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The small intestines extend from the ___________ to the ___________.
- pyloric sphincter
- ileocecal valve
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How long is the small intestine?
- during life: ave 15-18 ft
- after death: ave 22-23 ft
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Describe the diameter of the small intestine:
varies from 1 1/2" proximally to about 1" distally (gradually gets smaller)
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name the two main functions of the small intestines:
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most nutrients are reabsorbed through the:
small intestines
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what do we call local areas of contraction throughout the small intestines (localized peristalsis)?
rhythmic segmentation
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list the layers of the small intestines from outer to inner:
- serous layer
- muscular layer
- submucosa layer
- mucous layer
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what does the muscular layer of the small intestine consist of?
circular fibers on the inner later and longitudinal fibers on the outer layer
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describe the mucous layer of the small intestine:
it is thrown into circular folds that have villi that protrude outward
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name the three portions of the small intestines and their positions:
- duodenum: RUQ and LUQ (proximal portion)
- jejunum: primarily LUQ and LLQ (middle portion)
- ileum: primarily RUQ and RLQ (distal portion) 3/5 of sm. int.
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label
- A. gallbladder
- B. pancreatic ampulla of vater
- C. descending portion
- D. duodenum
- E. head of pancreas
- F. romance of the abdomen
- G. horizontal portion
- H. ascending portion
- I. ligament of treitz
- J. superior portion
- K. duodenal bulb/cap (common sidt for ulcers)
- ** sphincter of odie is where pancreatic duct empties into duodenum
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what is the name of the loops of the small intestine?
gyri mesentery
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what are the four major parts of the large intestine?
- cecum
- colon
- rectum
- anal canal
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what are the 5 major parts of the colon?
- ascending colon
- transverse colon
- descending colon
- sigmoid colon
- right (hepatic) and left (splenic) colic flexures
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name the functions of the large intestine:
- absorption of fluids
- elimination of waste products
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the digestive action that takes place in each pouch-like section of large intestine:
haustral churning
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how often does mas peristalsis occur?
at least once in 24 hours
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what is the last digestive step?
defecation
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what is the last stage of digestion?
bacterial break-down in large intestine, gas is a bi-product of the bacteria
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name the layers of the large intestine, from outer to inner:
- serous layer
- muscular layer
- submucous layer
- mucous layer
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describe the muscular layer of the large intestine:
inner layer of circular fibers and outer layer of longitudinal fibers arranged in three bands over the larger part of the intestine and in two bands over the remaining part.
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the bands of the outer muscular layer that cause the wall of the large intestine to pouch outward:
teniae coli
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the pouch-like segments of the large intestine:
haustra
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LABEL
- A. Right colic (hepatic) flexure
- B. Ascending colon
- C. Ileocecal valve
- D. Cecum
- E. Appendix (veriform process)
- F. Rectum
- G. Sigmoid colon
- H. Ileum
- I. Descending colon
- J. Left colic (splenic) flexure
- K. Transverse colon
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describe rebound pain and an abdominal condition it is common for:
- no pain when applying pressure, but pain presents when pressure is released
- common with appendicitis
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Which large intestine flexure is oriented more superiorly in the body?
the splenic (left) flexure is higher than the hepatic (right) flexure
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Where is the appendix located?
attached to the inferior, medial portion of the cecum
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how are the parts of the colon oriented in relation to each other?
the transverse colon and the sigmoid colon are more anterior, while the ascending colon and descending colon are more posterior
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If your patient is prone, where in the colon will the positive contrast appear?
transverse colon and sigmoid colon
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If your patient is supine, where in the colon will the positive contrast appear?
ascending colon and descending colon
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how long is the entire large intestine?
- approximately 5 feet long
- (rectal portion 6" long)
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specifically, how should the enema tip be inserted, in regards to the direction?
goes in anteriorly through the sphincter, then turn superiorly
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LABEL:
- A. sacrum
- B. anal canal
- C. rectum
- D. rectal ampulla
- E. anus
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what type, how much, and what consistency of contrast is commonly used for a small bowel series on a patient with no contraindications?
- thin mixture of barium (milkshake consistency)
- 16oz. (2 cups)
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What are some reasons for barium to be contraindicated for a small bowel series and what would be used instead?
- tear in mucosal lining, impaction, constipation, ileus (blockage in small intestine), surgery to follow
- use water-soluble contrast (i.e. gastrografin)
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Aside from being used when barium is contraindicated, what is another reason that water-soluble iodinated contrast might be added?
- to increase peristalsis
- (also, ice water increases peristalsic activity)
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what is an ileus and what often indicates the presence of one?
- a blockage in the small intestine
- air in the small intestine (air should never be there)
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What is the purpose of a small bowel series?
it is a study of the form and function of the three components of the small bowel, as well as to detect any abnormal conditions
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Generally speaking, what studies are done first?
- non-contrast studies and thyroid studies
- iodinated studies first, before barium (i.e. IVU before SBS)
- CT and MRI studies done before any barium studies
- B.E. done before UGI
- UGI done before SBS
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methods used in the examination of the small bowel:
- oral
- reflux feeling (large volume BE, last resort)
- enteroclysis (direct injection into intestinal tube: Bilboa, Sellink, or Miller-Abbot tube)
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what amount of contrast are used in B.E. studies?
- 1500mL bag for a normal BE
- 2 bags for a large volume BE (pt. usually sedated)
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What may have to be administered for a large volume B.E. if spasming of the intestines begins?
glucagon
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list the patient prep for a small bowel series:
- NPO after midnight
- no breakfast
- possible cleansing enema or suppository
- bladder emptied before exam and during exam as necessary
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what are the advantages of prone versus supine for a small bowel series and which do you use?
- prone compresses abdominal contents improving the radiographic quality
- supine shifts the stomach superiorly and laterally so that the retro gastric portions of the duodenum and jejunum are seen and prevents compression overlaps of the intestine
- you use projections according to the protocol of your radiologist
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describe the process of a small bowel series:
- scout KUB
- 16 ounces of contrast (2 cups)
- immediate KUB and 15 min. KUB 2" above crest
- 30 min. KUB, 45 min. KUB, 1 hour KUB
- continue according to radiologist instructions
- spot films of ilio-cecal valve when contrast reaches colon
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what should be done when taking spot films of the iliocecal valve for a small bowel series?
use compression over the RLQ to separate the bowel loops, may need to oblique the patient
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what study is this? how could you tell?
- small bowel series
- 1. (immediate) center above crest because contrast is still high
- 2. (15min) jejunum looks "feathery" while ileum is smoother (stacked coin)
- 3. (30min) usually move CR down to crest after this
- 4. (1 hour) stomach mostly empty
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What are these projections, and what study are they a part of?
- Fluoroscopic Ileocecal Valve Shots
- at the end of Small Bowel Series
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what is the purpose of the BE?
to radiographically study the form and function of the large intestine to detect any abnormal conditions
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what are the two studies of the large intestine that we routinely do (include subcategories)?
- single contrast studies (only positive contrast)
- double contrast studies (positive and negative contrast)
- -- single stage (air & barium administered selectively)
- -- double stage (barium, pt. evacs, then air)
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what is the advantage of a double contrast BE study, as opposed to a single contrast study?
better demonstrates the lumen; small polyps, ulcers, etc.
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describe the pt prep necessary for a BE study:
- NPO 8hrs prior to exam (usually stated "NPO after midnight")
- sometimes laxative prescribed (ex. dulcolax packet)
- sometimes cleansing enema administered
- **goal is thorough cleansing of large intestine
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what are some contraindications to laxatives or cathartics as pt. prep for a BE study? alternate instructions?
- gross bleeding
- severe diarrhea
- obstruction
- inflammatory condition such as appendicitis
- pt. placed on liquid diets 2-3 days prior to compensate
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what are the common contrast media used in a BE study?
- barium sulfate (positive contrast)
- water-soluble, iodinated contrast media like gastrografin
- air or carbon dioxide (negative contrast)
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what consistencies of contrast are commonly used for a single contrast study and a double contrast study?
- single: thinner barium, 15-25% weight to volume
- double: thicker barium, 75-95% weight to volume
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What study is this?
single contrast BE (w/o air)
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What study is this?
double contrast BE (with air)
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what temperatures are standard for a "warm" barium BE and a "cold" barium BE?
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what are the advantages of cold barium and the advantages of warm barium, for a BE?
- cold: irritates bowel less; gives it anesthetic properties; stimulates anal contraction; faster (opposite from UGI contrast)
- warm: less cramping/spasms
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What can long-term steroid use do that should be kept in mind if performing a BE?
weakens walls of intestines
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What position should the pt assume for a BE tip insertion?
sims position
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at what level should the BE contrast bag be placed?
- 18-24" optimal
- no more than 30" (too high, can move too fast and rupture lg. int.)
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what do you do to free the tubing of air right before inserting the enema tip for a BE?
lower bag and raise tip
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how far is the enema tip inserted for a BE?
3 1/2 to 4"
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describe inserting an enema tip for a BE:
- pt. in sims position
- lubricate tip
- free tubing of air
- ask pt to try to relax (deep breaths, blow it out)
- open gluteal fold
- insert tip 3 1/2 to 4" anteriorly past sphincter, then turn superiorly
- insert during exhale (abdominal muscles relaxed)
- ONE puff of air in balloon
- slide stopcock over to hold air in balloon
- put pt. in supine position
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common projections taken for a single conrast BE study:
(includes but not limited to)
- AP/PA
- both obliques
- sigmoid shot
- rectum shot
- post evacuation radiograph
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What does the post evac film for a BE study best demonstrate?
the mucosal pattern
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What is the study and the projection?
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a condition in which little pouches/ticks of the large intestine wall protrude outward due to weakening of the wall:
diverticulitis
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where is the negative contrast (air) demonstrated in a left lateral decubitus position?
- medial side of the descending colon
- lateral side of the ascending colon
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where is the negative contrast (air) demonstrated in a right lateral decubitus position?
- medial side of the ascending colon
- lateral side of the descending colon
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Prone or Supine?
supine
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Prone or Supine?
prone
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a condition when the colon twists upon itself causing a blockage; sometimes self-correcting but usually a surgical emergency:
- vovulus
- (more common in sigmoid and transverse colon because they're more mobile)
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a condition in which the bowel "telescopes" or collapses into itself; could cause blockage and need surgery:
- intussusception
- ( most common in the sigmoid colon)
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LABEL:
- A. left colic (splenic) flexure
- B. transverse colon
- C. descending colon
- D. sigmoid colon
- E. rectum
- F. ileum (sm. int.)
- G. cecum
- H. ascending
- I. right colic (hepatic) flexure
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common projections taken for a double contrast BE study:
- AP/PA
- all obliques (RAO, LAO, RPO, LPO)
- lateral rectum (ventral decub for air contrast)
- R & L lateral decub
- post evac (AP or PA)
- AP axial (sigmoid)
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what kvp would be used for a single contrast BE and for a double contrast BE?
- single: 100-125
- double: 80-90
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Name the study and projection/position:
- single contrast BE (w/o air), PA
- entire lg int should be demonstrated
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what is the purpose of the PA axial projection during a BE study?
to demonstrate the sigmoid; separates those loops of bowel
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Name the study and projection/position:
- double contrast BE (with air), AP axial
- better views rectosigmoid segment of lg. int.
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Name the study and projection/position:
- double contrast BE (with air), RAO position/PA oblique proj.
- hepatic flexure, ascending, and sigmoid colon open
- DOWN SIDE ANATOMY BETTER VISUALIZED
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during a BE study, what side is better demonstrated for PA oblique projections?
better demonstrate anatomy closer to the IR -- DOWN SIDE
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during a BE study, what side is better demonstrated for AP oblique projections?
better demonstrate anatomy farther from IR -- ELEVATED SIDE
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Name the study and projection/position:
- double contrast BE (with air), LAO position/AP oblique proj.
- left colic flexure and descending colon open
- DOWN SIDE ANATOMY BETTER VISUALIZED
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Name the study and projection/position:
- single contrast BE (w/o air), left lateral rectum
- rectosigmoid area demonstrated
- (centered to ASIS)
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Name the study and projection/position:
single contrast BE (w/o air), AP
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Name the study and projection/position:
- single contrast BE (w/o air), AP axial
- elongated view of rectosigmoid area
- sigmoid/rectum primary area of interest
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Name the study and projection/position:
- double contrast BE (with air), LPO position/ AP oblique proj.
- hepatic flexure, ascending colon, and rectosigmoid colon open
- BETTER SHOW ELEVATED SIDE
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Name the study and projection/position:
- double contrast BE (with air), RPO position/ AP oblique proj.
- splenic flexure, descending colon open
- BETTER SHOW ELEVATED SIDE
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Name the study and projection/position:
- double contrast BE (with air), Right lateral decub
- air filled left colic flexure and descending colon
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Name the study and projection/position:
- double contrast BE (with air), Left lateral decub
- air filled right colic flexure, ascending colon, and cecum
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Name the study and projection/position and label it:
- double contrast BE (with air), AP axial
- A. descending colon
- B. sigmoid area
- C. rectum
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