Synonym/Acronym
Air-contrast barium enema, double-contrast barium enema, lower GI series, BE.
Rationale
To assist in diagnosing bowel disease in the colon such as tumors, diverticula, and polyps.
Patient Preparation
Instruct the patient to eat a low-residue diet for several days before the procedure and consume only clear liquids during the 24 hr before the procedure, including the evening before the test. There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. The Canadian Anesthesiologists’ Society has fasting guidelines for preprocedural fasting. Related information can be located at https://www.cas.ca/English/Page/Files/97_Appendix%206.pdf.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Inform the patient that a laxative and cleansing enema may be needed the day before the procedure, with cleansing enemas on the morning of the procedure, depending on the institution’s policy. Patients with a colostomy will be ordered special preparations and colostomy irrigation depending on the area of the colon to be studied.
If studies involving the entire digestive tract are required (e.g., upper GI or barium swallow), verify that the barium enema is performed first to avoid retention in the abdomen of residual barium from the swallow study, which may obscure details of interest.
Pediatric Preps
| 2 years or younger | Clear liquid diet 24 hr prior to the procedure; a pediatric Fleet enema (a half or whole suppository [glycerin or bisacodyl (Dulcolax)] may be ordered instead of the enema) on the evening before and morning of the procedure up to 3 hr prior to the procedure; NPO for 4 hr before procedure | | 3–16 years | - Low-residue diet for 48 hr prior to procedure
- Clear liquid diet for 24 hr prior to procedure; castor oil or Neoloid, a flavored castor oil, may be ordered the night before the procedure; dose is based on either weight or age—for castor oil, 26–80 lb, give 1 oz; 81 lb or greater, give 2 oz; for Neoloid, 2–5 yr give 2 teaspoons (9.9 mL); 6–8 yr give 1 tablespoon (14.8 mL); 8–18 yr give 2 tablespoons (29.6 mL)—or bisacodyl oral tablet may be substituted based on age (3–8 yr give 1 tablet, 9 yr and older give 2 tablets)
- Fleet enemas, until fecal return is clear, up to 3 hr prior to procedure
- NPO for 4 hr prior to procedure
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Normal Findings
- Normal size, filling, shape, position, and motility of the colon
- Normal filling of the appendix and terminal ileum.
Study type: X-ray Contrast/Special; related body system: Digestive system.
This radiological examination of the colon, distal small bowel, and occasionally the appendix follow instillation of barium (single-contrast study) using a rectal tube inserted into the rectum or an existing ostomy; the patient retains the contrast while a series of images are obtained. Visualization can be improved by draining the barium and using air contrast (double-contrast study). Some of the barium remains on the surface of the colon wall, allowing for greater detail in the images. A combination of x-ray and fluoroscopic techniques are used to complete the study.
This test is especially useful in the evaluation of patients experiencing lower abdominal pain, changes in bowel habits, or the passage of stools containing blood or mucus. A barium enema may be therapeutic by reducing an obstruction caused by intussusception, or telescoping of the small intestine into the large intestine; this is a condition that most commonly affects children.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with suspected perforation of the colon should receive a water-soluble iodinated contrast medium, such as Gastrografin, to prevent barium from spilling into the retroperitoneum and causing an inflammatory reaction in the surrounding tissue.
Patients with conditions such as rapid heart rate, intestinal obstruction, megacolon, acute ulcerative colitis, acute diverticulitis, or suspected rupture of the colon; barium or water from the enema may make the condition worse.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal (GI) tract resulting from inadequate cleansing or failure to restrict food intake before the study can interfere with visualization. Residual stool can mimic a polyp.
- Retained barium from a previous radiological procedure.
- Spasm of the colon, which can mimic the radiographic signs of cancer. (Note: The use of IV glucagon minimizes spasm.)
- Inability of the patient to tolerate introduction of or retention of barium, air, or both, in the bowel.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
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| Gastrointestinal (altered—related to bowel disease, inflammation, infection, tumor) | Altered bowel sounds, compromised GI motility, diarrhea, constipation | | Pain (related to abdominal distention, GI inflammation, postoperative incision) | Crying, holding abdomen with guarding, verbalization of pain and pain characteristics, facial grimace | | Nutrition(insufficient—related to malabsorption, pain, inflammation) | Weight loss; dry, pale skin; hair pulls out easily; poor skin turgor; fatigue; dehydration; diarrhea; reported poor appetite |
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Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the colon.
- Explain that the procedure is performed in a radiology department and takes about 30 to 60 min.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that there may be moments of discomfort or pain experienced when the rectal tube is inserted.
- Pediatric Considerations: Preparing children for a barium enema depends on the age of the child:
- Provide assurance that a favorite toy or comfort item will be allowed into the examination room and, if appropriate, that a parent may be present during the procedure.
- Discuss how there will be monitors in the room enabling viewing of the procedure along with the health-care team.
- Encourage being truthful about unpleasant sensations (cramping, pressure, fullness) the child may experience during the procedure and to use words that they know their child will understand.
- Talk about the test right before the procedure; toddlers and preschool-age children have a short attention span.
Procedural Information
- Baseline vital signs will be recorded and monitored throughout the procedure.
- During the procedure the initial image is taken in the supine position.
- After the initial image, the position is changed to lying in the Sims position on the left side.
- A rectal tube is inserted into the anus; an attached balloon is inflated once situated against the anal sphincter.
- Older Adult and Pediatric Considerations: Reduced muscle tone occurs with advanced age, and fully developed muscle tone may not be present in children. Older adult patients and children may have difficulty holding the barium in the colon while images are taken. A balloon tip may be used to assist with retention of the barium; the buttocks are gently held together with tape if necessary.
- Barium is instilled into the colon by gravity, and its movement through the colon is observed by fluoroscopy.
- For patients with a colostomy, an indwelling urinary catheter is inserted into the stoma and barium is administered.
- Images are taken with the patient in different positions to aid in the diagnosis.
- If a double-contrast barium enema has been ordered, air is then instilled in the intestine and additional images are taken.
- After the procedure, most of the barium is removed using the rectal tube.
- Assistance to the bathroom is provided to expel residual barium, or the patient is placed on a bedpan if unable to ambulate.
- A postevacuation image is taken of the colon to verify expulsion of the barium.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Ask the patient about known allergens, especially allergies or sensitivities to latex (if a latex balloon tip is to be used) and administer ordered premedication with corticosteroids and diphenhydramine before the procedure.
Safety Considerations
- Older Adult Considerations: Older adult patients present with a variety of concerns when undergoing diagnostic procedures.
- Level of cooperation and fall risk may be complicated by underlying problems such as visual and hearing impairment, joint and muscle stiffness, physical weakness, mental confusion, and the effects of medications.
- Fall injury can be avoided by clear communication to the imaging team, ensuring assistance is provided in getting on and off the x-ray table and on and off the toilet at the end of the examination.
- Older adult patients are often chronically dehydrated; anticipating the effects of hypovolemia and orthostasis can also help prevent falls.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Complications are rare but may include:
- Abdominal discomfort and cramping (related to retention of barium)
- Allergic reaction (related to contrast reaction)
- Constipation, fecal impaction, or bowel obstruction (related to dehydration and/or retained barium)
- Peritonitis (related to leakage of barium into the peritoneal cavity; perforation of the colon or hemorrhage, resulting from changes in hydrostatic pressure during administration of the enema or manipulations of the tip of the enema tubing during barium administration to patients with a weak colon; a rare complication that may occur in children, immunocompromised patients, or patients whose colon is already weakened by disease)
Treatment Considerations
- Follow post-procedure vital sign and assessment protocol.
General
- Discuss how stools will be white or light in color for 2 to 3 days.
- Instruct the patient to notify the health-care provider (HCP) if unable to eliminate the barium, or if stools do not return to normal color.
- Advise patients with a colostomy that tap water colostomy irrigation may aid in barium removal.
Gastrointestinal
- Facilitate management of altered gastrointestinal function.
- Assess and trend bowel sounds, abdominal distention, and abdominal girth
- Ensure adherence to nothing by mouth (NPO) to rest the GI tract.
- Encourage dietary selections that will decrease gastric irritation once taking an oral diet; a dietary consult may assist.
- Monitor diarrhea and check stool for occult blood.
- Administer ordered medication to treat constipation or diarrhea.
- Provide instructions after the procedure to resume usual diet, fluids, medications, or activity, as directed by the HCP.
- Discuss taking an ordered mild laxative and increase fluid intake (four 8-oz glasses) to aid in elimination of barium, unless contraindicated.
- Carefully monitor for fatigue and fluid and electrolyte imbalance.
- Pediatric Considerations: Advise the parents of pediatric patients to hydrate the child with electrolyte fluid post barium enema.
- Older Adult Considerations: Note that chronic dehydration can also result in frequent bouts of constipation.
- Encourage older adults to hydrate with fluids containing electrolytes (e.g., Gatorade, Gatorade G2 or Gatorade zero sugar for individuals with diabetes, or Pedialyte) after the procedure and to use a mild laxative daily until the stool is back to normal color.
Pain
- Administer prescribed analgesics or opioids.
- Discuss and identify alternative methods of pain relief that work for the patient.
- Encourage movement to relieve gas.
- Assist the patient to move into a more comfortable position.
Nutritional Considerations
- Facilitate management of insufficient nutrition.
- Discuss how dietary changes are necessary to decrease pain and GI irritation.
- Consider recommending omission of oral dietary intake for a period of time to rest the bowel and allow healing; enteral, parenteral, or intravenous nutrition may be necessary.
- Suggest the use of a food diary that can be helpful to identify foods that precipitate pain and diarrhea.
- Suggest dietary alterations that include low-fat, low-fiber, limiting diary products, drinking plenty of fluids, and avoiding spicy food choices.
- Consider a dietary consult with cultural and ethnic considerations to improve caloric intake.
- Complete a daily weight and monitor albumin levels.
- Encourage small frequent meals to assist in decreasing pain and improving caloric intake.
Clinical Judgement
- Consider how food choice is an important part of an individual’s cultural identity. How do you support that identity and create a diet plan that the individual will adhere to?
Follow-Up and Desired Outcomes
- Recognizes colon cancer screening options and understands that decisions regarding the need for and frequency of occult blood testing, colonoscopy, or other cancer screening procedures may be made after consultation between the patient and HCP.
- Understands that colonoscopy may be used to follow up abnormal findings obtained by any of the screening tests.
- The most current guidelines for colon cancer screening of the general population as well as of individuals with increased risk are available from the American Cancer Society (www.cancer.org), U.S. Preventive Services Task Force (www.uspreventiveservices taskforce.org), and American College of Gastroenterology (http://gi.org). For additional information regarding screening guidelines, refer to the study titled “Colonoscopy.”
- Recognizes the value of rest, relaxation, and stress reduction with good diet maintenance to manage periods of bowel inflammation.
- Recognizes the value of contact information to attend a support group for grief counseling and end-of-life care.