What Is a Barium Enema?

What to Expect With a Lower GI Series

A doctor goes over a patient''s x-ray, screening for colon cancer.
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A barium enema, also known as lower gastrointestinal (GI) series, is a procedure in which a liquid containing barium sulfate is introduced into the rectum to obtain high-contrast X-ray images of the large intestine (colon). On its own, an X-ray produces poor images of soft tissue. By coating the tissue with barium, a chalky crystalline compound, the radiologist is able to get a relatively clear silhouette of the colon.

The X-ray technique used for a barium enema is known as fluoroscopy. It produces real-time video images, as opposed to pictures on film, making it possible to see the colon and adjacent structures in motion.

Purpose of Test

A barium enema in an indirect form of visualization used to examine the anatomy of the colon and occasionally the terminal ileum (the junction between the small and large intestines).

It may be recommended by your doctor if you have:

  • Chronic diarrhea
  • Chronic constipation
  • Rectal bleeding
  • Unexplained abdominal pain
  • Unexplained weight loss
  • Unexplained changes in bowel habits

Conditions Diagnosed

A barium enema is useful in highlighting abnormalities, growths, or changes in the structure of the colon. Among the conditions it can help diagnose:

  • Bowel obstruction, such as caused by adhesions (scarring), volvulus (twisting), or intussusception (the telescoping of the intestine into itself)
  • Celiac disease, an immune reaction to gluten resulting in the flattening of the intestinal lining
  • Colon polyps, fleshy growths in the colon that have the potential to turn cancerous
  • Colorectal cancer, cancer of the colon and/or rectum
  • Diverticular disease (including diverticulosis and diverticulitis), in which abnormal pockets form in the intestine
  • Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis

Test Limitations

A barium enema is not as commonly used as it once was. These days, your doctor is more likely to recommend direct visualization techniques, such as colonoscopy, or more sophisticated forms of imaging, such as a transrectal ultrasound or computed tomography (CT) colonography.

As opposed to these alternative procedures, a barium enema may be an uncomfortable and somewhat embarrassing experience given that your colon needs to be filled with liquid and the liquid needs to be held in place during the imaging process.

The test also has its limitations. Beyond the physical discomfort, a barium enema is not a reliable means of diagnosis of rectal disorders. Moreover, research suggests that it is more likely to miss small tumors when compared to a CT scan (22 percent versus 2 to 6 percent, respectively).

By contrast, colonoscopy is far more reliable in identifying strictures (intestinal narrowing) or fistulas (the abnormal of seepage from fluids) than a barium study.

A barium enema may be used to diagnose gastrointestinal bleeding but only if direct visualization methods are not possible. It has a limited role following complex surgery.

Risks and Contraindications

A barium enema is a relatively safe procedure to which you would be exposed to relatively low levels of radiation. Discomfort is the most common complaint, primarily associated with the increased pressure in the colon. Some people may experience nausea and intestinal spasms. Bloating, gas, and cramps are also common.

You may also experience side effects to the barium itself, including a mild headache, upset stomach, constipation, diarrhea, and headache. These symptoms tend to mild and resolve within in a day.

If you are given an injection of Buscopan (butylscopalomine) to prevent spasms, you may experience blurred vision for 30 to 60 minutes following the procedure.

Complications of a barium enema are rare but may include:

  • Arrhythmia (irregular heartbeat)
  • Barium impaction leading to bowel obstruction
  • Dilutional hyponatremia (water intoxication)
  • Drug allergy (occurring in only one of 750,000 cases)
  • Bowel perforation leading to acute peritonitis and shock

A barium enema is contraindicated during pregnancy and for people with acute gastrointestinal bleeding or active colitis. It should be used with caution in elderly or frail people and only if no other form of diagnosis is possible. If there is rectal inflammation or a recent rectal biopsy, the procedure should be delayed until the rectum is healed.

Before the Test

The preparations for a barium enema are quite extensive. The instructions need to be strictly followed to ensure minimal discomfort or optimal imaging.

Timing

When scheduling a barium enema, set aside at least two to three hours of your day. While the procedure itself can take 30 to 60 minutes, there are preparations that need to be made beforehand. You may also need a short time to recover if you experience symptoms and were given an antispasmodic injection.

Try to arrive at least 30 minutes in advance of your appointment so that you can sign in, relax, and not feel rushed.

Location

A barium enema is performed in a radiology unit at a hospital or a specialized testing facility. The room itself would be equipped with a radiographic table, a fluoroscopic X-ray machine with one or two tubes, and a digital monitor enclosed within a protected viewing compartment.

There would also be an enema stand with an enema tube. A bathroom would be situated nearby.

What to Wear

You would need to undress for the procedure. You should bring comfortable clothes that you don’t mind staining in case you have some rectal leakage on the way home. While the office will likely have lockers to store your wallet and cell phone, it is best to leave any jewelry and valuables at home.

Food and Drink

In order to obtain accurate images of your colon, you will need to completely empty your bowel of any fecal matter. This rsequire a restricted diet, laxatives, and possibly an enema. We refer to this as bowel preparation.

Once the appointment is scheduled, you would be give written instructions outlining what you can eat and how to vacate your bowel. In addition, your doctor would either give you a laxative dose to take home with you (in pill or liquid form) or provide you a prescription to fill at the pharmacy.

The bowel preparation instructions can vary but more or less follow a similar sequence:

  • 24 hours before the test, you would need to restrict yourself to a clear liquid diet. This includes the avoidance of milk or cream.
  • At around midday, you would take a laxative at the time and dosage prescribed by your doctor. You would need to stay home and close to a bathroom as the laxative will trigger frequent and watery bowel movements.
  • For the rest of the day, you would need to drink plenty of fluids to keep hydrated. You may also want to apply some petroleum jelly to your anus after each bowel movement to avoid chafing.
  • At bedtime, you may be asked to take another dose of the same or different laxative. Some labs recommend this two-part procedure; others don’t.
  • At midnight, you would need to stop drinking or eating.
  • On the morning of the test, some people with use a ball douche or enema to ensure the bowel is completely clean.

If you decide to douche, do not to overly irrigate the bowel as this can cause irritation. In most cases, douching will not be necessary if you have followed all of the instructions.

If you are diabetic, speak with your doctor about the appropriate foods to eat while on a clear diet and be sure to check your blood sugar frequently during the bowel preparation procedure.

Medications

When scheduling the barium study, be sure to advise your doctor of any and all drugs you may be taking, whether they be prescription, over-the-counter, homeopathic, traditional, or recreational. Some of these may need to be stopped for a day or even several days in advance of the procedure.

These may include:

What to Bring

In addition to your ID and health insurance card, you may want to bring a sports drink or snack with you since you will not have eaten for many hours. If you are diabetic, you will also want to bring your glucose monitor to check your blood sugar after the test.

While most labs will provide you a sanitary pad to protect your clothes from leakage, some people will bring their own just in case. You may also want to bring an extra pair of socks if you plan to walk in the X-ray room in your stockinged feet.

Cost and Health Insurance

The cost of a lower GI study can run anywhere from $200 to $2,000, depending on the provider and city you live in.

To this end, it is important to know the total costs in advance, including how much your health insurance will cover and what your co-pay and out-of-pocket expenses will be. With rare exception, the test would require insurance pre-authorization, which your doctor’s office can submit on your behalf.

If you are denied coverage for any reason, ask your insurer for a written reason for the denial. You can then take the letter to your state insurance consumer protection office and ask for help. Your doctor should also intervene and provide additional motivation as to why the test is essential.

If you are uninsured, you can speak with the lab to see if there are monthly payment options.

Other Considerations

In most cases, you would be able to drive yourself home after a barium enema. With that being said, if you experience any cramping or spasms during the procedure, you may want to sit for a half hour until your bowel has had the chance to recover.

The same applies if you were given an antispasmodic injection as this may cause blurriness for 30 to 60 minutes. If in doubt, bring along someone with you who can drive you home.

During the Test

On the day of the test, after signing in and confirming your insurance information, you may be asked to sign a liability form stating that you are aware of the purpose and risks of the procedure. You would then be taken to a changing room and provided a gown to change into.

Pre-Test

In addition to removing all of your clothing, you would be asked to take off any jewelry, eyewear, or removable dental appliances.  After changing into the gown, you would be met in the X-ray room by a radiologist and a radiology technician.

Throughout the Testing

After being positioned on the radiographic table, the technician would take several X-ray images to ensure your colon is clear. A digital rectal exam may also be performed.

A lubricated enema tube would then be eased into your rectum, and the tube would be connected to a prefilled bag containing a mixture of barium sulfate and water. If your doctor has requested a double-contrast (air-contrast) barium enema, air would also be pumped into your colon to provide a clearer image of the colonic structure.

The radiologist may give you a shot of Buscopan to relax the walls of your colon, particularly if you are undergoing a double-contrast procedure. The only exception would be for people with glaucoma or heart disease in whom the injected version of the drug is contraindicated.

At the end of the enema tube is a small balloon which can be inflated to keep liquid from seeping out of the rectum.  As your colon fills with barium, you may feel the urge to have a bowel movement. This is normal. Try to relax and hold it in, taking long, deep, slow breaths. While the procedure may uncomfortable, it doesn’t usually cause any overt pain.

Once enough barium has been introduced into your colon, imaging would begin. You may be asked to change positions to capture images from different angles. The radiologist may even press on your abdomen or pelvis to manipulate your colon into a better position for imaging.

If you have trouble keeping the fluid in, let the technician know. Don’t be embarrassed if you break wind or if any fluid leaks out. This is a common occurrence and one that the radiology team is more than prepared for.

When completed, the majority of the barium solution would be removed through the tube. You would then be directed to the bathroom to expel the rest.

Post-Test

Once you have cleaned yourself and changed back into your clothes, the radiologist will want to see if you are experiencing any side effects. If you are, you may be asked to sit quietly until the symptoms pass.

If you have diabetes, you will want to check your blood sugar and advise the medical staff if the reading is abnormal.

Before leaving, you may be given a laxative to help clear the rest of the barium from your system. Thereafter, you can resume your regular diet and restart your routine medications. Make every effort to drink plenty of water for the next 24 hours.

Your stools may appear white for a day or two after as your body gradually clears the barium from the bowel.  Some people may experience constipation which usually resolves within a day.

With that being said, if you do not have a bowel movement for more than two days or are unable to pass gas, call your doctor. You may be experiencing barium impaction and would require an enema to help clear the impaction.

Interpreting the Results

A day or two after the test, your doctor will review the results with you. The radiology report will detail both the expected and unexpected findings. It won’t necessarily diagnose your condition but rather outline what the findings suggest along with a list of possible causes.

In the end, a lower GI study is but one of several tools used to make a diagnosis. In addition to reviewing your medical history and current symptoms, clinical judgment would be needed to decide whether treatment can be started or further investigation is needed.

Follow-Up

Follow-up evaluations may be needed if the results are inconclusive or equivocal (ambiguous). While it can be aggravating not to get a definitive answer, an ambiguous result may motivate your insurance company to approve a more expensive, specialized test.

If the lower GI study is able pinpoint a cause, follow-ups will likely be needed to monitor your condition and/or assess your response to therapy.

A Word From Verywell

While a barium enema may be one of the more awkward imaging procedures, it does have its benefits. In the end, it is a nominally invasive technique with a low risk of complications. Because barium is not water soluble, it cannot be absorbed in the blood (lowering the risk of an allergic reactions). In some cases, a barium enema may provide just as much information as a more invasive colonoscopy and without the need for sedation. 

Moreover, modern X-ray systems are extremely dose-controlled to deliver the lowest level of exposure with minimal stray (scatter) radiation.

Generally speaking, the benefits of a barium enema far outweigh the possible consequences. If you are still uncomfortable with the procedure, speak with your doctor about alternatives and why they may or may not be appropriate for you. 

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