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X-Ray and Other Imaging Contrast Studies

By Walter W. Chan, MD, MPH, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital;Harvard Medical School

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X-ray and other imaging contrast studies visualize the entire GI tract from pharynx to rectum and are most useful for detecting mass lesions and structural abnormalities (eg, tumors, strictures). Single-contrast studies fill the lumen with radiopaque material, outlining the structure. Better, more detailed images are obtained from double-contrast studies, in which a small amount of high-density barium coats the mucosal surface and gas distends the organ and enhances contrast. The gas is injected by the operator in double-contrast barium enema, whereas in other studies, intrinsic GI tract gas is adequate. In all cases, patients turn themselves to properly distribute the gas and barium. Fluoroscopy can monitor the progress of the contrast material. Either video or plain films can be taken for documentation, but video is particularly useful when assessing motor disorders (eg, cricopharyngeal spasm, achalasia).

The main contraindication to x-ray contrast studies is suspected perforation, because free barium is highly irritating to the mediastinum and peritoneum; water-soluble contrast is less irritating and may be used if perforation is possible. Older patients may have difficulty turning themselves to properly distribute the barium and intraluminal gas.

Patients having upper GI x-ray contrast studies must have nothing by mouth (npo) after midnight. Patients having barium enema follow a clear liquid diet the day before, take an oral Na phosphate laxative in the afternoon, and take a bisacodyl suppository in the evening. Other laxative regimens are effective.

Complications are rare. Perforation can occur if barium enema is done in a patient with toxic megacolon. Barium impaction may be prevented by postprocedure oral fluids and sometimes laxatives.

An upper GI examination is best done as a biphasic study beginning with a double-contrast examination of the esophagus, stomach, and duodenum, followed by a single-contrast study using low-density barium. Glucagon 0.5 mg IV can facilitate the examination by causing gastric hypotonia.

A small-bowel meal is done by using fluoroscopy and provides a more detailed evaluation of the small bowel. Shortly before the examination, the patient is given metoclopramide 20 mg po to hasten transit of the contrast material.

Enteroclysis (small-bowel enema) provides still better visualization of the small bowel but requires intubation of the duodenum with a flexible, balloon-tipped catheter. A barium suspension is injected, followed by a solution of methylcellulose, which functions as a double-contrast agent that enhances visualization of the small-bowel mucosa.

A barium enema can be done as a single- or double-contrast study. Single-contrast barium enemas are used for potential obstruction, diverticulitis, fistulas, and megacolon. Double-contrast studies are preferred for detection of tumors.

CT scanning of the abdomen

CT scanning using oral and IV contrast allows excellent visualization of both the small bowel and colon as well as of other intra-abdominal structures.

CT enterography provides optimal visualization of the small-bowel mucosa; it is preferably done by using a multidetector CT (MDCT) scanner. Patients are given a large volume (1350 mL) of 0.1% barium sulfate before imaging. For certain indications (eg, obscure GI bleeding, small-bowel tumors, chronic ischemia), a biphasic contrast-enhanced MDCT study is done.

CT colonography (virtual colonoscopy) generates 3D and 2D images of the colon by using MDCT and a combination of oral contrast and gas distention of the colon. Viewing the high-resolution 3D images somewhat simulates the appearance of optical endoscopy, hence the name. Optimal CT colonography technique requires careful cleansing and distention of the colon. Residual stool causes problems similar to those encountered with barium enema because it simulates polyps or masses. Three-dimensional endoluminal images are useful to confirm the presence of a lesion and to improve diagnostic confidence.

CT enterography and CT colonoscopy have largely supplanted standard small-bowel series and barium enema examinations.

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