UNIT 3: Small Bowel Series (SBS) Small Intestine

Question 1

SMALL INTESTINE

Answer 1

-3 Parts:
-Duodenum
-Jejunum
-Ileum
-22 feet in length
-Lies within abdomen and pelvis
-Begins at PYLORIC ORIFICE and terminates at ILEOCECAL valve found between ileum and cecum of large intestine

Question 2

INSIDE THE SMALL BOWEL: villi

Answer 2

finger-like projections in the mucosa, which assist with the processes of digestion and absorption

Question 3

Duodenum

Answer 3

-10 inches long
-First 1-2” is DUODENAL BULB (Cap)
-Remainder is C-LOOP
-Encircles the head of pancreas
-Lies posterior to stomach
-Important in digestion
-Common bile duct & Pancreatic Ducts empty into duodenum

Question 4

Jejunum

Answer 4

-8 feet long
-Jejunum arises after duodenum passes behind the stomach and emerges on the left lateral side of stomach
-Duodenum joins Jejunum at Duodenojejunal Flexure and is supported by Ligament of Treitz (suspensory muscle of duodenum)

Question 5

Ileum

Answer 5

-15 feet long
-Extends from jejunum to cecum
-TERMINAL ILEUM (TI) is distal end of ileum
-ILEO-CECAL sphincter is found here
-ILEO-CECAL JUNCTION is where TI joins with cecum of large intestines

Question 6

Patient Prep

Answer 6

-Soft or low residue diet 2 days prior to study
-NPO after evening meal the day before exam
-Cleansing enema may be used to clear colon
-Bladder should be emptied prior to exam

*SBS usually performed with UGI. Exam known as UGI with small bowel follow through (SBFT)

Question 7

SBS methods

Answer 7

-Orally: Barium sulfate or gastrografin
-Reflux filling: Large volume of barium enema, reflux into small intestines
-Enteroclysis: Direct injection into bowel through intestinal tube

*Reflux and Enterocylsis methods performed when oral method fails

Question 8

AP OR PA SMALL BOWEL SERIES Positioning

Answer 8

-Projection: AP or PA
-IR: 14 x 17
-SID: 40”
-Pt. Position: supine or prone, site dependent
-CR: Perpendicular to IR
-Immediate to 20 minutes: 2” above the crest/L2
->20 minutes: at the iliac crest
-Breathing: Suspend on exhalation
-Annotate the time and position

Question 9

AP OR PA SMALL BOWEL SERIES Evaluation Criteria

Answer 9

-Proper collimation and marker outside the area of interest
-Entire small intestine on each image
-Stomach visualized on initial/ early images
-Time marker
-Vertebral column centered
-No rotation of patient

Question 10

Procedure

Answer 10

-AP KUB (Scout film)
-Pt. drink an additional cup of barium if done in conjunction with UGI
-If no UGI, pt drinks at least 3 cups of barium
-Gastrografin may be added to mixture to speed things along (site dependent)
-After patient finishes drinking, images are timed:
-Immediate
-15 minute
-30 minute
-And every 30 minutes there after until barium reaches ileocecal region
-Fluoroscopic ileocecal spots may be obtained using compression paddle
-Exam completed when barium is visualized in the cecum
-Approximately 2 hours

*DO NOT forget pt. care- that is a long time to lay on a cold, hard table

Question 11

Protocol

Answer 11

-Supplies: 120mL Gastrografin
-If Nasogastric Tube Present - 2- 60 cc syringes – compatible with Nasogastric Tube connection.
-Scout KUB
-Patient drinks 120 cc of Gastrografin or is administered through Nasogastric Tube
-Nasogastric Tube taken off suction.
-KUB obtained Immediately after contrast administration
-KUB obtained at 8 hours after contrast administration
-Always include Timer Marker

Question 12

PA vs AP SMALL BOWEL SERIES

Answer 12

PA:
-Compression leads to uniform penetration and better separation of the small bowel
-Best image quality

AP:
-Better visualization of the retrogastric portions of the duodenum and jejunum
-Maybe more comfortable for the patient

Question 13

ILEOCECAL SPOTS with COMPRESSION PADDLE

Answer 13

Question 14

ENTEROCLYSIS SMALL BOWEL SERIES

Answer 14

-Under fluoro control, Bilboa or Sellink tube placed at approx level of DUODENOJEJUNAL junction (near Ligament of Treitz)
-Barium & Methylcellulose injected through tube at a rate of 100ml/min
-Methylcellulose distends the bowel wall
-Spot films taken with fluoro tower
-Overhead abdominal films taken after this. Usually AP, PA, Obliques & lateral depending on physician preference
-May request Upright AP

Question 15

Pathology: MECKEL’S DIVERTICULUM

Answer 15

-Most common congenital abnormality of the small intestine
-Outpouching of the small intestine
-Most are found within 2 feet of the ileocecal valve

Question 16

Pathology: INTUSSUSCEPTION

Answer 16

-Segment of bowel “telescopes” on itself
-Common in ileocecal region
-More likely to occur in children
-Abdominal pain, vomiting, RUQ mass
-“Coiled Spring” appearance
-Treatment may include air or water enema

Question 17

Pathology: OBSTRUCTION

Answer 17

-Mechanical: Lumen of the bowel is occluded
-Paralytic Ileus: Failure of normal peristalsis

Question 18

Pathology: CROHN’S DISEASE/ REGIONAL ENTERITIS

Answer 18

-Inflammatory bowel disease involving the intestinal wall

-Fluoroscopy: evaluate lumen contour and mucosa

-Ulcers
-Lumen narrowing
-Thickening
-Strictures “string sign”
-Fistulas

Question 19

Labeled Images

Answer 19

Question 20

In the Immediate Image the following must be visualized:
a) Ileum and Ileocecal Valve
b) Stomach and Dudodenum

Answer 20

b) Stomach and Dudodenum

Question 21

SBS/SBFT is complete when contrast goes from ILIUM to CECUM.
A) True
B) False

Answer 21

False, it’s ILEUM

Question 22

Along with your marker, what is the other critical annotation that is needed for SBS?

Answer 22

Times

Question 23

Which comes first? Fluoroscopy or overhead images?

Answer 23

Small bowel exam: overhead images and then fluoroscopy
Upper GI exam: fluoroscopy and then overhead images