Detection of colorectal carcinoma on double contrast barium enema when double reporting is routinely performed: an audit of current practice

PURPOSE: To determine the sensitivity of double contrast barium enema (DCBE) in the detection of colorectal carcinoma (CRC) when double reporting is routinely performed. METHOD AND MATERIALS: Over a 1-year period all patients with a diagnosis of CRC within a large teaching hospital were identified. Using computer records, any patient with CRC who had had a DCBE within 5 years of diagnosis was identified. During this time period all DCBE were double reported by the radiographer or radiology trainee who performed the enema and by a consultant radiologist specializing in gastrointestinal radiology. RESULTS: Over the 1-year period 169 patients were identified with a diagnosis of CRC. Seventy patients had had a DCBE within the preceding 5 years. Sixty-four patients had had CRC diagnosed on the DCBE. One patient had a sessile polyp diagnosed, which was removed at colonoscopy and found to be an invasive adenocarcinoma. In five cases (7%) the CRC was not diagnosed on DCBE. In three cases the lesions could be seen retrospectively, in one case the lesion could not be seen and in one case the examination had been incomplete. CONCLUSION: In our series the miss-rate for CRC was 7%. Previous studies have shown miss-rates of 15-24%. These studies have not routinely employed double reporting. Our results suggest that double reporting of DCBE significantly reduces the miss-rate and that this reduction is due to fewer perceptive errors.     

The double contrast barium enema: a retrospective single centre audit of the detection of colorectal carcinomas.

AIM: To determine retrospectively the sensitivity and specificity of the double contrast barium enema (DCBE) as performed in one institution for the detection of colorectal carcinoma. SUBJECTS AND METHODS: Eight hundred and eighty barium enema reports were reviewed of consecutive adult patients who underwent DCBE and also had hospital case notes with a minimum follow up of two years, a later diagnostic colonoscopy, or operative and histological findings. RESULTS: Seventy-four true positive cases of colorectal carcinoma diagnosed at DCBE were confirmed at surgery and histological examination. There were four false positive diagnoses of carcinoma at DCBE. Eight false negative cases at DCBE were demonstrated within a two-year follow-up period. The sensitivity of the DCBE for detecting colorectal carcinoma was therefore 90.2% and the specificity was 99.5%. CONCLUSION: DCBE is a sensitive and highly specific investigation for the detection of colorectal carcinoma.     

Double contrast barium enema sensitivity: a comparison of studies by radiographers and radiologists

PURPOSE: A retrospective study of histologically proven cases of colorectal cancer (CRC) was performed to assess whether the sensitivity of the radiographer-performed double contrast barium enema (DCBE) differed from that of the radiologist-performed study. MATERIALS AND METHODS: Histologically proven cases of CRC were reviewed over a 3-year period to ascertain whether: the diagnosis had been made by DCBE in the 3 years before histological diagnosis; the lesion had been correctly diagnosed; the examination had been performed by a radiologist or radiographer. RESULTS: In the 3-year period there were 478 cases with histologically proven CRC. Of these, 239 (50%) had undergone DCBE as the initial radiological investigation of the colon. Sixty-four examinations had been performed by radiographers. A correct diagnosis was made in 58 cases (90.6%), the report was equivocal in one case (1.6%), there were four false-negatives (6.25%), and one case was abandoned (1.6%). One hundred and seventy-five examinations were performed by radiologists. A correct diagnosis was made in 157 cases (89.7%), the report was equivocal in one case (0.6%), there were 16 false-negatives (9.1%), and one case was abandoned (0.6%). CONCLUSION: A sensitivity of 90.6% for radiographer-performed studies compared favourably with 89.7% for radiologist-performed studies and supports the practice of radiographers undertaking barium enemas.     

早期结肠癌低张气钡双对比造影检查与纤维结肠镜对比分析

目的:对于早期结肠癌的检查,通过低张气钡双对比造影(DCBE)图像与纤维结肠镜检查图像对比观察,分析气钡双对比结肠造影在检出早期结肠癌中的价值。方法:20例经病理证实早期结肠癌病例,采用低张气钡双对比造影方法,实时点片。常规纤维结肠镜检查。结果:Ⅰ型11例,Ⅱa型6例,混合型1例,LST型2例,对比观察造影像及内镜像表现。结论:正确运用气钡双对比造影检查,对早期结肠癌的显示有较大价值。     

Limitations of combined flexible sigmoidoscopy and double contrast barium enema in patients with rectal bleeding

Eighty-seven outpatients with non-massive rectal bleeding or asymptomatic positive fecal occult blood were evaluated with 35 cm flexible sigmoidoscopy, double contrast barium enema (DBCE) and colonoscopy. 82% had hemorrhoids and 35% harbored colorectal neoplasia. The combination of flexible sigmoidoscopy and DCBE missed none of 7 malignant lesions. However, 36% of benign polyps greater than or equal to 1 cm and 60.25% of those less than 1 cm were not detected by this combination. The presence of hemorrhoids should not prevent a search for colon neoplasia and colonoscopy is the preferred method.     

Complications from radiographer-performed double contrast barium enemas

AIM: To determine the types and rates of complications encountered by radiographers when performing double contrast barium enemas (DCBE). MATERIALS AND METHODS: Seven hundred and forty-one questionnaires were posted to radiographers who had in the last 5 years attended one of the biannual barium enema training courses. RESULTS: Of 741 questionnaires posted 407 (54.9%) were returned completed. Approximately 348,000 barium enema examinations had been performed. Fifty-nine radiographers reported 89 complications, including 13 intra-peritoneal and 11 extra-peritoneal perforations. There were five deaths (mortality 1 in 70,000). Deaths resulted from two of 24 (10%) perforations, two of 45 (5%) cardiac events and one cerebrovascular accident that occurred during an examination. CONCLUSIONS: Radiographers have been regularly performing DCBEs for almost a decade. The mortality for radiographer-performed DCBE is similar to that previously reported for radiologists, although a slightly higher rate of perforation is noted and so this is an area where radiographer training should be targeted.     

Spasmolytic effect of peppermint oil in barium during double-contrast barium enema compared with Buscopan

AIM: To evaluate the efficacy of peppermint oil in barium as a spasmolytic agent during a double-contrast barium enema (DCBE). MATERIALS AND METHODS: A total of 383 DCBEs with positive results from occult blood tests were assessed. Patients were assigned to one of four groups: peppermint in barium (n=91), peppermint in tube (n=90), Buscopan (n=105), or no treatment (n=97). After a screening sigmoidoscopy, the DCBEs were performed using air as a distending gas. In the Buscopan group, the DCBE was performed with an intramuscular injection of 20mg Buscopan at the start of the examination. Patients in the no-treatment group underwent DCBE without any spasmolytic agent. A peppermint oil preparation (30ml) was mixed in the barium solution for patients in the peppermint-in-barium group, and the same dose of peppermint oil was included in the enema tube in the peppermint-in-tube group. The presence of spasm on a series of spot films was evaluated without information about the type of spasmolytic agent used. RESULTS: The percentage of patients in the four groups (no treatment, Buscopan, peppermint in tube, and peppermint in barium) with absence of spasm in the entire colon on the series of spot films was 13.4, 38.1, 41.8, and 37.8%, respectively. In the group using peppermint oil or Buscopan, the rate of patients with non-spasm examination was higher than that in no-treatment group (p<0.0005). Peppermint oil had the same spasmolytic effect as the systemic administration of Buscopan in the transverse and descending colon. Peppermint oil had a stronger effect in the caecum and the ascending colon than a Buscopan injection (p<0.005). There was no advantage to placing peppermint oil in the enema tube over mixing it in the barium solution. A total of 157 polyps were found during the DCBE procedures, and no differences were observed in the number of lesions among the four groups. Peppermint oil did not impair image quality. CONCLUSION: Barium solution mixed with peppermint oil was safe and effective for the elimination of colonic spasm during the DCBE procedure, and it could be used instead of Buscopan.     

National audit of the sensitivity of double-contrast barium enema for colorectal carcinoma, using control charts For the Royal College of Radiologists Clinical Radiology Audit Sub-Committee

AIM: To audit the sensitivity of double-contrast barium enema (DCBE) for colorectal carcinoma, as currently practised in UK departments of radiology. METHODS: As part of its programme of national audits, the Royal College of Radiologists Clinical Radiology Audit Sub-Committee undertook a retrospective audit of the sensitivity of DCBE for colorectal carcinoma during 2002. The following targets were set: demonstration of a lesion > or =95%; correct identification as a carcinoma > or =90%. RESULTS: Across the UK, 131 departments took part in the audit, involving 5454 examinations. The mean demonstration rate was 92.9% and the diagnosis rate was 85.9%, slightly below the targets set. The equivocal rate (lesion demonstrated, but not defined as malignant) was 6.9%, the perception failure rate was 2.8% and the technical failure rate was 4.4%. Control-chart methodology was used to analyze the data and to identify any departments whose performance was consistent with special-cause variation. CONCLUSION: When compared with the diagnosis rate (84.6%) and demonstration rate (92.7%) reported in the Wessex Audit 1995, [Thomas RD, Fairhurst JJ, Frost RA. Wessex regional audit: barium enema in colo-rectal carcinoma. Clin Radiol 1995;50:647-50.] a similar level of performance was observed in the NHS today, implying that the basic process for undertaking and reporting DCBE has remained relatively unchanged over the last few years. Improvement in the future will require fundamental changes to the process of reporting DCBE, in order to minimize the perception failure rate and accurately to describe lesions, so reducing the equivocal rate. Control-chart methodology has a useful role in identifying strategies to deliver continual improvement.     

Colorectal cancer: screening double-contrast barium enema examination in average-risk adults older than 50 years

PURPOSE: To retrospectively determine the diagnostic yield of double-contrast barium enema examinations performed for colorectal cancer screening of neoplasms 1 cm or larger or advanced neoplastic lesions of any size in average-risk adults older than 50 years. MATERIALS AND METHODS: The Institutional Review Board at the affiliated Veterans Affairs Medical Center approved this HIPAA-compliant study protocol and did not require informed consent from patients. Computerized databases revealed 276 double-contrast barium enema examinations performed for colorectal cancer screening in average-risk adults older than 50 years. Radiographic and pathologic reports were reviewed to determine the number of patients who had polypoid lesions 1 cm or larger, polyps smaller than 1 cm, or advanced neoplastic lesions of any size. Forty-five (16.3%) of the 276 patients underwent follow-up sigmoidoscopy or colonoscopy. Medical, endoscopic, and pathologic records were reviewed and compared with radiographic findings. RESULTS: The results of double-contrast barium enema examination revealed 74 (26.8%) of 276 patients with 104 polypoid lesions in the colon, including 32 patients (11.6%) with 41 polypoid lesions 1 cm or larger, 15 patients (5.4%) with 19 polyps 6-9 mm, and 27 patients (9.8%) with 44 polyps 5 mm or smaller. Endoscopy was performed in 24 (75%) of 32 patients, the results of which confirmed 23 (72%) of 32 radiographically diagnosed lesions 1 cm or larger in 16 (67%) of 24 patients. In two of these individuals, the polyps were hyperplastic. The remaining 14 patients had a total of 21 neoplastic lesions 1 cm or larger, including 11 tubular adenomas, seven tubulovillous adenomas, one villous adenoma with marked dysplasia, and two cancers. The diagnostic yield of screening double-contrast barium enema examination was 5.1% (14 of 276 patients) for neoplastic lesions 1 cm or larger and 6.2% (17 of 276 patients) for advanced neoplastic lesions of any size. CONCLUSION: Double-contrast barium enema examinations performed in average-risk adults older than 50 years have a diagnostic yield of 5.1% for neoplastic lesions 1 cm or larger and 6.2% for advanced neoplastic lesions, regardless of size.     

Colorectal cancer screening with CT colonography,colonoscopy, and double-contrast barium enema examination: prospective assessment of patient perceptions and preferences

PURPOSE: To prospectively assess and compare perceptions of and preferences for computed tomographic (CT) colonography, colonoscopy, and double-contrast barium enema examination (DCBE) by asymptomatic patients undergoing colorectal cancer screening. MATERIALS AND METHODS: A total of 696 asymptomatic patients at higher-than-average risk undergoing colorectal cancer screening were consecutively recruited to undergo both CT colonography and colonoscopy (group 1), and a like group of 617 patients was separately recruited to undergo both CT colonography and DCBE (group 2). Standard bowel preparations were different between the groups undergoing colonoscopy and DCBE. Each patient completed a questionnaire that assessed preparation inconvenience and discomfort, examination discomfort, willingness to repeat examinations, and examination preference. Survey results were compared for significance by using the Wilcoxon rank sum or chi2 test. RESULTS: The majority of patients considered the preparation to be uncomfortable (group 1, 460 of 515 [89%]; group 2, 482 of 538 [90%]) and inconvenient (group 1, 393 of 502 [78%]; group 2, 427 of 527 [81%]). Reported discomfort was similar at CT colonography and colonoscopy (P =.63) but was less at CT colonography than at DCBE (P <.001). Patients experienced significantly less discomfort than expected at both CT colonography and colonoscopy but not at DCBE. Patients' willingness to undergo frequent rescreening was significantly greater for CT colonography than for either colonoscopy or DCBE. The acceptable time interval between screenings was significantly shorter for all examinations if the bowel preparation could be avoided. Overall, patients preferred CT colonography to colonoscopy (group 1, 72.3% vs 5.1%; P <.001) or to DCBE (group 2, 97.0% vs 0.4%; P <.001). CONCLUSION: Patients undergoing colorectal cancer screening prefer CT colonography to both colonoscopy and DCBE. The majority of patients experience discomfort and inconvenience with cathartic bowel preparation.     

Reassessing the role of radiology in Hemoccult screening

During a recent regional screening program, 98 patients with a positive Hemoccult test were evaluated radiographically. Double-contrast barium enema (DCBE) detected all six carcinomas and 92% of 37 polyps. DCBE was also the most cost-effective procedure. Colonoscopy dramatically increased screening costs without providing evidence to support its use in all Hemoccult-positive patients. It is recommended that DCBE be the initial diagnostic test in Hemoccult-positive patients, to be supplemented in selected patients by flexible sigmoidoscopy or colonoscopy depending on the pathology evident on DCBE and on clinical circumstances.     

The dissection sign of nonreducible ileocolic intussusception

A retrospective study of 90 cases of ileocolic intussusception seen over a 5-year period was undertaken to identify features of failed hydrostatic reductions. A new, reliable sign of nonreducible intussusception was found: the dissection sign. Of the 90 cases, 23 demonstrated barium dissecting between the intussusceptum and intussuscipiens ; of those, nine had necrotic bowel found at surgery. All of the 23 cases with dissection failed hydrostatic reduction. Of the 23 patients, 22 were below age 2 years. None of those reduced by barium enema had dissection. The dissection sign on barium enema for ileocolic intussusception is an indication to discontinue hydrostatic reduction and to institute surgical treatment, especially in patients under age 2 years.     

Imaging of the colon

The highlight of articles published on radiologic examination of the colon is the increasing indication for use of the barium enema for screening for colorectal carcinoma. Radiologic screening for colorectal cancer promises to be more effective than mammograptive screening and more cost-effective than alternative means, such as colonoscopy. Important work on defocography suggests that measurements of anorectal angle and pelvic floor descent are nondiagnostic, and that rectal-wall changes are the important findings. Findings on CT scanning continue to be investigated in diseases, such as diverticulitis and tuberculosis, that affect both the colonic mucosa and pericolonic tissues. An important new trend is the use of sonography to investigate the colon for the presence of neoplasms.     

Comparison between CT Colonography and Double-Contrast Barium Enema for Colonic Evaluation in Patients with Renal Insufficiency

Objective

To compare the CT colonography (CTC) and double-contrast barium enema (DCBE) for colonic evaluation in patients with renal insufficiency.

Materials and Methods

Two sequential groups of consecutive patients with renal insufficiency who had a similar risk for colorectal cancer, were examined by DCBE (n = 182; mean ± SD in age, 51 ± 6.4 years) and CTC (n = 176; 50 ± 6.7 years), respectively. CTC was performed after colon cleansing with 250-mL magnesium citrate (n = 87) or 4-L polyethylene glycol (n = 89) and fecal tagging. DCBE was performed after preparation with 250-mL magnesium citrate. Patients with colonic polyps/masses of ≥ 6 mm were subsequently recommended to undergo a colonoscopy. Diagnostic yield and positive predictive value (PPV) for colonic polyps/masses, examination quality, and examination-related serum electrolyte change were retrospectively compared between the two groups.

Results

Both the CTC and DCBE were positive for colonic polyps/masses in 28 (16%) of 176 and 11 (6%) of 182 patients, respectively (p = 0.004). Among patients with positive findings, 17 CTC and six DCBE patients subsequently underwent a colonoscopy and yielded a PPV of 88% (15 of 17 patients) and 50% (3 of 6 patients), respectively (p = 0.089). Thirteen patients with adenomatous lesions were detected in the CTC group (adenocarcinoma [n = 1], advanced adenoma [n = 6], and non-advanced adenoma [n = 6]), as compared with two patients (each with adenocarcinoma and advanced adenoma) in the DCBE group (p = 0.003). Six (3%) of 176 CTC and 16 (9%) of 182 DCBE examinations deemed to be inadequate (p = 0.046). Electrolyte changes were similar in the two groups.

Conclusion

In patients with renal insufficiency, CTC has a higher diagnostic yield and a marginally higher PPV for detecting colorectal neoplasia, despite a similar diagnostic yield for adenocarcinoma, and a lower rate of inadequate examinations as compared with DCBE.     

Diagnostic yield of barium enema examination after incomplete colonoscopy

PURPOSE: To determine the diagnostic yield of barium enema examination for neoplastic lesions larger than 1 cm in diameter in the nonvisualized portion of the colon after incomplete colonoscopy. MATERIALS AND METHODS: A review of computerized gastroenterology and radiology databases identified 355 patients who underwent incomplete colonoscopy; 158 (44.5%) underwent subsequent barium enema examination (125 double-contrast and 33 single-contrast barium enema examinations). The radiographic reports were reviewed and compared with the endoscopic reports by one author to identify neoplastic lesions larger than 1 cm in the nonvisualized colon after incomplete colonoscopy. Six such lesions were found. In all six cases, the images from the barium enema examinations were reviewed together by two authors to determine the size, location, and morphologic features (polypoid, ulcerated, or annular) of the lesions. Medical, endoscopic, and surgical records were subsequently reviewed by one author to determine whether these represented true- or false-positive radiographic findings. RESULTS: Barium enema examination depicted six possible lesions in the nonvisualized colon after incomplete colonoscopy; five were found to be true-positive radiographic findings, and one was found to be a false-positive finding. The five true-positive findings included two annular lesions (both adenocarcinomas) and three polypoid lesions (all tubulovillous adenomas, with high-grade dysplasia in one). Thus, neoplastic lesions larger than 1 cm were found on barium enema images in the nonvisualized colon in five (3.2%) of 158 patients after incomplete colonoscopy. CONCLUSION: Barium enema examination had a diagnostic yield of 3.2% for neoplastic lesions larger than 1 cm in the nonvisualized colon after incomplete colonoscopy.     

Cost-effectiveness of colorectal cancer screening

PURPOSE: To determine the most cost-effective colorectal cancer screening strategy costing less than $100,000 per life-year saved and to determine how available strategies compare with each other. MATERIALS AND METHODS: Standardized methods were used to calculate incremental cost-effectiveness ratios (ICERs) from published estimates of cost and effectiveness of colorectal cancer screening strategies, and the direction and magnitude of any effect on the ratio from parameter estimate adjustments based on literature values were estimated. RESULTS: Strategies in which double-contrast barium enema examination was performed emerged as optimal from all studies included. In average-risk individuals, screening with double-contrast barium enema examination every 3 years, or every 5 years with annual fecal occult blood testing, had an ICER of less than $55,600 per life-year saved. However, double-contrast barium enema examination screening every 3 years plus annual fecal occult blood testing had an ICER of more than $100,000 per life-year saved. Colonoscopic screening had an ICER of more than $100,000 per life-year saved, was dominated by other screening strategies, and offered less benefit than did double-contrast barium enema examination screening. CONCLUSION: Double-contrast barium enema examination can be a cost-effective component of colorectal cancer screening, but further modeling efforts are necessary.     

Lymphoid follicular hyperplasia in excluded colonic segments: a radiologic sign of diversion colitis

Double-contrast barium enema (DCBE) studies showed lymphoid follicular hyperplasia (LFH) in excluded colonic segments after colostomy in 12 of 40 patients. In most patients with LFH, more than 80% of the excluded colon was affected. In eight patients, regression of LFH was demonstrated with DCBE studies after reanastomosis. This work suggests that LFH is the most common DCBE study finding in diversion colitis.     

Chronic ulcerative colitis and colon cancer: can radiographic appearance predict survival patterns?

Twenty-four patients with chronic ulcerative colitis and colon carcinoma who underwent barium enema examination prior to the diagnosis of cancer were studied in an attempt to correlate the radiographic appearance of the tumors with their biologic behavior, as well as to assess the accuracy of the barium enema in detection. Of the radiographically detected tumors, 65% displayed an annular infiltrative appearance, with the prime radiographic manifestation being relative nondistensibility of the involved segment. The remaining tumors had various appearances more typical of noncolitic colon cancer. Patients with infiltrative lesions had a much poorer prognosis than those with noninfiltrative lesions. Of 33 gross tumors described pathologically and/or surgically, only 70% were correctly detected by barium enema. It is suggested that periodic barium enema examinations are an unreliable means of following patients with ulcerative colitis if malignant degeneration is to be detected at an early and curative stage. Prophylactic proctocolectomy may be the best therapeutic approach.     

Value of double-contrast barium enema performed immediately after incomplete colonoscopy

OBJECTIVE: The purpose of this study was to evaluate the ease, completeness, and clinical utility of double-contrast barium enema (DCBE) performed immediately after incomplete colonoscopy. SUBJECTS AND METHODS: During a 30-month period, a prospective study was performed in 103 patients (79 women, 24 men) to determine the ease and completeness of DCBE immediately after failed colonoscopy and any additional useful information provided by the enema. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult). RESULTS: DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE. CONCLUSION: Immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases, often adds vital diagnostic information, and eliminates repeated bowel preparation and unnecessary delay in diagnosis.