Radiology cases, Barium Meal X-ray

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Barium Meal X-ray

The technique involves coating the lining of a stomach, which has been distended with gas. If the patient understands the procedure and feels cooperative before you start, the images are improved. The contrast is a fine suspension of barium sulphate, designed to remain in suspension in the acidic environment of the stomach. Its viscosity is made as low as possible, so as to fill the small irregularities in the normal mucosa of the stomach. You can imagine the secrecy and variations in its manufacture, where different wetting agents and lyophilic colloids are added to the mix. So far, I've heard nothing about incantations, but making the ideal contrast for stomach or bowel is a difficult task. Barium is chosen for its density, high atomic number, that allows thin coats to be visible on the X-ray. The gas is generated by swallowing sodium bicarbonate powder, disguised to taste better. The lemon juice, swallowed a little later, generates the gas, carbon dioxide. The patient is initially examined erect and stands obliquely in the Fuoroscopy unit.

The best double contrast of the Oesophagus is obtained, if the patient swallows the citric acid immediately before swallowing the Barium. I use (refill) the same cup for each and that seems to give time for the granules to dissolve. The faster the patient drinks (bigger swallows), then the greater chance for double contrast distension of the Oesophagus. The obliquity of the patient throws the shadow of the oesophagus clear of the density of the spine. There is debate about the best way to be oblique. I choose the way that the dominant hand, holding the cup of Barium, is furthest away from the table and so is projected most laterally away from the area of interest. If there is particular interest in the oesophagus, then the other oblique may be used to give additional information for subtle mucosal pathology.

The key to this examination is a smooth and rapid progression. The views must not take so long that a large amount of barium gets into the proximal jejunal loops, before the temporary bowel paralysing agent (atropinic analogue or glucagon) is given.

There should be time to do the prone swallows. The oesophageal movement and emptying are observed without the benefit of gravity. The phrenic ampulla, abolished by the oesophageal stripping wave, can be easily distinguished from the small hiatus hernia, which remains. At this point there may be enough barium in the duodenum to give good mucosal coating and the timing of the agent to arrest peristalsis. The patient, lying horizontally, is then shaken or asked to move so as to wash the mucosa of the stomach. I find the best way is to appeal to the child in the patient and go for the cheap laugh. This allows sufficient brute handling to be applied to get good wash-off of degraded mucus. It's more fun and there isn't time to explain the scientific principles if you intend to give the anti-peristaltic agent later.

A turn, initially right side up as the patient goes supine, will fill the body of the stomach with gas and enable a supine double contrast view of the body of the stomach.

The patient is then turned prone for an oblique double contrast view of the fundus. The lower oesophagus and cardia are also shown, en face. The duodenum fills with barium.

The patient is turned supine and the duodenum seems to fill easily from this position, uncompressed by the weight of the patient. Most of my patients have the agent to arrest peristalsis at this point. There is a compromise between allowing the duodenal mucosa to be washed by the barium and overfilling the jejunum. I find that the time it takes to give an intravenous injection is sufficient for some barium to fill the duodenum.

The patient is then immediately turned onto their left side. The 22 seconds, taken for the agent to reach the stomach allow one or two peristaltic contractions to replace barium suspension with gas in the duodenum before the stomach and duodenum relax. Double contrast views of the pyloric antrum and duodenum are then taken with varying degrees of rotation. The patient is then asked to turn through a full circle to recoat the mucosa with barium suspension. The patient ends up supine.

The table is tilted head down with the patient grasping a handle. They are asked to turn obliquely to the right, raising their left side from the table. The position and the effort involved seem a fair test for gastro-oesophageal reflux. This position gives another view of the greater curvature. Drinking or swallowing in this position can precipitate gastro-oesophageal reflux. If you are unconvinced by a normal result, then get the standing patient to bend over to pick up something at the end of the examination. This reproduces the usual situation that patients complain of and you may see the reflux.

The table is brought horizontal and the patient is then turned onto their left side. This fills the fundus. The table is then tilted head down and the patient made to turn semi-prone. While gaining this position, there will be another chance to check for gastro-oesophageal reflux. This semi-prone oblique head down position fills the pyloric antrum and duodenum with air. The projection frequently gives a good tangential view of the more anterior parts of the stomach.

It`s worth remembering that half of the mucosa of the stomach lies at the front. The appearance of the mucosal coating depends on whether it is dependent or not. Hanging drops will allow you to identify those features that lie on the anterior surface.

The examination can be completed with an erect view. The fundus is gas filled and the distensibility and flexibility of the stomach can be assessed. The view may also display any resting juice, often a clue to excess acid secretion.

Note: This sequence is designed to be taken smoothly and fairly rapidly. Good imaging usually depends on the patient being able to understand what is happening. If the examination is delayed at any stage, then the order of the views and medication may need changing. The point of the examination is to display an adequately distended viscus, free of confusion from overlying densities.

If the symptoms refer to dyphagia in the throat or pharynx, a separate set of images of this area can be taken at the end of the Barium-Meal examination. Don't rely on fluoroscopy to exclude the transient defect of a pharyngeal web, unless you can step through the individual frames in a recording. Double-contrast views can be obtained by oblique projection of each side of the pharynx and pyriform fossae when the patient tries to breath out, while holding the nose and closing the mouth. The cheeks are distended like those of a trumpeter.

IDM Nov 2006