Fluoroscopy Barium Fallow Through
1.
Indication of Barium
follow through:
a) Pain
b) Diarrhea
c) Anemia
d) Partial Obstruction.
e) Abdominal mass.
f) Facial small bowel enema.
2. Contra-indication of Barium follow
through:
a) Complete obstruction
b) Suspected perforation
Patient preparation:
সাধারণত রোগী ৬-৮ ঘন্টা খালিপেটে থাকতে হবে।
Contrast Media Requirement:
·
130 gm Barium
Sulphate+500 ml water.
·
7 UP/ Sprite
(Double Contrast)
Tachnique/Procedure:
1. Machine এর Foot Stand এ রোগীকে এ দাঁড় করাই।
2. গোলানো Barium Sulphate এর অর্ধেক গ্লাস খাইয়ে দিতে হবে।
3. Machine এ রোগীকে ঠিকমতো Position করে Monitor এ
Stomach লক্ষ
করি।
4. এবার Full Stomach এর একটি ছবি নেই।
5. গ্লাসে রাখা বাকি অর্ধেক Barium Sulphate রোগীকে খাইয়ে দিই।
6. Machine এর Screen এ Stomach এর Duodenum লক্ষ করি। Barium
Sulphate Duodenum area তে
গমন করলে Erect Position এ দুটি
Duodenum Cap এর
Spot Film নিই। (একটি Pressure দিয়ে অপরটি Pressure ছাড়া)।
7. তারপর মেশিনসহ রোগীকে শোয়াইয়া Right Anterior Oblique এবং Left Anterior Oblique Position এ Duodenum Cap এর আরও দুটি Spot Film নিতে হবে।
8. এই Barium Meal এর কাজসম্পূর্ন করার পর jejunal & Proximal part of Ilecal Loops
Visible (দৃশ্যমান)
হলে A/P Position- এ ১ টা X-ray নিতে হবে।
9. এই ১৫ মিনিটের ছবি ঠিক হলে ৩০ মিনিট পর Whole Intestine এর একটা X-ray নিতে হবে।
10. ৩০ মিনিটের ছবিতে Barium Sulphate সমপূর্ন Small Intestine অতিক্রম করে Ileo-cecal Junction- আসার ১ ঘন্টা পর আরেকটি X-ray করতে হবে।
11. যদি কোন কারণে ১ ঘন্টার ছবিতে Small Intestine- এর ছবি না আসে, তাহলে Barium Sulphate খাওয়ানোর ২ ঘন্টা পর ১ টা X-ray নিতে হবে।
12. এভাবে ৩ ঘন্টা, ৬ ঘন্টা, ৯ ঘন্টা, ১২ ঘন্টা এবং ২৪ ঘন্টার ফিল্ম রেডিওলজিষ্ট এর পরামর্শ অনুযায়ী নিতে হবে।
Picture: Barium follow through single contrast
Anatomy stomach
The stomach, is an intraperitoneal digestive organ
located between the oesophagus and
the duodenum.
It has a ‘J’ shape, and features a lesser and greater
curvature. The anterior and posterior surfaces are smoothly rounded with a
peritoneal covering.
In this article, we shall look at the anatomy of the stomach
– its position, structure and neurovascular supply.
Anatomical Position
The stomach lies within the superior aspect of the abdomen.
It primarily lies in the epigastric and umbilical regions,
however, the exact size, shape and position of the stomach can vary from person
to person and with position and respiration.
Anatomical Structure
Fig 1 – The parts of the stomach.
The stomach has four main anatomical divisions; the cardia,
fundus, body and pylorus:
Cardia – surrounds the superior opening of the stomach
at the T11 level.
Fundus – the rounded, often gas filled portion superior
to and left of the cardia.
Body – the large central portion inferior to the
fundus.
Pylorus – This area connects the stomach to the
duodenum. It is divided into the pyloric antrum, pyloric canal and pyloric sphincter.
The pyloric sphincter demarcates the transpyloric plane at the level of L1.
Greater and Lesser Curvatures
The medial and lateral borders of the stomach are curved,
forming the lesser and greater curvatures:
Greater curvature – forms the long, convex, lateral
border of the stomach. Arising at the cardiac notch, it arches backwards and
passes inferiorly to the left. It curves to the right as it continues medially
to reach the pyloric antrum. The short gastric arteries and the right and
left gastro-omental arteries supply branches to the greater
curvature.
Lesser curvature – forms the shorter, concave, medial
surface of the stomach. The most inferior part of the lesser curvature, the angular
notch, indicates the junction of the body and pyloric region. The lesser
curvature gives attachment to the hepatogastric ligament and is
supplied by the left gastric artery and right gastric branch of the hepatic
artery.
Fig 2 – The greater and lesser curvatures of the stomach
Anatomical Relations
The anatomical relations of the stomach are given in the
table below:
|
Anatomical Relation |
Structures |
|
Superior |
Oesophagus and left dome of the diaphragm |
|
Anterior |
Diaphragm, greater omentum, anterior abdominal wall, left
lobe of liver, gall bladder |
|
Posterior |
Lesser sac, pancreas, left kidney, left adrenal gland,
spleen, splenic artery, transverse mesocolon |
Sphincters of the Stomach
There are two sphincters of the stomach, located at each
orifice. They control the passage of material entering and exiting the stomach.
Inferior Oesophageal Sphincter
The oesophagus passes through the diaphragm through the
oesophageal hiatus at the level of T10. It descends a short distance to the inferior
oesophageal sphincter at the T11 level which marks the transition
point between the oesophagus and
stomach (in contrast to the superior oesophageal sphincter, located in the
pharynx). It allows food to pass through the cardiac orifice and into the
stomach and is not under voluntary control.
Pyloric Sphincter
The pyloric sphincter lies between the pylorus and
the first part of the duodenum. It controls of the exit of chyme (food
and gastric acid mixture) from the stomach.
In contrast to the inferior oesophageal sphincter, this is
an anatomical sphincter. It contains smooth muscle, which
constricts to limit the discharge of stomach contents through the
orifice.
Emptying of the stomach occurs intermittently when intragastric
pressure overcomes the resistance of the pylorus. The pylorus is normally
contracted so that the orifice is small and food can stay in the stomach for a
suitable period. Gastric peristalsis pushes the chyme through the pyloric canal
into the duodenum for further digestion.
Fig 3 – The peristaltic ejection waves of the stomach
Greater and Lesser Omenta
Within the abdominal cavity, a double layered membrane
called the peritoneum.
supports most of the abdominal viscera and assists with their attachment to the
abdominal wall.
The greater and lesser omenta are two
structures that consist of peritoneum folded over itself (two layers of
peritoneum – four membrane layers). Both omenta attach to the stomach, and
are useful anatomical landmarks:
Greater omentum – hangs down from the greater curvature of
the stomach and folds back upon itself where it attaches to the transverse
colon It contains many lymph nodes and may adhere to inflamed areas , therefore
playing a key role in gastrointestinal immunity and minimising the spread of
intraperitoneal infections.
Lesser omentum– continuous with peritoneal layers of the
stomach and duodenum, this smaller peritoneal fold arises at the lesser curvature and
ascend to attach to the liver. The main function of the lesser omentum is
to attach the stomach and duodenum to the liver.
Together, the greater and lesser omenta divide the abdominal
cavity into two; the greater and lesser sac. The stomach lies immediately
anterior to the lesser sac. The greater and lesser sacs communicate
via the epiploic foramen, a hole in the lesser omentum.
Fig 4 – The greater and lesser omenta.
Neurovascular Supply
The arterial supply to the stomach comes from the celiac
trunk and its branches. Anastomoses form along the lesser
curvature by the right and left gastric arteries and along the
greater curvature by the right and left gastro-omental arteries:
Right gastric – branch of the common hepatic artery,
which arises from the coeliac trunk.
Left gastric – arises directly from the coeliac trunk.
Right gastro-omental – terminal branch of the
gastroduodenal artery, which arises from the common hepatic artery.
Left gastro-omental – branch of the splenic artery,
which arises from the coeliac trunk.
The veins of the stomach run parallel to the arteries. The
right and left gastric veins drain into the hepatic
portal vein. The short gastric vein, left and right gastro-omental veins
ultimately drain into the superior mesenteric vein.
Fig 5 – Arterial supply to the stomach
Innervation
The stomach receives innervation from the autonomic nervous
system:
Parasympathetic nerve supply arises from the anterior
and posterior vagal trunks, derived from the vagus nerve.
Sympathetic nerve supply arises from the T6-T9
spinal cord segments and passes to the coeliac plexus via the greater
splanchnic nerve. It also carries some pain transmitting fibres.
Lymphatics
The gastric lymphatic vessels travel with the arteries along
the greater and lesser curvatures of the stomach. Lymph fluid drains into
the gastric and gastro-omental lymph nodes found at the
curvatures.
Efferent lymphatic vessels from these nodes connect to the coeliac
lymph nodes, located on the posterior abdominal wall.
Clinical Relevance: Disorders of the Stomach
Gastro-Oesophageal Reflux Disease
This is a digestive disorder affecting the lower
oesophageal sphincter. It refers to the movement of gastric acid and food
into the oesophagus.
GORD is a common condition, affecting 5-7% of the
population. Symptoms include dyspepsia, dysphagia, and an
unpleasant sour taste in the mouth.
There are three main causes of reflux disease:
Dysfunction of the lower oesophageal sphincter
Delayed gastric emptying
Hiatal hernia (see below)
Treatment involves lifestyle changes, medication such as a
PPI to reduce stomach acid, and as a last resort, surgery.
Hiatus Hernia
A hiatus hernia occurs
when a part of the stomach protrudes into the chest through the oesophageal
hiatus in the diaphragm. There are two main types of hiatal hernias;
sliding and rolling:
Sliding hiatus hernia – The lower oesophageal sphincter
slides superiorly. Reflux is a common complication, as the diaphragm is no
longer reinforcing the sphincter.
Rolling Hiatus Hernia – The lower oesophageal sphincter
remains in place, but a part of the stomach herniates into the chest next to
it. This type of hiatus hernia is more likely to require surgical correction to
prevent strangulation of the herniated pouch.
Fig 6 – Classifications of hiatus hernias. A is the normal
anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a rolling
type.
Anatomy small intestine
The small intestine is an organ located within the gastrointestinal tract. It is approximately 6.5m in the average person and assists in the digestion and absorption of ingested food.
It extends from the pylorus of the stomach to the ileocaecal
junction, where it meets the large intestine at the ileocaecal valve.
Anatomically, the small bowel can be divided into three parts: the duodenum,
jejunum, and ileum.
In this article, we shall examine the anatomy of the
small intestine – its structure, neurovascular supply, and clinical
correlations.
Fig 1 – The anatomical divisions of the small
intestine.
The Duodenum
The most proximal portion of the small intestine is
the duodenum. Its name is derived from the Latin ‘duodenum digitorum’,
meaning twelve fingers length. It runs from the pylorus of the stomach to
the duodenojejunal junction.
The duodenum can be divided into four parts: superior,
descending, inferior and ascending. Together these parts form a ‘C’ shape, that
is around 25cm long, and which wraps around the head of the pancreas.
D1 – Superior (Spinal level L1)
The first section of the duodenum is known as ‘the
cap’. It ascends upwards from the pylorus of the stomach, and is connected to
the liver by
the hepatoduodenal ligament. This area is most common site of
duodenal ulceration.
The initial 3cm of the superior duodenum
is covered anteriorly and posteriorly by visceral peritoneum, with the
remainder retroperitoneal (only covered anteriorly).
D2 – Descending (L1-L3)
The descending portion curves inferiorly around the head of
the pancreas.
It lies posteriorly to the transverse colon, and
anterior to the right kidney.
Internally, the descending duodenum is marked by the major
duodenal papilla – the opening at which bile and pancreatic
secretions to enter from the ampulla of Vater (hepatopancreatic ampulla).
D3 – Inferior (L3)
The inferior duodenum travels laterally to the left,
crossing over the inferior vena cava and aorta. It is
located inferiorly to the pancreas, and posteriorly to the superior
mesenteric artery and vein.
D4 – Ascending (L3-L2)
After the duodenum crosses the aorta, it ascends and curves
anteriorly to join the jejunum at a sharp turn known as the duodenojejunal
flexure.
Located at the duodenojejunal junction is a slip of muscle
called the suspensory muscle of the duodenum. Contraction of this muscle
widens the angle of the flexure, and aids movement of the intestinal
contents into the jejunum.
Fig 2 – The different parts of the duodenum. The liver, gall
bladder and transverse colon have been removed.
Clinical Relevance: Duodenal Ulcers
A duodenal ulcer is the erosion of the mucosa in
the duodenum. It may also be described as a peptic ulcer (although this
term can also be used to refer to ulcerations in the stomach). Duodenal
ulcers are most likely to occur in the superior portion of the
duodenum.
The most common causes of duodenal ulcers are Helicobacter
pylori infection and chronic NSAID therapy.
An ulcer in itself can be painful, but is not particularly
troublesome and can be treated medically. However, if the ulcer progresses to
create a complete perforation through the bowel wall, this is a surgical
emergency, and usually warrants immediate repair. A perforation may be
complicated by:
Inflammation of the peritoneum(peritonitis)
– causing damage to the surrounding viscera, such as the liver, pancreas and
gall bladder.
Erosion of the gastroduodenal
artery – causing haemorrhage and potential hypovolaemia shock.
Jejunum and Ileum
The jejunum and ileum are the distal two
parts of the small intestine. In contrast to the duodenum, they are
intraperitoneal.
They are attached to the posterior abdominal wall by mesentery (a
double layer of peritoneum).
The jejunum begins at the duodenojejunal flexure. There
is no clear external demarcation between the jejunum and ileum – although
the two parts are macroscopically different. The ileum ends at the ileocaecal
junction.
At this junction, the ileum invaginates into the cecum to
form the ileocecal valve. Although it is not developed enough to control
movement of material from the ileum to the cecum, it can prevent reflux of
material back into the ileum (if patent, see below).
Fig 3 – The ileocecal junction
Clinical Relevance: Characteristic Features of the
Jejunum and Ileum
During surgery, it is often necessary to be able to
distinguish between the jejunum and ileum of the small intestine:
|
Jejunum |
Ileum |
|
Located in upper left quadrant |
Located in lower right quadrant |
|
Thick intestinal wall |
Thin intestinal wall |
|
Longer vasa recta (straight arteries) |
Shorter vasa recta |
|
Less arcades (arterial loops) |
More arcades |
|
Red in colour |
Pink in colour |
Vasculature and Lymphatics
Duodenum
The arterial supply of the duodenum is derived from two
sources:
Proximal to the major duodenal papilla – supplied by
the gastroduodenal artery (branch of the common hepatic artery from the coeliac
trunk).
Distal to the major duodenal papilla – supplied by
the inferior pancreaticoduodenal artery (branch of superior
mesenteric artery).
This transition is important – it marks the change from
the embryological foregut to midgut. The veins of the
duodenum follow the major arteries and drain into the hepatic portal vein.
Lymphatic drainage is to the pancreatoduodenal
and superior mesenteric nodes.
Jejunum and Ileum
The arterial supply to the jejunoileum is from the superior
mesenteric artery.
The superior mesenteric artery arises from the aorta at the
level of the L1 vertebrae, immediately inferior to the coeliac trunk. It
moves in between layers of mesentery, splitting into approximately 20 branches.
These branches anastomose to form loops, called arcades. From the arcades,
long and straight arteries arise, called vasa recta.
The venous drainage is via the superior
mesenteric vein. It unites with the splenic vein at the neck of the
pancreas to form the hepatic portal vein.
Lymphatic drainage is into the superior
mesenteric nodes.
Fig 4 – Arterial supply to the jejunum and ileum of the
small intestine
Clinical Relevance: Ileocaecal valve
The ileocaecal valve represents the separation
between the small and large intestine. Its main function is to prevent the
reflux of enteric fluid from the colon into the small intestine. It is also
used as an landmark during colonoscopy, indicating that the limit of the colon has
been reached and that a complete colonoscopy has been performed.
The ileocaecal valve is also important in the setting
of large
bowel obstruction. Should the ileocaecal valve be competent, a closed
loop obstruction can occur and cause bowel perforation. Should the
ileocaecal valve be incompetent (i.e. allow backflow of enteric contents into
the small bowel) then the situation is less emergent and the trajectory of the
obstruction less rapid.
Anatomy Colon.
The colon (large intestine) is the distal part of the gastrointestinal tract, extending from the cecum to the anal canal. It receives digested food from the small intestine, from which it absorbs water and electrolytes to form faeces.
Anatomically, the colon can be divided into four parts – ascending, transverse, descending and sigmoid. These sections form an arch, which encircles the small intestine.
In this article, we shall look at the anatomy of the colon – its anatomical structure and relations, neurovascular supply, and clinical correlations.
Anatomical Position
The colon averages 150cm in length, and can be divided into four parts (proximal to distal): ascending, transverse, descending and sigmoid.
Ascending Colon
The colon begins as the ascending colon, a retroperitoneal structure which ascends superiorly from the cecum.
When it meets the right lobe of the liver, it turns 90 degrees to move horizontally. This turn is known as the right colic flexure (or hepatic flexure), and marks the start of the transverse colon.
Transverse Colon
The transverse colon extends from the right colic flexure to the spleen, where it turns another 90 degrees to point inferiorly. This turn is known as the left colic flexure (or splenic flexure). Here, the colon is attached to the diaphragm by the phrenicocolic ligament.
The transverse colon is the least fixed part of the colon, and is variable in position (it can dip into the pelvis in tall, thin individuals). Unlike the ascending and descending colon, the transverse colon is intraperitoneal and is enclosed by the transverse mesocolon.
Descending Colon
After the left colic flexure, the colon moves inferiorly towards the pelvis – and is called the descending colon. It is retroperitoneal in the majority of individuals, but is located anteriorly to the left kidney, passing over its lateral border.
When the colon begins to turn medially, it becomes the sigmoid colon.
Sigmoid Colon
The 40cm long sigmoid colon is located in the left lower quadrant of the abdomen, extending from the left iliac fossa to the level of the S3 vertebra. This journey gives the sigmoid colon its characteristic “S” shape.
The sigmoid colon is attached to the posterior pelvic wall by a mesentery – the sigmoid mesocolon. The long length of the mesentery permits this part of the colon to be particularly mobile.
Paracolic Gutters
The paracolic gutters are two spaces between the ascending/descending colon and the posterolateral abdominal wall.
These structures are clinically important, as they allow material that has been released from inflamed or infected abdominal organs to accumulate elsewhere in the abdomen.
Anatomical Structure
The large intestine has a number of characteristic features, which allows it to be distinguished from the small intestine:
Attached to the surface of the large intestine are omental appendices – small pouches of peritoneum, filled with fat.
Running longitudinally along the surface of the large bowel are three strips of muscle, known as the teniae coli. They are called the mesocolic, free and omental coli.
The teniae coli contract to shorten the wall of the bowel, producing sacculations known as haustra.
The large intestine has a much wider diameter compared to the small intestine.
These features cease at the rectosigmoid junction, where the smooth muscle of the teniae coli broaden to form a complete layer within the rectum.
Fig 2 – The macroscopic features of the large intestine.
Anatomical Relations
The colon has numerous important anatomical relations in the abdomen, as shown in Table 1:
Anterior | Posterior | |
Ascending colon | Small intestine Anterior abdominal wall | Iliacus and quadratus lumborum Right kidney Iliohypogastric and ilioinguinal nerves |
Transverse colon | Greater omentum Anterior abdominal wall | Head of the pancreas |
Descending colon | Small intestine Greater omentum Anterior abdominal wall | Iliacus and quadratus lumborum Left kidney Iliohypogastric and ilioinguinal nerves |
Sigmoid colon | Urinary bladder | Sacrum Ileum |
Neurovascular Supply
The neurovascular supply to the colon is closely linked to its embryological origin:
Ascending colon and proximal 2/3 of the transverse colon – derived from the midgut.
Distal 1/3 of the transverse colon, descending colon and sigmoid colon – derived from the hindgut.
Arterial Supply
As a general rule, midgut-derived structures are supplied by the superior mesenteric artery, and hindgut-derived structures by the inferior mesenteric artery.
The ascending colon receives arterial supply from two branches of the superior mesenteric artery; the ileocolic and right colic arteries. The ileocolic artery gives rise to colic, anterior cecal and posterior cecal branches – all of which supply the ascending colon.
The transverse colon is derived from both the midgut and hindgut, and so it is supplied by branches of the superior mesenteric artery and inferior mesenteric artery:
Right colic artery (from the superior mesenteric artery)
Middle colic artery (from the superior mesenteric artery)
Left colic artery (from the inferior mesenteric artery)
The descending colon is supplied by a single branch of the inferior mesenteric artery; the left colic artery. The sigmoid colon receives arterial supply via the sigmoid arteries (branches of the inferior mesenteric artery).
Marginal Artery of Drummond
The marginal artery (of Drummond) is a clinically important vessel that provides collateral supply to the colon – thereby maintaining arterial supply in the case of occlusion or stenosis of one of the major vessels.
As the terminal vessels of the superior mesenteric and inferior mesenteric artery approach the colon, they split into many branches, which anastomose with each other. These anastomoses form a continuous arterial channel which extends the length of the colon – the marginal artery. Long, straight arterial branches (called vasa recta) arise from the marginal artery to supply the colon.
Venous Drainage
The venous drainage of the colon is similar to the arterial supply:
Ascending colon – ileocolic and right colic veins, which empty into the superior mesenteric vein.
Transverse colon – middle colic vein, which empties into the superior mesenteric vein.
Descending colon – left colic vein, which drains into the inferior mesenteric vein.
Sigmoid colon – drained by the sigmoid veins into the inferior mesenteric vein.
The superior mesenteric and inferior mesenteric veins ultimately empty into the hepatic portal vein. This allows toxins absorbed from the colon to be processed by the liver for detoxification.
Fig 3 – The major arteries and veins supplying the colon.
Innervation
The innervation to the colon is dependent on embryological origin:
Midgut-derived structures (ascending colon and proximal 2/3 of the transverse colon) receive their sympathetic, parasympathetic and sensory supply via nerves from the superior mesenteric plexus.
Hindgut-derived structures (distal 1/3 of the transverse colon, descending colon and sigmoid colon) receive their sympathetic, parasympathetic and sensory supply via nerves from the inferior mesenteric plexus:
Parasympathetic innervation via the pelvic splanchnic nerves
Sympathetic innervation via the lumbar splanchnic nerves.
Lymphatic Drainage
The lymphatic drainage of the ascending and transverse colon is into the superior mesenteric nodes. The descending colon and sigmoid drain into the inferior mesenteric nodes.
Most of the lymph from the superior mesenteric and inferior mesenteric nodes passes into the intestinal lymph trunks, and on to the cisterna chyli – where it ultimately empties into the thoracic duct.
