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LARGE INTESTINE (COLON INLOOP)

Rini Indrati

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ANATOMY
Merupakan tab berongga dgn p = 1,5 m dari caecum canalis ani, diameter ratarata 2,5 inchi, semakin ke ujung semakin kecil.

Bagian-bagian colon

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Haustra

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PHYSIOLOGY
Diperlukan waktu 16 20 jam untuk mencapai sekum Fungsi colon 1. Absorbsi air, garam dan glukosa 2. Sekresi musin oleh kelenjar lapisan dalam 3. Menyimpan selulosa 4. Defekasi

Pergerakan colon : mencampur dan mendorong

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RADIOGRAPHIC PROCEDURE
DEFINITION The radiographic study of the large intestine with contrast media to demontrate the large intestine and its components (Form and function) with single contrast and double contrast.

PURPOSE To radiographically study the form and function of the large intestine to detect any abnormal conditions

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INDICATIONS
1. 2. 3. 4. 5. Colitis : Penyakit2 inflamasi pd colon Carsinoma Diverticulum : merupakan kantong yg menonjol pada dinding kolon, terdiri lapisan mukosa dan muskularis mukosa Polyps : Penonjolan selaput lendir Volvulus : Penyumbatan isi usus krn terbelitnya usus ke bagian yg lain Invagination : melipatnya bagian usus besar ke bagian usus itu sendiri Intussusception : Atresi ani : tidak adanya saluran dari colon yg seharusnya ada Stenosis : Penyempitan saluran usus besar Mega colon : Suatu kelainan kongenital yg terjadi krn tidak adanya sel ganglion di pleksus mienterik & sub mukosa pada segmen colon distal menyebabkan feses sulit melewati segmen aganglionik.
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6.
7. 8.

9. 10.

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CONTRA INDICATIONS
1. Perforation : terjadi krn pengisian media kontras secara mendadak dan tekanan tinggi Acut Obstruction / penyumbatan
Refleks fagal (wajah pucat, bradikardi, keringat dingin dan pusing) Diare berat

2.
3. 4.

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EXAMINATION PREPARATIONS (1)


PATIENT :
1. 2. 3. 48 jam sebelum pemeriksaan pasien makan makanan lunak rendah serat 18 jam sebelum pemeriksaan (jam 3 sore) minum tablet dulkolak 4 Jam sebelum pemeriksaan (jam 5 pagi) pasien diberi dulkolak kapsul per-anus selanjutnya dilavement Seterusnya puasa sampai pemeriksaan 30 menit sebelum pemeriksaan pasien diberi sulfas atrofin 0,25 1 mg/oral untuk mengurangi lendir pada mukosa kolon 15 menit sebelum pemeriksaan pasien diberi suntikan buskopan utk mengurangi peristaltik usus

4. 5.
6.

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EXAMINATION PREPARATIONS (2)

EQUIPMENT:

1. Pesawat sinar-X + fluoroscopy 2. Kaset secukupnya 3. Bahan kontras barium sulfat dengan perbandingan 1 : 8 4. Irigator dengan standartnya termasuk selang dan kanula 5. Kateter 6. Klem 7. Kantong barium disposible kalau ada
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EXAMINATION PREPARATIONS (3)


MATTER : 1. 2. 3. 4. 5. 6. 7. Media kontras : Barium sulfat : 70-80% W/V (Weight/Volume), banyaknya sesuai panjang kolon 600 800 ml Air hangat, jangan gunakan air panas Vaselin/jelly Kocok / aduk media kontras sebelum digunakan TOPICAL ANESTHETIC / dp digunakan LIDOCAINE untuk meminimalkan konstraksi, GLUCAGON/IV untuk SPASM. SIMS POSITION Instruksi pada pasien : a) Kurangi kontraksi Anal b) Relax Otot Abdominal usahakan relax palpasi; c) bernafas dengan mulut mengurangi Spasm (kontraksi dan kram Memasukkan kanula saat ekspirasi.

8.

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TEKNIK PEMASUKAN MEDIA KONTRAS


1. 2. Metode kontras tunggal Metode kontras ganda A. Kontras ganda satu tingkat B. Kontras ganda dua tingkat

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1. METODE KONTRAS TUNGGAL


Pemeriksaan hanya menggunakan barium sulfat sbg media kontras
Kontras dimasukkan ke kolon sigmoid, desenden, transversum, ascenden sampai daerah sekum Dilakukan pemotretan full filling Evakuasi dibuat foto post evakuasi

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2. METODE KONTRAS GANDA (1)

A. Kontras ganda satu tingkat


Kolon diisi barium sulfat sebagian selanjutnya ditiupkan udara untuk mendorong barium melapisi kolon Selanjutnya dibuat foto full filling

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METODE KONTRAS GANDA (2)


B. Kontras ganda dua tingkat
1. Tahap pengisian
- Kolon diisi barium sulfat sampai kira-kira fleksura lienalis atau pertengahan colon transversum - Pasien disuruh merubah posisi agar barium masuk ke seluruh kolon

2. Tahap pelapisan

Menunggu 1-2 menit supaya barium melapisi mukosa kolon Pasien disuruh BAB

3. Tahap pengosongan 4. Tahap pengembangan

Dipompakan udara ke dalam kolon : 1800 2000 ml, tidak boleh berlebihan krn akan timbul komplikasi : reflek fagal ( wajah pucat, bradikardi, keringat dingin dan pusing) - Pemotretan dilakukan apabila yakin seluruh kolon mengembang semua - Posisi pemotretan tergantung dari bentu dan kelainan serta tempatnya - Proyeksi PA, PA oblik lateral (rektum) - Proyeksi AP, Ap oblik ( kolon transversum termasuk fleksura - Proyeksi PA, PA oblik pasien berdiri ( fleksura liealis dan hepatika) TRL-1 RINI INDRATI 19

5. Tahap pemotretan

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RADIOGRAPHIC POSITIONING
1. 2. 3. 4. 5. 6. 7. 8. 9. PA / AP RAO LAO LPO/ RPO LATERAL RECTUM RIGHT LATERAL DECUBITUS LEFT LATERAL DECUBITUS PA POST EVACUATION AP AXIAL / AP AXIAL OBLIQUE (LPO) ( BUTTERFLY) 10. PA AXIAL / PA AXIAL OBLIQUE (RAO) ( BUTTERFLY)
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1. PA/AP PROJECTION
PATHOLOGY DEMONSTRATED
1. Obstruction including illeus, volvulus and intussusception, are demonstrated.

2. Double contrast media barium enema is ideal for demonstrating diverticulosis, polyps and mucosal change
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1. PA /AP PROJECTION
PP : Patient is prone or supine, with a pillow for head PO : Align midsagital plane to midline of table Ensure that no body rotations exist CR : CR is perpendicular to IR CP to level of iliac crest Min SID is 100 cm
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1. PA/AP PROJECTION
STRUCTURE SHOWN : The transverse colon should be primarily barium filled on the PA and airfilled on the AP with a double contrast study Entire large intestine should be demonstrated including the left colic flexure

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PA AND/ OR AP PROJECTION : BARIUM ENEMA.

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2. RAO POSITION
PATHOLOGY DEMONSTRATED:
Obstruction including illeus, volvulus and intussusception, are demontrated. Double contast media barium enema is ideal for demonstrating diverticulosis, polyps and mucosal change

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2. RAO POSITION
PP:
Patient is semiprone , rotated into a 35 - 450 right anterior oblique, with a pillow for head PO : Align midsagital plane along axis of table, with right and left abdominal margins equidistant from center line of table and/or CR Place left arm up on pillow, rigt arm down behind patient, and left knee partially flexed Check posterior pelvis and trunk for 350 to 450 rotation CR : Direct CR perpendicular to IR to a point about 2,5 cm to the left of midsagital plane Center CR and IR to level of illiac crest Minimum SID 1s 100 cm

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2. RAO POSITION
STRUCTURE CRITERIA :

The right colic flexure and the ascending and sigmoid colon are seen open without significant superimposition. The entire large intestine is included, with the possible exception of the left colic flexure, which the best demonstrated in LAO position The rectal ampulla should be included on lower margin of radiograph

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3. LAO POSITION
PP Patient is semiprone rotated into 35 to 450 left anterior oblique, with a pillow for head. PO Align midsagital plane along long axis of table, with right and left abdominal margins equidistant from center line of table and or CR Place right arm up on pilolw, lelt arm down behind patient and right knee partially flexed Check posterior pelvis and trunk for 350 to 450 rotation CR : Perpendicular to IR, directed to a point about 2,5 cm to the right of midsagittal plane Center CR & IR to 2,5 to 5 cm above iliac crest Minimum SID is 100 cm
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3. LAO POSITION

Structure Shown : The left colic flexure should be seen as open without significant superimposition

The descending colon should be well demonstrated


The entire large intestine should be included

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4. LPO and RPO POSITIONS


PP
Semisupine, rotated 35o to 45o into right and left porterior oblique, with a pillow for head

PO

Flex elevated side elbow and place in front of head, place opposite arm dowb by patients side Partially flex elevated side knee for support to maintain this posiution Align mitsattal plane along long axis of table with righ and left abdominal margin equidistant from center line of table

CR

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direct CR penpendicular to IR Angle CR and center of ir to level of iliac crest and about 2,5 cm latealto elevated side of midsaggital plane see notes Minimum SID is 100 cm 30

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4. LPO and RPO POSITIONS


Structure shown : LPO The right colic flexura hepatic and ascending and recto sigmoid portions should appear open without significant superimposition RPO The left colic flexure and the descending portions should appear open without significant superimposition
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5. LATERAL RECTUM POSITION/ VENTRAL DECUBITUS LATERAL

PATHOLOGY DEMONSTRATED
Lateral position is ideal for demonstrating polyps, stricture and fistulae between the rectum and bladder / uterus. The ventral decubitus is best for double-contras study

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5. LATERAL RECTUM POSITION/ VENTRAL DECUBITUS LATERAL


PP ; Patient position is lateral recumbent, with a pillow for head PO : Align mid axilary plane to midline of table and or IR Flex and superimpose knees, place arms up in front of head Ensure no rotationsexist, superimpose shoulders and hips CR : CR is perpendicular to IR Center CR to level of ASIS and midcoronal plane ( midway between ASIS and posterior sacrum)

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5. LATERAL RECTUM POSITION/ VENTRAL DECUBITUS LATERAL

Structure show : Contrast filled rectosigmoid region is demonstrated

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6. RIGHT LATERAL DECUBITUS POSITIONS (AP/PA)

Pathology demonstrated: This position is especially helpfull in demonstrating polyps of the left side or air filled portions of the large intestine

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6. RIGHT LATERAL DECUBITUS POSITIONS (AP/PA)


PP : Patient is lateral trecumbent positions with a pillow for head and lying on right side on a radiolucent pad, with portable grid placed behind patient t back for an AP Projection PO : Position patient and/or IR so that iliac crest is to center of IR and to CR Place erm up, with knee flexed Ensure no rotation exists, superimpose shoulders and hips from above CR : Direct CR horizontal, perpendicular to IR Center CR to level of iliac crest and MSP
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6. RIGHT LATERAL DECUBITUS


POSITIONS (AP/PA)
Structure shown : Entire large intestine is demonstrated to include air filled left colic flexure and descending colon

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RLD

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7. LEFT LATERAL DECUBITUS POSITION

Pathology demonstrated :
This position demontrates the entire contrast filled large intestine and is especially helpful in demonstrating polyps. It best demonstrates the right side, which includes air filled portions of the large intestine

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7. LEFT LATERAL DECUBITUS POSITION


PP : Position patient and/ or IR so that iliac crist is to center of IR and to CR PO : Position patient and / IR so that iliac crest is to center of IR and to CR Place arms up, with knee flexed Ensure no rotaion exist, superimpose shoulders and hips from above CR Direct CR horizontal, perpendicular to IR Center CR to level of iliac and midsagital plane

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7. LEFT LATERAL DECUBITUS POSITION


Structure shown : Entire large intestine is demonstrated. With air filled right colic flexure, ascending colon and cecum

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LLD

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8. PA (AP) Projection postevacuation

Pathology demonstrated :
This position demonstrates the mucosal patern of large intestine with residual contras media for demonstrating small polyps and defect

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8. PA (AP) Projection postevacuation


PP: Patient is prone or supine, wih a pillow for head PO : Align MSP plane to midline of table and/or CR. Ensure no body rotation exists CR: CR is perpendicular to IR. Center CR and center of ir iliac crest Minimum SID 100 cm .

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8. PA (AP) Projection post evacuation


Structure shown : Entire large intestine should be visualized, with only a residual amount of contras media

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9. AP AXIAL OR AP AXIAL OBLIQUE (LPO) PROJECTIONS

Pathology Demonstrated :
Polyps or other pathologic processes in the rectosigmoid aspect of the large intestine

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9. AP AXIAL OR AP AXIAL OBLIQUE (LPO) PROJECTIONS


PP : Position patient supine or partially rotated into an LPO position, with a pillow head PO : AP axial : Position patient supine and align MSP to midline of table Extend legs, place arms down gby patients side or up across chest, ensure no rotation LPO : Rotate patient 300 - 400 into LPO Raise right arm, with left arm extended, and right knee partially flexed CR : Angle CR 300 - 400 cephalad AP : - Direct CR 5 cm inferior to level of ASIS, and to MSP LPO : - Direct CR 5 cm inferior and 5 cm medial to right ASIS

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9. AP AXIAL OR AP AXIAL OBLIQUE (LPO) PROJECTIONS

Structure shown :
Elongated views of the rectosigmoid segmen should be visible with less overlapping of sigmoid loop than with a 90 AP Projections

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10. PA AXIAL /PA AXIAL OBLIQUE (RAO)

PATHOLOGY DEMONSTRATED: This projecstion demontrates polyps or other pathologic prochesses in the rectosigmoid aspect of the large intestine ; air contrast best visualizes for this pathologic process.

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10. PA AXIAL /PA AXIAL OBLIQUE (RAO)


PP : Position patient prone or partially rotated into and RAO position with a pilow for head. PO : PA : - Position patient prone and align MSP to midline of table Place arms up beside head or down by sides away from body Ensure no rotation of pelvis or trunk RAO Rotate patient 35 450 into RAO Place left arm up, right arm down by side, and left knee partially flexed CR : Angle CR 30 -400 caudal PA : Align CR to exit at level of ASIS and to MSP RAO : Align CR to exit at level of ASIS and 5 cm to left of lumbar spinosus processes

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10. PA AXIAL /PA AXIAL OBLIQUE (RAO)


Structure Shown Elongated views of rectosigmoid segments of the large intestine are shown without excessive superimposition. The double contrast study best visualized this region of overlapping loop of bowl

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Splenic flexure

Hepatic flexure

Descending Colon Ascending Colon Sigmoid Colon

Rectum Double contrast RAO position, PA Oblique Projection 7/13/2012 TRL-1 RINI INDRATI 52

Splenic flx

Descending Colon Transverse Colon Hepatic Flx

Ascending Colon

Sigmoid Rectum

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Double Contrast AP projection

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Transv Colon

Cecum

Sigmoid Append Sigmoid Rectum

PA Axial prjection 30 to 40 Caudad

Rectum PA axial double contrast Projection.

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FIGURE 5. Meconium ileus. Contrast enema demonstrates a microcolon.


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Normal stomach and small intestines 15 minutes after barium administration.


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figs 2-2, 2-3. These radiographs were taken 45 minutes after barium administration. Barium is visible within the large intestine.

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