Fluoroscopic and Radiographic Examination

• During the infusion of the barium suspension, the examiner performs frequent, intermittent fluoroscopic examination of the small bowel. This is accompanied by frequent graded-pressure palpation of the abdomen with the balloon compression paddle or F-Spoon (with a lead glove on the examiner's hand). The palpation permits separation and x-ray penetration of barium-filled and overlapping loops and allows displacement of air bubbles and undigested food particles which may simulate small bowel polyps. Intermittently, the patient should be turned obliquely to one side and then the other in order to get different, almost 3-dimensional, perspectives of the bowel loops.

• The attention of the fluoroscopist should alternate between following the head of the barium column and returning to other areas of the abdomen where loops of bowel are already filled in order to reevaluate these loops and to take spot images. Periodically, the examiner should look at the proximal duodenum and fundus of the stomach for evidence of reflux (which would lead him to decrease the infusion flow rate).

• Spot images are obtained with the digital camera or in the 1-on-1 format on 10" x 12" films at 125 kVp. Graded compression with the balloon paddle is indispensable during filming. Compression spot images should cover every area of the abdomen containing contrast-filled small bowel. Steep RPO and LPO views of the pelvis are necessary to fully evaluate loops of ileum tucked deeply into the pelvis.

• After the entire small bowel is filled with contrast, a technologist will take two 14" x 17" overhead films of the abdomen, both prone: one with a vertical beam and the other with 35 degrees of caudad anglulation to improve visualization of pelvic loops.

• If the terminal ileum or loops of bowel packed deep in the pelvis are not adequately evaluated because of under filling or overlapping, a peroral pneumocolon should be performed (see Peroral Pneumocolon).