5. STANDARD: PERFORMANCE OF ADULT BARIUM ENEMA EXAMINATIONS.
A. INTRODUCTION: Examination of the colon by barium enema procedure of proven efficacy. The goal of the radiological examination is to establish the presence and nature of disease by producing the optimum quality study at the minimum radiation dose necessary. The following standard is for performance of the barium enema in adult patients.
B. INDICATIONS: The indications for barium enema examination include, but are not limited to, suspected neoplasms, diverticular disease and inflammatory bowel disease. However, the barium enema may be helpful in diagnosing almost all disease states intrinsically or extrinsically affecting the colon. History and symptoms serving as indications for the barium enema examination include abdominal pain, diarrhea, constipation, bleeding, anemia, abdominal masses, intestinal obstruction, fever or sepsis, polyposis syndromes, and a personal or familial history of colon neoplasm, and history of previous neoplasm.
C. PHYSICIAN QUALIFICATIONS: Examinations must be performed by or under the direct supervision of a licensed physician at the site. The physician should have the following qualifications:
(1) The physician shall have spent a minimum of three months in documented formal training in the performance and interpretation of gastrointestinal fluoroscopy in an approved residency training program, and
(2) The physician shall have documented training and understanding of the physics of diagnostic radiology, and the equipment needed to produce the images. This should include conventional plain film radiology, tomography, fluoroscopy, film-screen combinations, conventional and digital image processing, and the processing and development of films. In addition, the physician must be familiar with the principles of radiation protection, the hazards of radiation exposure to both patient and radiographic personnel, and the monitoring requirements.
Certification by the American Board of Radiology or American Osteopathic Board of Radiology is considered proof of adequate physician training.
D. RADIOLOGICAL TECHNOLOGISTS: Full state licensure is required. Qualifications for technologists performing gastrointestinal radiography should be in compliance with existing operating procedures or manuals at the imaging facility and in compliance with the current ACR policy statement that fluoroscopy by a technologist is limited to a positioning or localizing procedure.
E. EQUIPMENT AND QUALITY CONTROL
(1) Examinations should be performed with fluoroscopic image intensification and radiographic equipment meeting all applicable federal and state radiation standards.
(2) Each imaging facility should have documented policies and operations for monitoring and evaluating the effective management, safety, and operation of imaging equipment. The quality control program should be designed to minimize patient, personnel and public radiation risks and maximize the quality of the diagnostic information.
(3) At least annually, equipment performance should be monitored and a quantitative dose determinations should be conducted by a qualified medical radiation physicist.
(4) There should be review of the standards for equipment and radiation safety that are currently recognized by such national organizations as the National Council on Radiation Protection (NCRP), the National Electrical Manufacturers Association
(NEMA), the American Association of Physicists in Medicine (AAPM), the American College of Medical Physicists (ACMP) or other appropriate federal and state regulatory bodies.
F. COLON PREPARATION: The preparation should consist of any effective combination of dietary restriction, hydration, osmotic laxatives, contact laxatives and cleansing enemas. This should result in a colon which is free of fecal material and excess fluid. In certain clinical situations, preparation may be limited or omitted.
G. EXAMINATION PRELIMINARIES
(1) An appropriate medical history should be available.
(2) The barium enema tip should be inserted by a physician; or a radiological technologist, or a professional nurse trained in enema tip insertion. A retention cuff may be used. It should be inflated carefully.
H. EXAMINATION TECHNIQUE: The following examination descriptions may be modified by the physician to produce examinations of equal or greater quality. The physician should modify any or all parts of the examination as warranted by clinical circumstances and the condition of the patient.
(1) Single-contrast examination: The following is presented as an example of the single-contrast examination.
(a) Barium suspension of approximately 15-20% weight/volume.
(b) Kilovoltage of 100 KVP or greater (depending on the patient's size) during filming.
(c) Manual or mechanical compression of all accessible segments of the colon during fluoroscopy.
(d) Spot films should demonstrate all segments of the colon in profile which are not routinely visualized on overhead films
(e) Overhead films to include frontal and oblique views of the entire filled colon, an angled-beam view of the sigmoid colon, and a lateral view of the rectum.
(f) A post-evacuation film is recommended.
(g) The quality controls specific to this study are:
(i) Each accessible segment of the colon is seen in compression during fluoroscopy, and
(ii) Each segment of the entire colon is seen without overlap, and
(iii) Radiographic technique should attempt to penetrate all segments of the barium filled colon.
(2) Double-contrast Examination. The following is presented as an example of the double-contrast examination:
(a) High density (80% weight/volume or greater) barium suspension commercially prepared specifically for this examination.
(b) Kilovoltage of 90 KVP or greater (depending on the patient's size).
(c) Barium suspension and room air (or carbon dioxide) are introduced under fluoroscopic control to achieve adequate coating and distention of the entire colon. Intravenous or intramuscular glucagon may be administered to facilitate bowel distention and patient comfort.
(d) The colon should be examined flouroscopically during the course of the examination.
(e) Some combination of films should be taken to attempt to demonstrate all of the segments of the colon in double-contrast. A suggested list of possible views would include the following:
(i) Spot films of the rectum, sigmoid colon, flexures and cecum in double-contrast.
(ii) Large format films including prone and supine views of the entire colon, an angled view of the sigmoid colon and a lateral view of the rectum.
(iii) Both lateral decubitus views of the entire colon using a horizontal beam (a wedge filter is recommended.)
(f) The quality controls specific to the double contrast study are:
(i) Complete barium coating of the entire colon has been achieved, and
(ii) The colon is well distended with gas, and
(iii) An attempt is made to see each segment of the colon in double-contrast on at least two films taken in different positions.
I. BARIUM ENEMA QUALITY CONTROLS. The following quality controls should be applied to all barium enema examinations:
(1) When examinations are completed, patients should be held in the fluoroscopic area until films have been checked by the physician.
(2) Poorly exposed or positioned films should be repeated as necessary.
(3) An attempt should be made to resolve questionable radiologic findings before the patient leaves. Repeated fluoroscopy of the patient should be performed as necessary.
(4) Where sufficient follow-up information can be obtained, the following is suggested for a quality control program:
(a) Correlate radiological, endoscopic and pathologic findings where available.
J. QUALITY IMPROVEMENT
(1) Procedures should be systematically monitored and evaluated as part of the overall quality improvement of the facility. Monitoring should include the evaluation of the accuracy of radiologic interpretations as well as the appropriateness of the examination.
(2) Incidence of complications and adverse events should be recorded and periodically reviewed in order to identify opportunities to improve patient care. The data should be collected in a manner which complies with statutory and regulatory peer review procedures in order to protect the confidentiality of the peer review data.
K. BARIUM ENEMA REPORT: The report should describe the nature, number and location of or extent of lesions in the colon. Any limitations of the radiologic examination should be described and additional studies should be suggested when appropriate.
L. COMMUNICATION WITH REFERRING PHYSICIAN:
(1) Any results which mandate immediate intervention or treatment by the responsible physician necessitate direct and immediate verbal communication between the radiologist and the responsible physician. This should be documented.
(2) Findings of less urgent nature may be communicated by indirect means such as mail, recorded messages, computer printouts or FAX. In every instance the time it takes to transfer information shall not unreasonably delay the treatment of a condition diagnosed on the barium enema exam.
EFFECTIVE DATE: December 1, 1991
AMENDED: February 22, 1995
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