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Relevance of Barium Study in Present Scenario

Sep 29 | 1:30 PM

This interesting session on 'Relevance of barium study in present scenario' is organized by KREST, Kochi in association with IRIA, Thiruvalla. A barium X-rays, a radiographic examination of the gastrointestinal tract is often used to diagnose GI conditions. However, in this world of enhanced technology where procedures such as endoscopy procedures are so routinely performed how relevant is the barium meal radiology. Let's gain some insights with Dr. Ramesh Chander

[Music] good evening everyone welcome to the third crest kochi program on netflix this is organized in association with iria kerala tiruvala city chapter now may i invite dr dr chandra shegran keshavadas professor of radiology from the prestigious sri citra tirinal institute for medical sciences and technology tiruvanthapuram and sir is also the kerala iria central council member welcoming sir for the opening remarks over to you sir thank you judy good evening to all my friends and students today uh we have with us an eminent radiologist professor ramesh chandra who was a professor and head of punjab institute of medical sciences at jalandhar punjab formerly he was a professor in head government medical college amritsar he is an examiner for md as well as dnb examinations and i was the president of the the present president of the amritsar radiology forum he also has a lot of leadership qualities and uh he has proved himself as a [Music] well-respected president of ira punjab earlier he was vice president and joint secretary and also the governing body member of the indian college of radiology and imaging now sir is going to talk today on a very important topic and that is about the relevance of barium studies today in radiology practice now when this topic came to me and i was asked to introduce it i should first first of all confess that i am not an expert in this area because i work in an institution which is mainly for neurological and cardiological diseases we hardly see much cases of gastrointestinal diseases however during the early days when i had joined the department we had thoracic surgeons who were interested to understand about the vascular rings around the esophagus or about achilles cardia which are the surgeries which they occasionally used to do other than that we hardly do this technique but when i was asked to be a chair in this session i immediately called one of my colleagues who had worked in all india institute and i asked him how many barium studies do your department do he's actually he had taken a fellowship in gastrointestinal radiology so he told me that we do about four to five and most of these are for motility disorders and then for leaks and small intestinal imaging and so there is a relevance so even though there is the cross-sectional imaging like the ct has come uh after that mr has come many new technology and ultrasound also being a technique which can be utilized still there is a lot of relevance for barium studies and sir being an examiner is going to uh for you and also being a teacher for a very long time i am sure that he will be able to give a lot of tips on how to diagnose these conditions using barium studies sir we welcome you for this meeting and i hope this students and my friends and radiologists here a lot from this stuff thank you very much sir and thank you judy for inviting me here thank you sir now i welcome dr ramesh chandra professor and head of department in radiology punjab institute for medical sciences jalandhar sir is also the punjab ira state president and i invite sir to deliver his talk on the relevance of barium studies in the present scenario over to you sir good evening everybody i am thankful to the organizing committee for inviting me to deliver the lecture on which most of us consider it as an outdated investigation but it is a very part and parcel of our subject and it is the most easy and difficult part and i today i will be going to discuss you with various aspects of barium first 30 40 slides will be both radical portions that is that is the basic knowledge required to perform the investigation then later on i will discuss the important cases with you so this is my brief cv and [Music] now my present topic is barium study examination in the present scenario now coming to the contrast media the earliest contrast media used in the git was iodized oil commonly called a lipid oil now what is it it is a iodine plus a thigh listeners of poppy seed the first contrast was employed in radiology it was in 1921 okay so why this was discarded or why it is not used it is because it causes it were used in myelography and it causes irritation chemical irritation of the nerve roots and the main important was that intraposition or leakage into the venous system which was very dreadful and the only indication at present is in unexplained infillity cases it it is still it can be used i can say so in myelography and for other purposes because of irritation of the nerve roots and leakage into the venous system causing embolism so it is no longer used in our day to day practice now coming to the important component which is a barium barium is now the our main contrast is end and we can say that our git practice is dependent upon only on the barium now coming to the barium barium has got four salts the main examiner asks what are the other salts of barium so there are four barium salts one is barium chloride so why it is not used barium chloride is a water soluble white substance and highly toxic and moreover it absorbs in our git system so it cannot be used now coming to next it is barium nitrate now again why barium nitrate is not used because it is a toxic it causes irregular heartbeat and muscle weakness so the toxic irregular heartbeat we cannot use it now next comes barium carbonate we all know what is that poison i think you all are knowing rat poison is a barium carbonate so again we cannot use now the fourth salt is barium sulphate it is orderless insoluble and it is our bread and butter we can say that so so it is now barium sulphate which is used in our day to day practice now coming to barium sulfate it has got atomic number of 56 it is highly insoluble in and in it if it is soluble in water then it means it can be absorbed into our body system because of its pro because of its it this property it is idle uh contrast media and it causes good mucosal coating and as a result of which it causes thin layer of barium over the mucosa and we can introduce a second contrast media that is air then there is absence of artifact or forming and it is very cost effective now this is the jar which is available in the market our group is 250 and now the main examiner asks what is inside this jar it is a 300 grams of barium sulphate solution is inside this jar so the so it is a 300 grams which mostly ask now the question is this is a powder form how you are going to make it a this is a powder and we have to add a adequate amount of water and then we are using gas also now from where we will procure the gas the gas is in the lid itself if you open up at the at the start and the lid if you open the lid there is acid and base now what are properties of ideal barium it should be of high density stable suspension and should not fluctuate now not the various method of dilution which i i have that is weight by weight weight by volume and volume by volume that used in our conventional radiology is weight by volume now that one jar of barium if we add 70 ml of water the solution which will be ready is about 150 ml and that 150 ml of that barium solution it is at 200 weight by volume it is now in the market different preparations are easily available you don't have to make it but for your practical point of view and an institution or in small cities where that ready-made solutions are not available we have to make it as a resident i have made all these solutions very simple just add a 70 ml of water to that one but that took 300 grams and it the solution comes out to be 150 ml and it is a 200 if we add two glasses of water then it comes 100 if 3 then 50 this is how we make a solution by ourself it is a very easy not so hard so these are various preparations which are available one is micro bar suspension which is available in the market then micro bar hd that i have told you and discuss with you then micro bar paste which is used for varying swallow now in my 25 year of practice i have not seen any major complication of barium examination but for your theoretical purpose and as a knowledgeable person as a good radiologist you must be aware of what can be the disadvantages of barium if the barium leaks into the mediastinum or peritoneum it causes inflammation that is medicine nitrous and peritonitis which further leads to fibrosis and if we have to perform the ct examination then you know the barium causes artifacts so so we have to plan our investigation so before we the patient is sent for barium we must uh do the ct or any other investigation which is required before performing the perium examination now now the major complications in cases where the perforation occurs it leads into very peritoneal cavity which is a which causes pain and severe hyperbolamic shock and with best of management it carries a 50 percent of the motility rate and of those 50 percent that survive 30 percent will develop peritoneal adhesions and granuloma formation so please be careful in cases of suspected perforation patient don't try this barium okay for that we can use the iodine contrast media which i am going to tell you later on so what happens if the patient aspirate like we have advanced carcinoma patients okay and in that case is the patient aspirate into the so it is not so serious it can only leads to pneumonitis and granuloma formation and physiotherapy is the only thing that is required now if this barium enters into our vascular system then from ulceration or anything then so these are complication which you must be it is perforation aspiration and interruption so for those patients uh who are we are suspecting that they can be case of perforation then we are going to use a water soluble contrast material and in cases of meconium alias okay not barium so these are minor complication with the contrast media we should not use high or smaller and it may cause pulmonary edema and hypovolemia okay we should use low or smaller contrast media in cases of perforation of the patient now coming to the next that is carbon dioxide and less of an air is used in conjugation with the barium to achieve a double contrast now the question arises from where we are going to get that gas producing is end that i have told you that is in the pouch pouch of the jar and what is there and what produces the gas it is sodium bicarbonate which is popularly called as baking soda and citric acid so these two are solution that is sodium bicarbonate and citric acids now what is the concentration acid is about 1.6 grams and base is about 2.4 grams these are for resident purpose they must be aware of and what is the amount of gas that acid 1.6 that is baking soda and citric acid produces it is about 450 cc which is quite adequate for our purpose of this study now coming to the indication for where we do barium swallow i hope you are all where birim swallow is a contrast study done from oral cavity up to the fundus of the stop so what are the indication you are well aware that is dysphasia pain during swelling mortality disorders to look for various structural lesions these are main indication and what is a barium solution that what is the concentration which is used it is eighty two hundred percent that is barium sulfate solution is used in cases of barium swallow now now next question is what is single contrast and what is double contrast single contrast is only barium is used it is 8200 and double contrast is when we introduce air okay so single contrast is mainly mainly done to look for any compressions displacements modality disorders and double contrast is look for ulcers small lesions for that double contrast is used so technique overnight fasting is required patients should avoid smoking or chewing gums why if the patient is having had a food then what will be there then food particles may be there which can disturb and may stimulate some pathology and overnight fasting is required because uh then comes the smoking and chewing gums it causes increased secretions as a result of increased secretions the the barium does not cause the mucosa so i have seen one or two cases when i was a resident and it is very difficult to coat the mucosa if the patient is smoking or giving gums or having a high amount of alcohol so we have to give instruction to the patient and before that we must take history of the patient that any previous surgery has been performed because we have to modify the examination accordingly in case of pregnancy we are not going to do that examination then we have to follow the rule of ten that is all the x-ray examination should be performed following or within the 10 days of normal menstruation then the patient is asked to remove jewelry eyeglasses any metal objects that may interfere with our investigation then the detailed procedure is very important and we have to practice with the patient because compliance of the patient is a must and without their cooperation it is very difficult to perform the investigation now technique you are already aware for a double contrast we use a 250 weight by volume and for single contrast it is 180 to 100 percent first of all for any investigation we take a scout film to rule out any foreign body abscess or fistula formation then the fluoroscopic unit is up to the level of patient patient neck and we ask the patient to take a mouthful of barium until we give the command then the first of all write literally we should be obtained to rule out any aspiration or penetration then frontal views are taken now the question arises in which conditions do we perform the prone examination in examination and in my earlier speech also the most of the audience they asked me sir when is the prone film taken the only indication is for mortality disorders look for osophageal viruses and high testornia so these are only condition where prone film is required so this is the procedure you all know very simple i think all the residents they must have seen and done their self so so otherwise the lecture will be very long so this is a double contrast so this is a ascendant base which i which i was talking so 2.4 gram is the base that is citric acid and acid is 1.6 gram so it produces a about 450 cc of gas so this is in the lead of the jar and now coming to the normal barium swallow we can see the in frontal and lateral view the valiuply and peripheral sciences have been well outlined by the contrast media and it can be a source of malignancy so whenever you are going to perform barium we have to demonstrate value collide and piriform sinuses now we all know not me of the osophagus it is a muscular tube it is about 18 to 25 centimeters in length it is divided into t three nautical segments one is cervical thoracic and abdominal so this is anatomy you all know so this is a single contrast only single contrast we do for any compressions okay look look for any and gross abnormality mortality disorders then we give a contrast look for various muscular lesions or ulcerations now very important there are normal constrictions which are present in the osophagus and some of them may confuse and give it as a pathological narrowing so we must be aware what are normal constrictions of the esophagus one is spiritually at the junction with the pharynx then at the level where aorta and left mean bronchus is crossed it causes constrictions at that points and inferiorly at that diaphragmatic center it causes constriction so these are normal three constrictions they are normally present they are not pathological you must be aware whenever you report a barium swallow now coming to what are normal impressions on the osophagus which are seen on the barium swallow one is at the level of your decart then at the crossing of the left mean bronchus and then the impression of left a team as a resident we have seen so many impressions of the left atrium on the osophagus and it has been beautifully it can be demonstrated on the lateral view now coming to the various anatomical structures which you are going to see we have a phrenic ampulla it is a normal expansion of the distal osophagus it does not contain any gastric then we have airing and bearing these are indentation at the upper level is a and at the lower level is b then we have a zigzag that is z line it is a basically a s comma columnar mucosal junction then we have a diagrammatic impression that is in serine so these are normal anatomy of the ge junction which we are going to see in various pathological conditions now and as i have told that bearing is not normal and automatically seen so this is a case of hernia where you can see that earring then phrenic ampulla bearing and gastric fools okay so this is a case of hyatus arnia just to demonstrate what is earring what is bearing in the barium swab now so this is a primary wave of contraction is not preceded by the relaxation in small gut but it is a normal natural phenomena [Music] and after the primary wave starts so we have to modify our technique of barium examination if the patient is having severe dysphasia a little dilute barium is given initially and further filling depends upon the abnormality for pharyngeal web we have to record and video fluorography for foreign body impactions cotton soaked with barium can be used okay then carcinoma then high viscosity normal density barium is given then in the cases of ecclesia we have to clean that esophagus because uh secondary eclisia due to carcinoma can be missed and very important test is we give hot water or tea tea to the patient and if you suspect cardiac laser if the patient sits the heart tea or hot water immediately the cardiac laser disappears so that is almost diagnostic test that the case we are handling is case of cardiac ecclesia now for to look for trichoesophageal fasciculus birim should be fluid like and patient should be lying lateral make the patient prone if a facility is not identified in the lateral position a facility seen please stop the procedure since the bearing aspirated can lead to granuloma formation okay to look for height asania we require high abdominal pressure to demonstrate hiatus hernia and patient has to strain or we have to do manual compression of the abdomen if motility disorder is suspected then it is a best to avoid spasmolytic gent as it will further decrease the modality and we will be creating another case of obstruction and creating problem for us so in mortality disorders no buscopan or glucagon injection is given coming to the important cases this is a brico pharyngeal paralysis a normal cryptopharyngeal para bulge is seen at the level of c7 the persistence of bulls or paralysis can be due to failure to relax or weakness of the pharyngeal constrictor muscles or due to radiotherapy so we get so this is a typical swallow showing that cryptopharyngeal paralysis now coming to the cryptopharyngeal web so cryptopharyngeal web they always rise from the interior wall never from the posterior wall it is circumferential and yet fact of contrast passing through a distal to the web may be seen uh most than 50 percent of the patient are symptomatic and it can lead to the carcinomas so we should be very careful so the only problem in this cricopharyngeal web is that we have to identify from venous plexus so how we are going to identify that it is a cricopharyngeal web or a venous plexus the venous plexus impressions are a phased as the bolus distance the lumen but in cases of crico pharyngeal web it will not be there so in if there is venus plexus then the that impressions on the osophagus will be phased as the bonus distance the lumen okay so that is the main differentiating point between the cryptopharyngeal web and venus plexus now another case of diverticula verticalize now what these are uh friendship vertical these are posterior outposting they are mostly seen in 70 to 80 year of age group and these are seen at lateral view and mostly at the level of c5 and c6 and 90 percent patient have a history of high test hernia and gastrointestinal flux disease now we have got two types of diverticuli one is true and other is false what is the true where all the osoficial layers are involved and false is where only mucosa and some mucosa are herniating through the muscular layer so next is these these vertically these are classified according to the mechanism of formation so one is fraction and other is also fraction is country due to the pulling forces on the outer respect of the osophages okay that is attraction that can be due to scarring fibrosis and inflammation pulsing is due to secondary due to increased intra-aluminal pressure example is jenkins vertical law now again showing you the mid-thoracic attraction diverticuli now this is a jenkins dwarf column jenkins uh jenkins was a german pathologist who first discovered we can see the value like piriform sinuses and the jenkins dwarticulo now coming to the at the same level we can have a carcinoma in the carcinoma we have a mucosal irregularity then there is holdup of the contrast and there is shouldering so we have to correlate that if there is shouldering or if there is any issue that needs further investigation and biopsy is required now another important condition is malaria biosphere it is also vegas that distill osophagus is showing a linear tear of mucus of this due to excessive wounding and barium is cracking into the wall so this is a melody based tear and if there is full thickness here that is bob syndrome which can be serious it can lead to medicineitis and death so this is a typical case of mellow vs tear now coming to another important condition that is diffuse osophageal spasm to diagnose a case of diffuse osophageal spasm manometry is the gold standard diagnostic test the patient that complain of chest pain dysphasia and they are more than 50 years old it is because of loss of inhibitory neurons these are no these are due to non-peristaltic contractions pushing the contrast media in two directions okay so this is a case of diffuse osophysial spasm and we call it as a corkscrew osophagus another case showing you how the name corkscrew osophagus came into the existence now coming to the other case that is ecclesia and this is a typical case of cardiac ecclesia which you are going to see and what we see we see a destiny we see that there is filling of the contrast hold up of the contrast media there is narrowing and the junction fails to open fully we see a red tail or bird beak and what important is that we can see that there is intact mucosa and food can be traced it is smooth no irregularity no shouldering is seen and if we give a hot water to the patient it will disappear so we can confidently write the diagnosis of glacial cardiac so what is bird big so this is the name from where the bird beak the sign came so we see that proximal osophageal dilatation where the tapering of the distal osophages resembling a bird beak and we can see that few diverse is there in the dilated proximal osophagus now another case of scleroderma and we can see that upper we have striated muscles and then lower two third we have a smooth and straighted muscles scleroderma mainly affects the smooth muscle so there occurs hold up of the contrast but the g junction is normal in these patients now another uh condition it is a pathological angular narrowing and it is a best demonstrated in the prone film that is cartis ring now coming to the various infections of the osophagus we have candida herpes cytomegalos and tb and there can be non-infectious causes that can be due to reflux osothritus radiation and caustic now coming to the how we are going to differentiate the ulcers of the osophagus now coming to the herpes also they are small else's less than 5 mm normal mucosa is seen between these vessels then candies these are plaque-like reticular shaggy margins and cytomegalo and hiv viruses they have a typical elliptical large ulcers so we i am going to show you the cases this is a can due to fungal infection candiasis so normal mucosa background is seen and diffuse granular or nautilus mucosa can be seen then again herpes ososite as we can see that bust punch out ulcer on a normally because so we see it as a sessile filling defect now coming to the reflex esophagitis early diagnosis is made up by endoscopy and we can see that fine nudular macularity then we have a thickened longitudinal force on the barium then we have circular muscles passed and transverse force scarring that can be seen in cases of reflex osophyllitis so the end end stage is the barrett's also vegas and we should be care of barrett's orsophagus because it can leads to the carcinoma and it demonstrates a relatively smooth non-distensible tapered area of nerving in mid to distal osophagus the mucosa at this level is particular then another case of uh that can be long tepid structure is seen it is in the late stage and earliest it is here we use the contrast media that is uh low osmolar contrast media he used that is iodine and earlier we can see that edema is there but this is a case of long standing we see just a tapered stricture long stricture which is smooth then this is another important case though any other investigation diagnostic modality can show you the intramural diverticulosis as beautifully as can be demonstrated by the barium enema so barium nema is the investigation of choice for intramural diverticulosis so it is a common sequence which is seen in a reflex oscillators basically it is submucosal gland that is a gland duct that is dilated and we see it on a barium as a multiple flask shaped projections now coming to the hernias we have a pouch of stomach which is a more than two centimeter that is a more than three gastric fools deadline and height is more than three centimeter so this is a case of high testonia which you can easily diagnose it is a very simple now another case of rolling hernia here the cardia that remains below the diaphragm but fundus herniates through the weakness and it is a leads to slight free deposition to reflex and it is a noun reducible so we have seen that in this and this uh hernia we have seen that it is a a above the g junction and it is a the height is more than three centimeter and more than three gastric fools are above but in this case of rolling the cardia is below only a fundus herniates through the weakness of the diaphragm again another case of stricture due to long-standing reflux another another osophageal narrowing with proximal pooling smooth margin and there is hold off of contrast but if we see the mucosa and from both sides we compare anterior and posterior it is very smooth and it shows a benign ulceration then dysphagia livoria is due to osophagus may be compressed by the congenital aberrant right subclavian artery so we can see that if the patient is diagnosed we can just simply see as a oblique tubular extrinsic compression which is seen in the upper osophagus now coming to what is bullseye lesion it is seen in cases of gastric metastatic lesions from melanoma or lymphoma in carcinoid tumors then gastric lipomas so this is a typically this is a case showing how the bull's eye lesion look like so coming to the double barrel also figures what does it means it means the uh intramural osteophysial dissection is the most commonly seen in the middle age or elderly the other causes can be trauma regular pathy instrumentation ingestion of foreign body and osteophysial duplication so next slide so this is how a double barrel osophagus looks like on barium swallow now coming to the various benign tumors of the esophagus so these are leo myoma these are some causal mass arising from circular or longitudinal smooth muscles these are solitary or sometimes can be multiple the characteristic feature is it is a round filling defect but we can see that splitting of the barium around the tumor is seen if we see any these type of round filling defects in the osophagus and splitting of the barium around the tumor so it is a diagnostic of leo myoma so another case of leumin we can see that splitting of the barium around these filling defects so another important term used is very commonly in radiology is apple core okay so apple core always indicate in git pathology so it is irregular narrowing okay and along with apple core we can see that soft tissue mass then the abnormal area forms an acute angle with the normal mucosa inferiorly indicating a mucosal thickening so all these feature these are sign of malignant tumors in git may may be a large gut small gut or barium or osophagus in the barium we can easily identify that apple core soft tissue mass abnormal area forming acute angle inferiorly all these sign indicates that this lesion is a malignant pathology now again case of carcinoma osophagus you can see apple core irregularity nodularity shouldering all these features these are seen in cases of carcinoma of the esophagus now what are various complications it is a leakage of perium from unsuspected perforation then aspiration of the contrast this is how aspiration of the contrast into our lungs looks like now coming to the barium meal i think we are short of time so i will not go into detail of the procedure and will discuss with you the interesting cases so the indication is malignancies of gastroesophageal junction stomach and deodorant then upper abdominal mass look for various motility disorders and tb or git hammers these are clinicians they want to make sure what is happening so the main symptom that patient present with to the clinician is weight loss vomiting anemia dyspepsia so contraindication is suspected perforation when angiography is to be performed we have to perform the angiography before and otherwise due to barium we will not be able to do that any fishless complication with any other organ or the recent biopsy from the git add interposition of the barium into lead can lead to the serious mortality disorders now coming to barium anatomy we can see that fundus then local fools body donald c loop then we have to use hypotonic agents to decrease the mortality so that we can beautifully capture the lesion so the hypotonic agent that most commonly used is vascopan and then again we can use glucagon where we short duration of action is required so technique you are already aware so uh to look for various causal patterns uh we can do single a single contrasty used to again look for any compressions displacement any extrinsic impressions okay any mortality disorders or any contra hold up of the contra cross is visible in the stomach even after six hour of the film we call it as a delayed and for for single contrast fundus is best seen in spine body in rector prone and enter in prone so it is opposite to double why because the air that travels upward so and barium it trickles downward that is solid it so did your normal phenomena and these are various views by which we can see uh the various uh we have to demonstrate the greater or lesser curvature fundus pluricant from c loop and most importantly the total cap so when we give the small amount of barium we have to rotate the patient in this direction uh from left side because we have to coat the whole of the stomach so these are various views which are performed for a barium wheel again an erect view this is how the where the barium will be seen in a direct view so single versus double contrast so again i have already discussed single contrast is done look for polaroid fistulas any loss gastrography any filling defects due to large mass masses and double contrast is to look for any ulcers or origins which are better seen so coming to the gastric mucosa on barium we have a gastric reggae these are longitudinal force seen in the mucosa of the fundus and body and it's a more prominent in the greater creature then what is area gastric gastrin these are fine reticular network of barium coated grooves between 1 to 5 mm islands of dimkoza these are more visible in the old patients now double contrast view of the normal reutil cap and loop this is a whole normal normal cap will look like now what is the advantages of barium over endoscopy this is the question for the resident they must be aware so advantages of barium meal over endoscopy is that it's a very economical easier to perform it is a dynamic study of neuromuscular function that is reflux and delay damping that can be seen only on barium studies so it is a dynamic study of neuromuscular function and moreover the structure of brown melt is that can be better seen by the barium studies only the diverticuli that can be missed and i have seen many cases that has been missed by endoscopy and we have diagnosed that cases then we can see that extrinsic compressions are better seen than defining then we have to define the anatomy especially in the post-operative patients and that is a beautifully seen that is beautifully seen and what are advantages of endoscopy that is better lesions can be seen it can be diagnostic and therapeutic as well now another important sign you must be aware and you must give instruction to the patient that the patient will come to you next day running that i am getting white stools so you and it is difficult to flush you have to explain the patient beforehand you have to take adequate volume of water and you have you can take a laxative because the whites too they are normal normal human being normal a patient they are afraid that why there is white stools so you have to explain and the patient should not leave the department because there may be blurring of the vision because of injection vascular pain and they can cause accidents so minimum 30 minutes or when the blurring is over you have to keep the patient in your department so if there is ulcer in the gastric you have to look whether it is a benign or malignant ulcer so what are features of brain gastric ulcer the outposting of the lc crater binds the gastric contour so it is a smooth rounded and deep crater and smooth gastric fools that reach the margin of the user then we have a hamptons line what is hampton's line it is a 10 millimetric reduced line seen at the neck of a gastric ulcer which is seen in barium study and it is due to mucosa overhanging the ulcer curator now what are features zestive of malignant gastric ulcer that is it does not produce bind the gastric contour it is irregular shallow ul circulator nebula nuclear gastric foods that do not reach the margin of the ulcer and important sign is carbon meniscus sign and it it always indicates a malignant ulcerated neoplasm that the ulcer inner margin is convex towards the lumen i am going to show the case of carbon meniscus sign so these are benign gastric also why because they are uh the acid is projecting burn the normal barium filled gastric lumen so uh so we can see that the normal contour and burn that contour it is still where the gastric ursus can be seen so it is a minuses now again thick and fold reaching so this is again case of a benign ulcer then more than 95 percent of the adrenal also they are associate they occurs in the derdenam and they are mostly as we know that they are mostly due to h pylori infection and almost 95 percent of the ulcer of the deuternum they are benign so in the chronic retinal ulcers they give a cloverleaf deformity and we can see that there is symmetric narrowing of the belly in the second slide this is our due to chronic ulceration of the journal cap now coming another that is a caramel meniscus sign we see that intra-luminal ulcer that is not projecting on the expected margin of the stomach it is a regular nodular mass surrounding the ulcer and the semicircular or ulcer that can be seen the inner margin is convex towards the lumen which has been marked by the black arrow this is a hamptons hump ulcer showing you that that whole nine cell and this is a malignant as a malignant user we can see that convex margins and this is a case of hampton's hemp in brionesis now this is how acute erosive gastritis these look like these are small mucusal erosions seen as a small pool of barium that can be seen that has been marked with the black arrow then most common cause of thickened fold and gastric and drum or body body again due to h pluri infection these are various manifestations again emphatic hyperplasia which is uh due to chronic h pylori infection again another important disease which is called as mantras disease it is there is you can see that thickened globulated fools in the gastric fungus and body with relative sparing of the antrum again another case of atrophic gastritis we can see that there there is presence of narrow tubular stomach with decreased or absent causal force predominantly in the body and fundus also known as bald fundus so this is a case of atrophic gastritis now another case of crohn's disease this is a early case of crohn's disease with depth also crohn's disease can be presently a trans mural and it can it can involves any part of the gat system and then as showing you another case of ram horn sign so what is ram's horn sign it is a conical narrowing of the antrum it is seen in cases of crohn's disease because of the interim and deuteronomy they merged together as a single tubular structure so this is called as wronghorn sign so coming to the hyperplastic polyp so these are these are the polyps they look like so in another case showing you the sacile polyp is present in the pleura can room then another trunculated enter polyp which is seen in the another patient and this dark pier has an inner ring shadow overlying the head of the polar producing a mexican head sign now another important sign is glutinol wind shock sign what is rotary even shock sign it is due to intra luminal dodinar diverticula which is surrounded by a radiolucent line did vertical arising in the second portion of the rotonum and extending into the third portion and these arrow lines have been marked for you to look that deodorant bin shock sign now the another case of gastric cancer that is linked up plastic pattern that is the capacity is grossly reduced it is a we call it as a leather bottle stomach with no peristalsis so this is the end stage of gastric cancer now another case showing you the gastric outlet obstruction again i have informed you that if the contrast is still present after six hours we call it as a that this case is of an obstruction now what is a mushroom sign it is seen in chronic hyperchloric stenosis and also in other conditions conditions and that sign has been marked with black arrow for your reference now coming to another important investigation which is a barium meal follow-through study and you already know the procedure due to a shortage of time i am going to skip these theoretical portions because you are well aware now coming to directly to the engine part so this is a normal anatomy of the bearing meal follow through we can see that the username which has a feathery echo pattern whereas helium is a character character less means no definite character is seen so we have to take a basic plane film so why we are going to what is the importance of this plane film because morphology of gas we can study the morphology of gas shadows than acute dilatation which can be seen in cases of trauma or metabolic disorders distended proximal loops in obstruction then perforation air under the dome of diaphragm inner and outer wall of the bowel the air in the belly track then retroperitoneal or so kidney sign calcification air fluid levels appendiculate all foreign body these can be seen in plain film so i have told you so many uh indications why we must do the plane film before starting our investigation so we must have our image intensifier and spot film devices so the main here the technique is compression palpitation mucosal relief and spot film so for kosher relief studies we have to stop peristalsis and pasco pan is the injection which is given so we have to take films at 15 minutes 30 minutes one hour one and a half hour two hour and we have to follow okay so that is why the name given is a biryani meal follow through study so first film 15 minutes 30 minutes one hour one and a half hour and two hours and we follow now advantages of barium meal follow-through study no discomfort or intubation to the patient like it is a physiological process as transient time and neuro muscular function that can be assessed now coming to the various sign that is stack of coincide it is seen in cases of leukemia pancreatic cancer hemophilia lymphoma myeloma and chemotherapy so this is this is showing you the barium in a patient with small bowel hematoma with a demonstration stack of coin sign then coming to another important sign that is coiled spring sign this sign describes the appearance of the second in the presence of pendulum sequel into consumption so this is a case showing you the whole coil spring appearance looks like now what is a picket fence pattern so picket fence pack when you have already been wasted to the western country so that name is given from the picket fence which is there in the westernized world countries and that name you can see that this is due to cute small bowel asthma submucosal hemorrhages they causes a narrow loops now another important case that arrow has been marked we we have performed the barium follow-through and the alien we can see that alum cycle fish lab which has been beautifully outlined by the grass media now coming to another important that what is michael's vertical which you can see normally in your barium studies michael dwerticulum is a smooth outpatching with a narrow neck at antimycentric border and in the distal loop of balian normally it is seen within the 18 inches of elliptical wall now coming to another important disease that is a crohn's disease and we have to definition between crohn's disease and ulcerative colitis and crohn's disease we see string sign then there is a segmentation of small bone flocculation of the contrast and we can see various signs which i am going to discuss with you now another important condition and that is tuberculosis the most common reason which is involved is illegical region okay now the question arises why this electrical reason why why the pathology or tuberculosis or any other pathology is more common in iliocycle it is because of abundance of lymphoid tissue is there then there is increased physiological stasis then there is increased rate of water and electrolyte absorption and here the minimal digestive activity with greater contact time with the macrossal surfaces is there so that is cause of why the electrical tuberculosis is common here so now another case which i am going to discuss is uh showing we can see that contrast which is seen in the deodorant or upper part and at the same time we can see that contrast in the colon large gut transverse colony seen but no contrast is seen in the ilium okay no jojnam and nowhere no in the descending colon or ascending colon so this is a case of rednolic fisla now another sign important sign that is string sign and a string sign is not common in chromosome disease it can be seen in tuberculosis and other pathologies now coming to the barium animal you already know that patient have to first we have to in left lateral position after hepatic flexor the contrast is given that the patient is asked to spine then up to the hepatic flexor then the contrast is stopped then then we have to take the various images and double contrast study is done by introduction of air and these pumps are available and we have to give injection buscop and 20 milligram to stop the peristalsis now spot films are taken and we have to see that where our various pathologies are there so we have to take over couch and under couch now the question is what is overcaused filament what is under couch when the axle tube is overlying or on the ceiling it is called as overcoat when it is underlying the table it is an undercover very simple so complication of barium nema it is uh you can see the transient bacteremia or cardiac arrhythmia rectal distensions or venous interruptions and perforation of the bone these are rare you must be aware now showing you the important cases one is familiar adenomatous polyposis now what is this condition these are hundreds of adrenometers polyps these are seen mostly these are seen up to this 16 year of age group puberty patients the main complaint of the patient is rectal bleeding diarrhea or abdominal pain and the rectum is mostly spared and imaging underestimates the severity of the disease why because most of these products they are less than 5 mm and imaging they are not so helpful so why we what is the importance of diagnosis because by the 40 year of phase all the cases of this disease they are going to get this carcinoma so we have to go for the patient has to go for total cholectomy okay so we have to make the diagnosis correctly on the basis of this investigation now another important condition which you must have seen in the case is very common case is hisaparent disease it is a common cause of neonatal colonic obstruction and there is short segment of clonic a gangliosis that is absence of ganglion it is never seen in immature and fence okay the factory segment is of small caliber with the proximal dilatation and the typical feature is appearance now coming to another important condition is med cut valueless it is a complication of bala rotated bowl and we can see a tapering or baking or we call it as a corkscrew sign now another case showing you that vertical losses the barium stands from the lumen outward into the vertical this is a westernized disease it is seen in old days and these vertically they are from filming few millimeters to few centimeters so uh i think i have covered most of the interesting cases and i am thankful and to the audience for listening me to this technique we have our interventio neurosurgeons who are very interested in a ct and mri we have so many sonographers who are willing to compete compete with us with ultrasonography but um no thing or have a guts to report our conventional radiology or basic investigation so it is going to stay here and we as a radiologist have a definite as an interpretation and in our conventional ideology we must not forget that these are our bread and butter and we have to make our presence felt because of our security and reporting and doing these investigations thank you so much for giving me opportunity to express my views thank you so much thank you sir and that was an excellent talk with a special mention on the on those conditions where barium imaging is done and with so many take home points with regards to the radiology resident exam point of view and special mention on various cases and signs which were shown in your presentation sir thank you there was one query from our viewer uh how to differentiate between small amount of aspiration versus post-op leaks in the cases of sp aspiration the first we have to take the history as i have told you history is very important okay and in cases of aspiration again i have told you it is not a so big issue okay and in post operative there is always a history of surgery okay and in there if we are doing that barium if the patient aspirate we are seeing on the screen that the patient has aspirated the contrast because we are doing the fluoroscopic examination live and and if there is due to surgery we are seeing that patient has not coughed up have not shown any sign and symptom patient is seeing so it is very simple so it is a fluoroscopy real live live where we you can see directly thank you sir i think that's about it from the query point of view sir thank you very much sir

BEING ATTENDED BY

Dr. Sivakoti kiran Kumar & 434 others

SPEAKERS

dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Ramesh Chander

Dr. Ramesh Chander

Professor & Head, Radiodiagnostics, PIMS Jalandhar| Former HOD, GMC,Amritsar

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Ramesh Chander

Dr. Ramesh Chander

Professor & Head, Radiodiagnostics, PIMS Jala...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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