RECTAL CONTRAST

Indication for CT with rectal contrast:

• Concern for fistula to rectum (usually from vagina or bladder)

EQUIPMENT:

1. Enema bag

2. Tip included in enema bag (sometimes may not have a balloon as this may obscure a fistula, but beware enema content likely will leak everywhere)

3. Hemostat clamp

4. Lube

5. Premixed: ~50 mL Isovue-370, added to ~1.5 L of Warm water (will not use all of this)

6. Drainage bin

STEP-BY-STEP PROCEDURE:

1. Review rectal contrast order. Often, may need to call ordering physician/team to discuss proper indication.

   • Look up patient chart on Epic and review prior imaging, to understand what type of surgery(s) the patient may have had (concern for friable tissue, etc.)

2. Introduce yourself to the patient, discuss the steps and address any concerns..

3. Ask techs to do a pre-contrast CT (2.5 mm slice thickness) so you can assess anatomy.

4. Do pre-procedural checklist - timeout, right patient, right procedure.
   Remember: Hand hygiene/wear gloves.

5. Have patient lay on their side so you can access the anal area.

6. Do a brief digital rectal exam with lube prior to inserting tube.

7. Coat enema tube tip with lube.

8. Use both hands - one to expose the anal area, and the other to hold the catheter tip.
   Insert enema tip carefully into the rectum, not more than 5 cm (tailor to the post-surgical anatomy - i.e. don't rupture anastamosis site!). (May need to ask patient to relax, or cough.)
   DO NOT force the tip in if you feel resistance!!! (Risk of perforation or injury)
   DO NOT administer into stool... patient should have evacuated bowel prior to procedure.

9. Insufflate the balloon to prevent leak, prior to filling rectum.
   Consider taping the tubing so it doesn't fall out.

10. Fill rectum with ~500 mL or less of enema fluid mixture, as tolerated by patient.

    • Ideally bag should be raised above head level, to allow contrast to fill rectum/distal colon.
      Note: Be nice, warn the patient - during this filling phase, may feel mild coolness, discomfort, generalized fullness.

11. Clamp off tubing.
    DO NOT remove tip yet!!! (not until last step - #16).

12. Have patient lay flat / supine for scanning.

    • Ask patient to relax as much as possible/remain still until CT scan is complete.

13. Scan the patient / wait.

14. Check images at the machine/with technologist. (Ask attending if necessary before next steps of removing tube).

15. Lower bag and unclamp tubing into a bin, to evacuate patient

16. Remove enema tube tip.