Catheter Tip Position

A small balloon catheter is used for CTE because of the lack of viscosity of water and the low viscosity of the other neutral enteral agents, (9 F MCTE catheter, EZ EM Inc., Westbury NY). This small soft catheter obviates the need for conscious sedation. The balloon and catheter tip are ideally positioned distal to the crossing of the superior mesenteric artery. The balloon is inflated with 30-40 ml of air. A 60 ml syringe of air is injected into the infusion lumen and additional air is injected into the balloon if air refluxes proximally. This also allows us to see if the catheter tip is in a diverticulum. Our technique of performing CTE with neutral enteral and iv contrast is summarized in Table 1.

We observe the position of the balloon and gauge the response of the patient to the rate of initial infusion (100 ml/min). If the balloon is pushed back to the descending segment at this rate, we decrease the infusion rate to 80 ml/min. In some patients, particularly those with irritable bowel syndrome, patients complain of abdominal pain at this rate even if the balloon is not pushed back, in which case we decrease the rate to 60 ml/min. This is also done when patients complain of nausea. We raise the rate by 20 ml from the fluoroscopic rate at the CT table. If the patient evacuates some of the water when no CT unit is immediately available, we infuse 2 l on the CT table before iv contrast is given. In patients with prior surgery that involved the ileocecal valve, we decrease the amount infused at CT to 1 l but increase the infusion rate to 150 ml/min, if possible. The high rate of infusion keep the

Table 1. CT enteroclysis with neutral enteral/iv contrast

Fluoroscopic Phase a. Balloon positioned in distal duodenum to the left of the spine b. 0.3 mg glucagon iv c. Infuse 2 l of water at 100 ml/min - adjust as described Transfer patient to CT table

CT Phase d. Give 0.3 mg glucagon iv e. Infuse 1.5 l of water at 120 ml/min f. iv contrast: 4 ml/sec, total 150 ml CT acquired at 50 sec delay g. Balloon deflated and catheter retracted to level of black marker, refluxed water in stomach decompressed before catheter withdrawn small bowel distended for a longer time. The glucagon (or buscopan) keeps the small bowel aperistaltic and allows the patient to hold the large amount of contrast in the small bowel and colon. We give the glucagon in two small doses to diminish the nausea that is common with higher doses and to prolong its effect.

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