve during a barium enema examination. This method has beenadvocated as the technique of choice for demonstrating the terminal ileumradiologically.303' The whole small intestine can be demonstrated by reflux-ing barium from the colon into the terminal ileum.32 A large volume ofbarium suspension is required (2000-4500 ml) and it is possible to make itreflux as far as the duodenum and into the stomach. The complete refluxexamination is particularly useful in the investigation of patients with smallintestinal obstruction.

PER ORAL PNEUMOCOLON EXAMINATION OF ILEOCAECAL REGIONExcellent visualisation of the ileocaecal region can be obtained by adminis-tering barium orally and introducing air rectally when the barium is in theregion of the terminal ileum and caecum.33 The patient is prepared as for adouble-contrast enema and then barium suspension is given orally. Theprogress of the barium column is checked and when the head of the columnreaches the transverse colon, air is introduced rectally and films are taken.Crohn's disease of the terminal ileum and carcinoma of the caecum areparticularly well demonstrated by this technique.33

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The oral double-contrast method, the complete reflux examination, andthe oral pneumocolon technique have never gained acceptance and are usedonly occasionally.

Direct techniques for introducing barium into the small intestine

DUODENAL INTUBATIONDuodenal intubation for the purpose of introducing contrast medium andobtaining radiographs of the distended duodenum for diagnostic purposeswas described by a number of investigators in the early part of thecentury.3436 Pesquera in 19295 was the first to advocate duodenal intubationfor introducing contrast medium directly to outline the small intestine and toovercome the shortcomings of the barium follow-through. He infused amixture of barium, acacia, and water under gravity through a tube into theduodenum. The column of contrast medium was observed fluoroscopicallyas it advanced through the small intestine and the contours of the coils ofintestine and their freedom under the palpating hand were assessed.Deformities and abnormalities were detected and radiographs were taken.He found that the entire small intestine could be studied in less thanhalf-an-hour and he hoped that the method he described would provevaluable in the detection of small intestinal pathology. He illustrated hispaper with an example of two strictures of the distal ileum that had not beenshown on a previous barium follow-through.Nine years passed before another paper by Ghelew and Mengis appeared

advocating a similar technique.37 Ghelew and Mengis passed a tube to thefourth part of the duodenum and injected thorium oxide suspended in waterto outline the small intestine. They also injected air through the tube toobtain double-contrast views. A simple water suspension ofbarium sulphatewas infused under gravity, like an enema, through a duodenal tube byGershon-Cohen and Shay.38 They found that complete filling of the entiresmall intestine could be accomplished in eight to 15 minutes using800-1200 ml barium. A very satisfactory radiographic examination of thesmall intestine was performed. They also injected air to obtain double-contrast views in order to check on the findings of the single contrastexamination. The technique was called 'barium enteroclysis' and con-sidered to be far superior to the progress meal. They suggested that it wouldprove useful in the diagnosis of regional enteritis, ileocaecal tuberculosis,tumours, obstruction, and diverticula of the small intestine. Wissenberg39examined 21 patients with the technique described by Gershon-Cohen andShay and found that it gave an even distribution of contrast mediumthroughout the intestine and showed morphological changes clearly.The small bowel enema was the title used by Schatzki when he reported

his experience with the technique in 72 examinations in 1943.4° He suggestedthat- it was helpful but not obligatory to have the colon empty beforeperforming the examination. Like Gershon-Cohen and Shay he also used alarge volume of dilute barium (500-1000 ml) and allowed it to run into theduodenum under gravity from a container. The head of the column reachedthe caecum in normal cases in about 15 minutes. A constant flow of fluid wasnecessary and any interruption delayed the examination markedly accord-ing to Schatzki. He stated that the primary purpose of the method was thedemonstration of organic pathology and when successfully carried out it was

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better than any other available method for the study of morphologicalchanges in the small intestine. The results were so good that he recom-mended it to be used as a routine procedure.The experience of Lura4l' was similar when he performed 300 examina-

tions during a four year period using a technique similar to that described bySchatzki. The technique, according to Lura, made inspection of the wholesmall intestine possible in 15 minutes. The advantages mentioned were thatthe examination was independent of pyloric function, complete filling of thesmall intestine was obtained, and part of the contrast medium could bewithdrawn and air introduced.Any improvement in the degree of accuracy of radiological diagnosis of

localised lesions of the small intestine must depend on some method ofexamination other than a barium follow-through as the routine techniqueaccording to Scott-Harden.42 He believed that the method advocated bySchatzki had not found universal favour for two reasons. There was difficultyexperienced in performing the duodenal intubation and the complete fillinghad the disadvantage of obscuring the individual coils of small intestine. Hedesigned a tube comprised of a stiff outer sheath for use in the stomach with amore flexible duodenal element which could slide inside the gastric tube andbe accurately manipulated at the pylorus and passed to the duodenojejunalflexure fairly easily. With the tip of the tube at the duodenojejunal flexure asyringe with a two-way tap injected 60-90 ml of barium. A tube was attachedto the other opening of the two-way tap; it was then connected to a bottlecontaining 0*9 litres (11/2 pints) of water which was injected. The bariumflowed freely to the caecum leaving a varying length of small intestineoutlined by mucosal adhesion with double-contrast. Proximal to this, thebarium was washed from the mucosa leaving a clear field, thus preventingobscured vision of the segment under examination at any time. The outlineof the whole small intestine was usually complete within 10 minutes of thestart of the injection.

Pygott and his colleagues in 196043 stated that a satisfactory demonstrationof the entire small intestine with the barium follow-through, or one of itsmodifications, was often not obtained particularly in the presence of disease.They adopted the Scott-Harden tube and used successive injections ofbarium suspension and tap water and observed the progress of the contrastmedium. Controlled filling of the intestine was obtained and in the normalsubject the caecum was reached in 15-20 minutes. They found it an accuratemethod in infiltrative lesions such as Crohn's disease and very valuable inpatients in whom an obstructive or constrictive lesion of the small intestinewas likely to be found.The Scott-Harden technique was also used by Trickey and his col-

leagues." It gave excellent results in the duodenum and proximal ileum.They frequently failed to show the mucosal detail of the terminal ileumbecause of dilution of the barium suspension by the ensuing water 'flush'. Toavoid this they used 1 1 litres (2 pints) of a solution, containing methyl-cellulose and a wetting agent as a flushing fluid, which they injected after theinitial injection of barium suspension. They considered that the techniquereduced considerably the chances of missing a lesion and that the lines ofdemarcation between normal and abnormal intestine were exaggeratedbecause of the mild distension obtained.A grey KIFA catheter was used for introducing the barium into the

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duodenum by Glanville and Hugh.45 They emphasised the importance ofusing a radiopaque catheter rigid enough to be manipulated through thestomach yet sufficiently supple to negotiate the sharp bend between the firstand second parts of the duodenum. The catheter was passed through thenose with the patient sitting in a chair. When the tip reached the third part ofthe duodenum the barium was injected to outline the spmall intestine. Theysucceeded in getting the catheter to enter the duodenum in 21 consecutiveexaminations.During the last decade there has been renewed interest in duodenal

intubation techniques for examining the small intestine mainly due toSellink's work. He indicated that the specific gravity of the contrast fluid wasan exceedingly important factor which had not received sufficient attentionand barium suspensions were often used with a specific gravity which wasmuch too high.46 After experiments with a phantom to test contrast fluids hedecided that the best results could be obtained with a barium suspension of1 -2 specific gravity for a thin patient and 1 -25 for an obese patient. However,when he started using the contrast medium in patients he found that aspecific gravity of 1 -25-1-32 was better.He suggested the use of a large quantity of contrast fluid, 1200 ml of dilute

barium, administered by infusion into the duodenum. Thorough cleansingof the colon was necessary as the presence of faeces in the caecum retardedthe passage of barium through the distal part of the ileum. The other majorcontribution by Sellink was the adoption of the Bilbao-Dotter tube forduodenal intubation. The tube was originally developed for performinghypotonic duodenography,47 based on the Seldinger technique48 for vascularcatheterisation. Sellink used a lengthened version of the Bilbao-Dotter tubebecause it could be inserted further into the duodenum. He concluded thatthe radiological examination of the small intestine by means of the infusioncould save considerable time, the information obtained was far superior tothat achieved with the conventional method and he suggested that the oraladministration of contrast medium should be abandoned and replaced bythe infusion as a routine technique.49The Bilbao-Dotter tube was further modified when the gauge was reduced

from a size 14 French to a size 12 French.50 Its smaller size gives increasedflexibility and enables it to be passed with ease through the nose, stomach,and duodenum. The modified catheter passes quickly through the duodenumand in most cases it is possible to advance the tip about 10 cm into thejejunum.The technique used by Sellink for examining the small intestine has been

described in detail.5` 2 A low residue diet and aperients are prescribed andfluids are encouraged on the day before the examination in order to obtain aclean distal ileum and colon. Cleansing enemas are not performed as thecleansing fluid and faecal material may be washed into and retained in thedistal ileum. The patient fasts ovemight before the barium examination.The catheter* is passed so that the tip lies at or just distal to the ligament of

Treitz.50 Barium suspension diluted to a specific gravity of 1.25-1V3 for adultpatients and more dilute for younger patients is used for the infusion. Abarium hydrometert is necessary to obtain the correct specific gravity. The

*William Cooke Europe ApS.tPhillips Medical Systems.

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dilute barium is infused under gravity at a rate of 100 ml per minute. A totalof 800-1200 ml of the dilute barium suspension is used. If the head of thebarium column has not reached the terminal ileum after the infusion of 1200ml of barium, water is infused at the same speed so that a constant flow ismaintained until barium reaches the terminal ileum.

Large radiographs are taken to show all the loops of small intestine. Spotviews are taken, often with compression, of the pelvic loops of ileum, theterminal ileum and any other segments of interest. The radiographs aretaken at high kilovoltage (115-120 kV). Patients may develop an episode ofdiarrhoea after the examination and they should be warned of this.

Fleckenstein and Pedersen53 considered that the Sellink method was thebest ofthe duodenal intubation techniques for examining the small intestine.They carried out a study in which they compared the infusion technique(Sellink modification) with the conventional barium follow-through in thesame patients. Fifty-two patients were examined by both methods and it wasconcluded that visualisation of the jejunum and ileum, with the exception ofthe terminal ileum, was significantly better with the infusion technique.Although the two methods gave equal visualisation of the terminal ileumthey stated that the infusion method was better suited to demonstrate theextension of a pathological process in this region.

After the publications by Sellink, a number of centres have adopted histechnique or a modification of it. An air-contrast modification of the Sellinkexamination is performed by some radiologists,28 `457 while others prefer thesingle contrast dilute barium technique described by Sellink.5258`2 Adouble-contrast method using barium and an 0.5% aqueous suspension ofmethylcellulose is preferred by Herlinger63 6 and Vallance.65 The increasingnumber of radiologists using duodenal intubation techniques for introducingbarium into the small intestine is in itself an indication that many aredissatisfied with the conventional barium follow-through.The barium infusion is considerably better than the barium follow-through

in the diagnosis and management of Crohn's disease. Eighteen patients withCrohn's disease, verified histologically, were included in Sellink's first com-munication.46 He found the infusion examination much more accurate thanthe follow-through. Four patients with histories of previous resectionsshowed clear evidence of recurrent Crohn's disease on the barium infusion.These had not been identified on the previous barium follow-throughexaminations.

Thirty-six cases of Crohn's disease were confirmed by pathologicalexamination in the series by Dyet and his colleagues54 and no false-positivesor false-negatives were found. They concluded that the barium infusion wasnot only useful in making the diagnosis, but essential for demonstrating thefull extent of the disease in the small intestine, including complications suchas fistulae, particularly if surgery were contemplated. They used Sellink'smethod, but injected air after the barium reached the terminal ileum inorder to get double-contrast views.

Sanders and Ho58 showed Crohn's disease in 37 out of 150 patientsexamined by the Sellink method, nine of whom had previous conventionalfollow-through examinations. Crohn's disease was missed in two of thefollow-through examinations, they were reported to be normal. A fistula tothe sigmoid colon had not been seen on the follow-through in anotherpatient. Crohn's disease with multiple strictures and obstruction was shown

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in another where the follow-through showed possible obstruction only.They concluded that the infusion examination was better for assessing thesmall intestine radiologically.Ekberg` examined 43 patients who had Crohn's disease with the barium

follow-through and then with an intubation technique at intervals varyingfrom four days to four-and-a-half years. Sixty per cent were examined withinan interval of less than one year. The intubation method was an air-contrastmodification of Sellink's technique. The double-contrast examinationrevealed more clearly all the pathological changes of Crohn's disease exceptfistulae and showed the demarcation of diseased intestine from normalintestine more distinctly.

During a two-and-a-half year period 100 patients with Crohn's diseaseofthe small intestine were examined by the Sellink technique at the RadcliffeInfirmary, Oxford.6768 The dilute barium distended the normal and diseasedsegments of the small intestine and proved to be an excellent contrast agent.The radiological signs of Crohn's disease were well demonstrated. Discreteand fissure ulcers, longitudinal ulceration, sinuses, and fistulae were wellshown. Other signs that were clearly identified included thickening anddistortion of the mucosal folds, cobblestoning, strictures in many caseswith proximal dilatation, asymmetrical involvement, skip lesions, andpseudopolyps. The extent of diseased and normal small intestine wascorrectly estimated before resection in all patients who came to operationand there was excellent correlation between the radiological appearancesand the findings at morbid anatomy.6769 The ability to differentiate betweennormal small intestine and diseased segments without repeated examina-tions was a major advantage of the Sellink technique.Other investigators have testified to the superiority of intubation methods

in Crohn's disease of the small intestine.59626365 The improved accuracy ofthe barium infusion in making a diagnosis and demonstrating the changes ofCrohn's disease of the small intestine is recognised by physicians andsurgeons interested in the disease.7'72 The examination is particularly usefulin the detection of recurrent disease after previous surgery.7'The barium infusidn is an excellent method for detecting and demonstrat-

ing other diseases of the small intestine such as carcinoid tumours,5173lymphomas,5' Yersinia enterocolitica infection,74 and in the diagnosis ofMeckel's diverticulum.7576The site of small bowel obstruction can be shown and in many cases the

cause identified.77 It should also prove helpful in identifying adhesions aftersurgery for previous inflammatory bowel disease.78 We recently demon-strated ischaemic strictures of the small intestine in two patients after bluntabdominal trauma.79 In each case the stricture was clearly identified by theinfusion examination.The changes seen on the infusion examination in the small intestine of

patients with coeliac disease have been described.5180 However, in myexperience it is not reliable and a jejunal biopsy should be the initialdiagnostic procedure when coeliac disease is suspected. The infusion exami-nation should be reserved for patients with i suspected complication ofcoeliac disease such as small bowel lymphoma, or those in whom the jejunalbiopsy is normal.

Dilute barium is an excellent contrast agent in the small intestine whenradiographs are taken at high kilovoltage; it is particularly good at demon-

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strating fissure ulcers, sinuses, and fistulae. It gives better distension of theintestine than air, which passes through very quickly and fails to distendnarrowed segments adequately. Severe stenosis may be overlooked on thedouble-contrast views because prestenotic dilatations do not distend aseasily and overlapping ring shadows are not as clear and diagnostic as a loopwell-filled with barium.52 Ekberg` prefers a double-contrast method usingbarium and air. The air-contrast method is unlikely to demonstrate sinusesand fistulae as well as the dilute barium. Fistulae were demonstrated lessfrequently by Ekberg using the double-contrast method than with thebarium follow-through.6cThe use ofbarium and an aqueous solution of methylcellulose can result in

excellent detail of the normal mucosa.6364 The barium is injected first andwhen the aqueous suspension is injected it pushes the barium forwardleaving a thin coating of barium on the mucosa. The diseased segments,however, appear to be demonstrated much better by the barium at the headof the column than by the double-contrast produced by the combinedbarium and aqueous suspension of methylcellulose. It may be that theincreased secretions of the abnormal mucosa make it difficult for the thinlayer of barium to remain adherent to the wall of the diseased segment as theaqueous solution flows past. The dilute barium on the other hand distendsthe diseased segment and need not adhere to the mucosa to produce goodvisualisation.Some radiologists are reluctant to perform duodenal intubation as they

consider it time-consuming, difficult to perform, and uncomfortable for thepatient. Once the technique is mastered it normally takes only 5-10 minutesto pass the tube to the ligament of Treitz. With the colon prepared and cleanthe barium usually reaches the caecum in 5-15 minutes. If there is noobstructive lesion the whole examination is completed in 15-30 minutes inthe great majority of patients. Technicians are trained in some departmentsto perform the intubation part of the procedure5' and as a result theexamination is less time-consuming for the radiologist. Most patientstolerate the procedure very well.When the intubation technique is first adopted there can be difficulties,

but it becomes relatively easy with experience. The part of the procedurelikely to give most problems to the inexperienced is getting the tip of thecatheter to pass through the pylorus and past the junction of the first andsecond parts of the duodenum. If the patient is turned on his left side orupward pressure is exerted on the greater curve aspect of the prepyloricgastric antrum or both, it is nearly always possible to get the tip of thecatheter into the second part of the duodenum. Only on rare occasions,usually when there is an abnormality of the pylorus or proximal duodenum,is it impossible to pass the catheter to the ligament of Treitz. Reflux ofbarium from the duodenum to the stomach can occur and may inducevomiting. It rarely occurs if the tip of the catheter is positioned distal to theligament of Treitz. The large catheter sometimes proved impossible to passinto the third part of the duodenum and it never passed the ligament ofTreitz.

It has been suggested that the radiation dose to the patient is highwith the infusion technique.'9 However, Vogel and Lohr8' found thatthe radiation dose was similar to that obtained with the barium follow-through.

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INTUBATION OF SMALL INTESTINEA number of intestinal tubes are used for decompressing the distendedintestine in patients with small intestinal obstruction. The Miller-Abbotttube82 has a balloon at the tip which is inflated with air when it reaches theduodenum. The peristaltic activity takes it through the small intestine until itstops at the site of obstruction. Other tubes have a mercury filled bag at theend which is taken to the site of obstruction by peristalsis.83-85 Very usefuldiagnostic information can be obtained by injecting barium fhrough theseintestinal tubes when they are no longer advancing and have reached the siteof obstruction.63 86-89Friedman and Rigler90 felt that satisfactory delineation and demonstra-

tion of lesions of the small intestine remained a challenge to the radiologist.They used a triple lumen small intestinal tube with two balloons and sideholes in between. With this tube it was possible to inflate both balloons andinject barium and air so that a double-contrast examination of the intestinein between could be obtained. If the proximal balloon only was inflated thedistal part of the intestine could be examined. On the other hand if the distalballoon only was inflated the proximal intestine could be demonstrated. Asimilar technique was advocated by Greenspon and Lentino9' in selectedcases and they called it retrograde enteropathy. A modified Miller-Abbotttube was used and the balloon was partially inflated when it reached theduodenum so that it would act as a bolus and pass through the smallintestine. The balloon was fully distended in the distal part of the smallintestine so that it obstructed the lumen and barium was injected to outlinethe proximal intestine. The balloon was then deflated and an examination ofthe distal intestine carried out.These types of catheters have not become popular for routine investiga-

tions of the small intestine, but they are used in a few centres63 64 to investi-gate small intestinal obstruction.

Summary

The barium follow-through is still the most widely used technique forexamining the small intestine with contrast medium despite evidence that itis not accurate for detecting and demonstrating diseases that cause morpho-logical changes in the small intestine. Duodenal intubation techniques arenow replacing the follow-through in many centres. Excellent visualisation isachieved when the barium is introduced directly through a tube into thesmall intestine. The single-contrast dilute barium infusion method describedby Sellink is very satisfactory. Reports from centres using intubationmethods indicate that they give much more accurate information than thefollow-through. Diagnostic information may be obtained by injectingbarium through intestinal tubes that are being used to decompress thedistended intestine in patients with small intestinal obstruction. Per oralpneumocolon examination of the ileocaecal region and the complete refluxexamination help to evaluate the ileum, particularly the terminal ileum.

Department ofRadiology D J NOLANJohn Radcliffe HospitalHeadington, OxfordReceived for publication 15 January 1981

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