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Double-Contrast Barium Enema Examination Technique¹

¹ From the Department of Radiology, Hospital of the University of Pennsylvania, MRI, Bldg 1, 3400 Spruce St, Philadelphia, PA 19104. Received June 18, 1999; revision requested August 12; revision received August 27; accepted August 30. Address correspondence to S.E.R. (e-mail: rubesin@oasis .rad.upenn.edu).

View larger version (115K): [in a new window]   Figure 1a. Barium pool obscures polyp in splenic flexure. (a) Spot radiograph obtained with the patient in a right posterior oblique position shows the splenic flexure. The barium pool obscures the en face mucosal detail of the descending limb of the splenic flexure. The luminal contour is seen either as a continuous white line (black arrow) or as a smooth edge of the barium column (white arrow). (b) Spot radiograph obtained with the patient in an erect right posterior oblique position shows the splenic flexure. A 7-mm polyp is manifested in the shape of a bowler hat. The brim of the hat (solid arrows) represents barium trapped between the base of the polyp and the adjacent normal mucosa. The dome of the hat (open arrow) represents the top of the polyp. The polyp is pointed inward, toward the longitudinal axis of the bowel.

View larger version (87K): [in a new window]   Figure 1b. Barium pool obscures polyp in splenic flexure. (a) Spot radiograph obtained with the patient in a right posterior oblique position shows the splenic flexure. The barium pool obscures the en face mucosal detail of the descending limb of the splenic flexure. The luminal contour is seen either as a continuous white line (black arrow) or as a smooth edge of the barium column (white arrow). (b) Spot radiograph obtained with the patient in an erect right posterior oblique position shows the splenic flexure. A 7-mm polyp is manifested in the shape of a bowler hat. The brim of the hat (solid arrows) represents barium trapped between the base of the polyp and the adjacent normal mucosa. The dome of the hat (open arrow) represents the top of the polyp. The polyp is pointed inward, toward the longitudinal axis of the bowel.

View larger version (98K): [in a new window]   Figure 2. The mucosal surface en face. Close-up view from a spot radiograph of the sigmoid colon shows a 1.9-cm polypoid adenocarcinoma in a 68-year-old man with right upper quadrant pain and subsequently proved liver metastases. The mass is manifested as a barium-etched hemispheric line (solid arrows) surrounding tiny radiolucent tumor nodules outlined by barium in the interstices of the tumor; representative nodules are identified by the open arrow. The normal mucosal surface is featureless and gray.

View larger version (140K): [in a new window]   Figure 3a. Polyp demonstrated in barium pool. (a) Spot radiograph obtained with the patient in a left-side-down position (left lateral view) shows the rectum early in the examination. At the edge of the barium pool, there is a 7-mm lobulated radiolucent filling defect (arrow). The enema tube tip obscures the distal rectum. (b) Spot radiograph obtained with the patient in a right-side-down position (right lateral view) shows the rectum after enema tube tip removal. The polyp is not depicted definitively. The distal rectum is no longer obscured by the enema tube tip. This polyp is a tubular adenoma.

View larger version (146K): [in a new window]   Figure 3b. Polyp demonstrated in barium pool. (a) Spot radiograph obtained with the patient in a left-side-down position (left lateral view) shows the rectum early in the examination. At the edge of the barium pool, there is a 7-mm lobulated radiolucent filling defect (arrow). The enema tube tip obscures the distal rectum. (b) Spot radiograph obtained with the patient in a right-side-down position (right lateral view) shows the rectum after enema tube tip removal. The polyp is not depicted definitively. The distal rectum is no longer obscured by the enema tube tip. This polyp is a tubular adenoma.

View larger version (147K): [in a new window]   Figure 4a. Colonic cancer not obvious on overhead images. (a) Spot radiograph obtained with the patient in a right posterior oblique position shows a 3-cm coarsely lobulated polypoid mass (arrows) on the anteromedial wall of the cecum and ascending colon, superior to and overlapping the ileocecal valve (arrowhead). (b) Close-up view from an overhead radiograph of the colon shows the edge of the ileocecal valve (arrow). The tumor is obscured by the barium pool. This is the best image of the cecum from of a series of overhead images, including the decubitus views.

View larger version (136K): [in a new window]   Figure 4b. Colonic cancer not obvious on overhead images. (a) Spot radiograph obtained with the patient in a right posterior oblique position shows a 3-cm coarsely lobulated polypoid mass (arrows) on the anteromedial wall of the cecum and ascending colon, superior to and overlapping the ileocecal valve (arrowhead). (b) Close-up view from an overhead radiograph of the colon shows the edge of the ileocecal valve (arrow). The tumor is obscured by the barium pool. This is the best image of the cecum from of a series of overhead images, including the decubitus views.

View larger version (167K): [in a new window]   Figure 5. Spot radiograph obtained with the patient in a near-erect position shows the middle of the transverse colon. The interhaustral folds are straight; a representative fold is identified with an arrow. The haustral sacculations are distended, but not overdistended and flattened.

View larger version (94K): [in a new window]   Figure 6a. Value of the prone-angled view to display the sigmoid colon en face. (a) Spot radiograph of the rectum obtained with the patient in a left posterior oblique position shows a coarsely lobulated, barium-etched line (arrows) disrupting the normally smooth surface. (b) Overhead radiograph of the pelvis with the tube angled 30° caudad and the patient in a prone position shows the rolled edges (arrows) of a long, centrally ulcerated, plaquelike lesion, which in this position is seen in profile and is akin to the Carman meniscus sign. This is an adenocarcinoma at the rectosigmoid junction.

View larger version (117K): [in a new window]   Figure 6b. Value of the prone-angled view to display the sigmoid colon en face. (a) Spot radiograph of the rectum obtained with the patient in a left posterior oblique position shows a coarsely lobulated, barium-etched line (arrows) disrupting the normally smooth surface. (b) Overhead radiograph of the pelvis with the tube angled 30° caudad and the patient in a prone position shows the rolled edges (arrows) of a long, centrally ulcerated, plaquelike lesion, which in this position is seen in profile and is akin to the Carman meniscus sign. This is an adenocarcinoma at the rectosigmoid junction.

View larger version (129K): [in a new window]   Figure 7a. Value of compression in the demonstration of overlapping loops. (a) Spot radiograph obtained with the patient in a prone position shows overlap of the sigmoid colonic loops. (b) Spot radiograph obtained with the patient in a prone position, with a compression balloon pushing on the anterior abdominal wall, shows separation of two of three sigmoid loops.

View larger version (150K): [in a new window]   Figure 7b. Value of compression in the demonstration of overlapping loops. (a) Spot radiograph obtained with the patient in a prone position shows overlap of the sigmoid colonic loops. (b) Spot radiograph obtained with the patient in a prone position, with a compression balloon pushing on the anterior abdominal wall, shows separation of two of three sigmoid loops.

View larger version (125K): [in a new window]   Figure 8a. Prone versus supine position for viewing the sigmoid colon and rectum. (a) Spot radiograph obtained after enema tube tip removal with the patient in a supine position. The distal rectum is seen in air contrast. The most caudal loop (arrow) of sigmoid colon is filled with barium. (b) Spot radiograph obtained with the patient in a prone position, but the radiograph is printed in the same anatomic position as a to allow direct comparison of images. Barium in the distal rectum now obscures en face mucosal detail. The most caudal loop (arrow) of sigmoid colon is now seen with air contrast. (a and b reprinted, with permission, from reference 19.)

View larger version (127K): [in a new window]   Figure 8b. Prone versus supine position for viewing the sigmoid colon and rectum. (a) Spot radiograph obtained after enema tube tip removal with the patient in a supine position. The distal rectum is seen in air contrast. The most caudal loop (arrow) of sigmoid colon is filled with barium. (b) Spot radiograph obtained with the patient in a prone position, but the radiograph is printed in the same anatomic position as a to allow direct comparison of images. Barium in the distal rectum now obscures en face mucosal detail. The most caudal loop (arrow) of sigmoid colon is now seen with air contrast. (a and b reprinted, with permission, from reference 19.)

View larger version (146K): [in a new window]   Figure 9a. Spot radiographs of the sigmoid colon with the patient in (a) a left posterior oblique position and (b) a steep right posterior oblique position. Identical segments of the sigmoid colon are identified by similar arrows. Changing the position of the patient changes the location of the barium pool and allows depiction of different segments of bowel en face.

View larger version (140K): [in a new window]   Figure 9b. Spot radiographs of the sigmoid colon with the patient in (a) a left posterior oblique position and (b) a steep right posterior oblique position. Identical segments of the sigmoid colon are identified by similar arrows. Changing the position of the patient changes the location of the barium pool and allows depiction of different segments of bowel en face.

View larger version (104K): [in a new window]   Figure 10. Spot radiograph of the splenic flexure with the patient in an erect right posterior oblique position. Diverticula are filled with barium (short arrows) and coated with barium (long arrow).

View larger version (99K): [in a new window]   Figure 11. Spot radiograph of the splenic flexure with the patient in a horizontal right posterior oblique position. The contour of the descending limb is sacculated. Subtle mucosal ulceration is manifested as shallow barium-filled ulcers surrounded by radiolucent halos (arrows). One week prior to this examination, this patient had acute rectal bleeding during an airplane flight. Endoscopic biopsy results revealed ischemic changes.

View larger version (135K): [in a new window]   Figure 12. Spot radiograph of the hepatic flexure obtained with the patient in an erect left posterior oblique position. The right breast is elevated manually out of the radiation field.

View larger version (117K): [in a new window]   Figure 13. Cross-table lateral overhead radiograph obtained with the patient in a left-side-down decubitus position.

View larger version (116K): [in a new window]   Figure 14. Cross-table lateral overhead radiograph obtained with the patient in a right-side-down decubitus position.

View larger version (126K): [in a new window]   Figure 15. Cross-table lateral overhead radiograph of the rectum obtained with the patient in a prone position.