Main research techniques
Traditional contrast-enhanced examination of the small intestine is performed in two main ways:
- Small bowel follow-through (small bowel follow-through): the patient orally takes a large volume of barium sulfate or water-soluble contrast. As the substance moves through the GI tract, a series of radiographs is acquired.
- Enteroclysis (enteroclysis): a large volume of contrast is injected under pressure via a nasoenteric tube. This approach provides excellent control over the distension of the intestinal lumen.
The examination is necessarily accompanied by fluoroscopy, during which the physician applies compression and changes the patient's body position. To outline the walls and achieve maximum detail of the relief (especially in enteroclysis), double contrast is used — the introduction of air into the intestinal lumen following the contrast agent.
Role of the method in modern diagnostics
For a long time, barium follow-through was the gold standard for evaluating the small intestine, but its role has now significantly diminished. The main advantage of barium suspension is higher spatial resolution compared to tomography, which allows for exquisite mucosal detailing when performed optimally.
Reasons for abandoning the method:
- Radiation exposure. Modern consensus states that the diagnostic value of traditional GI radiography often does not justify the radiation dose received.
- Limited data. The method shows only the internal lumen and is completely blind to extraluminal (extramural) changes, mesenteric involvement, and enlarged lymph nodes.
- Discomfort. The procedure is stressful, especially in pediatric practice.
Due to these shortcomings, in non-emergency conditions (e.g., when evaluating inflammatory bowel disease), barium has been superseded by MRI and ultrasound. For diagnosing intestinal obstruction, barium follow-through is also being replaced by ultra-low-dose multidetector CT and capsule endoscopy.
Radiological signs in GI pathologies
Evaluation of the mucosal relief and motility allows for the differentiation of several specific diseases:
- Progressive systemic sclerosis (scleroderma): causes diffuse motility disorders (pseudo-obstruction). Dilatation of the duodenum and jejunum, decreased peristalsis, and delayed barium transit are observed. Sacculations (pseudodiverticula) form — large outpouches with a wide base and "square" contour. An increased number of mucosal folds gives the classic "wire spring" (wire spring) or "hidebound appearance" (hidebound appearance) sign.
- Crohn's disease (Crohn disease): multiple aphthous erosions are detected in the stomach, and in the duodenum, thickened and nodular folds form a "cobblestone mucosa" pattern (cobblestone mucosa).
- Ménétrier's disease (Ménétrier disease): massively thickened, lobulated, and bizarre folds are visualized (predominantly in the proximal stomach). The most important differential sign from carcinoma: in Ménétrier's disease, the folds remain elastic and pliable, whereas in carcinoma the wall becomes rigid. Additionally, an increased amount of fluid may be determined in the small intestine, preventing adequate coating of the mucosa by barium.
- Zollinger-Ellison syndrome (Zollinger-Ellison syndrome): characterized by thickened folds and pronounced signs of increased gastric secretion.
- Eosinophilic gastroenteritis: manifests as thickening of the folds, as well as narrowing and rigidity of the antrum with mucosal nodularity.
- Hypertrophic gastritis: radiologically manifests as a marked enlargement of the gastric areae (areae gastricae), which correlates with peptic ulcer disease.
Scleroderma tightens the skin externally and springs the intestine internally: remember the "hidebound appearance" and "wire spring" signs due to the accumulation of mucosal folds.
Class and exam questions
How does contrast follow-through differ from enteroclysis?
During a follow-through, the patient drinks the contrast independently, whereas in enteroclysis, the substance is injected under pressure through a special nasoenteric tube for better intestinal distension.
Why has barium follow-through in IBD been superseded by MRI and CT?
Fluoroscopy delivers a high radiation dose and does not allow visualization of inflammation outside the intestinal lumen (extraluminal abscesses, lymph nodes, mesentery).
How to distinguish Ménétrier's disease from gastric carcinoma on a radiograph?
In Ménétrier's disease, giant mucosal folds remain elastic and pliable upon compression, whereas in cancer, the gastric wall is rigid and aperistaltic.
What is the essence of double contrast?
After the liquid contrast (barium) is introduced into the intestinal lumen, air is injected. This allows the walls to be distended and the finest details of the mucosal relief to be mapped out.
What else to study on this topic
- CT and MR enterography: bowel distension techniques and types of contrast agents
- Radiological presentation of Crohn's disease on CT and MRI
- Ultrasound diagnostics of inflammatory bowel disease (IBD) in children
- Differential diagnostics of neuromuscular GI diseases
- Zollinger-Ellison syndrome: association with MEN-1 and tumor visualization
Master the entire topic in the "Diagnostic Radiology" course
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- Complete study guide on "Barium GI Series" and 2,199 more pages of the subject
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Other topics in the section "Diagnostic Radiology of the Abdominal Organs"
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