Small-bowel obstruction masking synchronous large-bowel obstruction: a need for emergency barium enema

Synchronous obstruction of large and small bowel may be missed radiologically and even at laparotomy when the small-bowel obstruction masks the large-bowel obstruction. The five patients reported illustrate this problem. It can only be diagnosed in certain patients by barium enema after small-bowel obstruction has been shown on plain radiographs. In four patients, this was especially applicable: patients with known or suspected abdominopelvic malignancy with loops of small bowel and pelvic colon involved by either tumor spread or irradiation fibrosis after treatment. One patient had ischemic strictures manifesting rather unusually in this manner.     

Comparison of multidetector CT and barium studies of the small bowel: inflammatory bowel disease in children

OBJECTIVE: We compared barium studies of the small bowel with multidetector CT (MDCT) in the evaluation of the small bowel during the initial presentation of inflammatory bowel disease in a pediatric population. SUBJECTS AND METHODS: This was a prospective study. Eighteen children undergoing workup for inflammatory bowel disease underwent MDCT, colonoscopy, and barium studies of the small bowel before commencement of therapy. Examinations were independently reviewed. The patients and their guardians completed a questionnaire assessing the acceptability of each study. RESULTS: In 13 of 18 children, the findings of MDCT and barium studies of the small bowel concurred in the evaluation of terminal ileum disease. In three of these children, MDCT detected skip segments of small-bowel disease not detected on barium studies of the small bowel. In two of 18 children, the terminal ileum was not visualized on barium studies of the small bowel, whereas MDCT showed substantial terminal ileum disease in both children. In three of 18 children, there was discordance between the two tests regarding terminal ileum disease. However, these discordant imaging findings were all subtle. In addition, MDCT revealed extraenteric abnormalities, clinically relevant in two children (ureteric obstruction and perirectal abscess), and showed the colon in all children, seven of whom had incomplete colonoscopy. The questionnaire revealed that 16 of 18 patients preferred MDCT to small-bowel barium studies. The reasons given were poor tolerance of oral barium and the long duration of barium studies of the small bowel. CONCLUSION: MDCT can be an alternative to barium studies of the small bowel for evaluation of the small bowel in patients with inflammatory bowel disease. MDCT also offers additional, clinically relevant information not obtained by small-bowel barium studies.     

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.     

Acute gastrointestinal hemorrhage: the changing role of barium examinations.

The emergency evaluation of a patient with acute life-threatening gastrointestinal hemorrhage requires the coordinated efforts of medical, surgical, and radiologic personnel. In most patients with an acute upper gastrointestinal hemorrhage, endoscopy represents the primary diagnostic procedure. Arteriography may follow, depending on the identification of the lesion at endoscopy or the need for therapy through the vascular catheter. Arteriography should precede endoscopy when bleeding is massive or the clinical situation suggests that therapy by a catheter must be instituted on a more urgent basis. When personnel are available to perform endoscopy and arteriography, the barium examination of the upper gastrointestinal tract is best postponed for a few days until the patient can be stabilized completely. In the patient with massive red rectal bleeding and a negative nasogastric aspirate, the arteriogram is clearly the procedure of choice for the emergency diagnostic evaluation. Bleeding diverticular and vascular ectatic lesions can be diagnosed only by arteriography and treatment can usually begin immediately by a catheter infusion of vasopressin. Colonoscopic and barium enema examinations of the acutely bleeding patient are not reliable. In addition, the presence of barium in the colon interferes with arteriography for a number of hours. The barium examination of the colon should be performed at some time during the hospitalization to exclude other possible bleeding lesions and to provide a better overall anatomic assessment of the colon. Both the retrograde and antegrade small bowel enemas are useful in detecting obscure small bowel bleeding lesions that occasionally present as a massive lower gastrointestinal hemorrhage.     

Recognition and prevention of barium enema complications

The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, complications may result. Many of these can be prevented by proper equipment and careful attention to technique. When a complication does occur, prompt recognition and management is vital in decreasing morbidity and mortality. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02% to 0.04% of patients. Rarely the colon may burst due to excessive transmural pressure alone. However, a colon weakened by iatrogenic trauma or disease is more likely to perforate during an enema than is a normal healthy bowel. Injury to the rectal mucosa or anal canal due to the enema tip or retention balloon is probably the most common traumatic cause of barium enema perforation. Inflation of a retention balloon within a stricture, neoplasm, inflamed rectum, or colostomy stoma is particularly hazardous. Recent deep biopsy or polypectomy with electrocautery makes the bowel more vulnerable to rupture. The tensile strength of the bowel wall is impaired in elderly patients, patients receiving long-term steroid therapy, and in disease states including neoplasm, diverticulitis, inflammatory bowel disease, and ischemia. Intraperitoneal perforation leads to a severe, acute peritonitis with intravascular volume depletion. The ensuing shock may be rapidly fatal. Prompt fluid replacement and laparotomy are essential. If the patient survives the initial shock and sepsis, later complications caused by dense intraperitoneal adhesions may develop. Extraperitoneal perforation is usually less catastrophic but may result in pain, sepsis, cellulitis, abscess, rectal stricture, or fistula. Intramural extravasation often forms a persistent submucosal barium granuloma which may ulcerate or be mistaken for a neoplasm. The most dramatic complication of barium enema is venous intravasation of barium. Fortunately, this is quite rare as it may be immediately lethal. Most cases have been attributed to trauma from the enema tip or retention balloon, mucosal inflammation, or misplacement of the tip in the vagina. Bacteremia has been found in as many as 23% of patients following barium enema and, in rare cases, may cause symptomatic septicemia. Other less common complications include barium impaction, water intoxication, allergic reactions, and cardiac arrhythmias. Preparatory laxatives and cleansing enemas have been implicated in some instances of dehydration, rectal trauma, water intoxication, and perforation. Careful review of the indications for examination, previous radiographs, and clinical history will identify many of the patients at greater risk for complications so that appropriate precautions may be observed.(ABSTRACT TRUNCATED AT 400 WORDS)     

An analysis of bowel perforation in patients with intussusception

A barium colon examination is recommended for the diagnosis and reduction of intussusception in children, except when bowel perforation is evident either radiographically or clinically. In our experience and contrary to recent reports neither radiographic evidence of bowel obstruction nor an age of less than six months is a contraindication. We reviewed 40 patients diagnosed as having had intussusception and found five children aged more than six months with perforations discovered at operation. Three of the five children had plain radiographic findings of small bowel obstruction as did nine other children. In four of the 12 children with evidence of small bowel obstruction a successful hydrostatic reduction of the intussusception was carried out. Barium studies were performed for diagnosis and therapy in eight children with ileo-colic intussusception aged six months or less, four of whom had evidence of small bowel obstruction. In five, including two with obstruction, reduction of the intussusception was successful. The major contraindication to barium examination is radiographic or clinical evidence of perforation.     

Small bowel phytobezoars: detection with radiography

The authors reviewed the radiographic findings in 19 patients with phytobezoars of the small bowel. The most common predisposing causes were previous gastric outlet surgery and persimmon ingestion. Twelve patients underwent contrast material-enhanced studies of the upper gastrointestinal tract, and one patient underwent a barium enema study. These examinations revealed four gastric, two duodenal, and eight small bowel phytobezoars in 10 patients. The obstruction caused by small bowel phytobezoars frequently occurred in the jejunum or proximal ileum, more proximally than has been reported in previous series. Barium studies are useful in differentiating obstruction due to postoperative adhesions from obstruction caused by bezoars. In addition, barium studies enable the detection of residual gastric bezoars. This information has important implications in patient treatment because bezoar obstruction is unlikely to respond to conservative treatment, and concurrent gastric bezoars must be removed to prevent recurrent bowel obstruction.     

Multiplanar spiral CT enterography in patients with Crohn's disease using a negative oral contrast material: initial results of a noninvasive imaging approach

The aim of this study was to prospectively define the role of multiplanar spiral CT enterography with a new negative oral contrast material for noninvasive assessment of the small bowel in patients with Crohn's disease. Thirty patients with established Crohn's disease prospectively underwent spiral CT enterography at 45-60 min after distension of the small bowel with 1400 ml of a negative oral contrast material (Mucofalk water enema). Spiral CT scans were obtained 50 s after administration of intravenous contrast material with the following parameters: 5-mm collimation; 7.5-mm/s table feed; and 3-mm reconstruction interval. The adequacy of bowel opacification, luminal distension, and the contribution of two-dimensional multiplanar reformatted imaging were assessed by two observers. Spiral CT imaging findings were compared with results of enteroclysis as well as endoscopic and histological findings in all patients. Spiral CT enterography with Mucofalk water enema was well tolerated in 29 of 30 patients. Findings on spiral CT enterography were comparable with those of barium studies in 25 of 30 patients, superior to those on barium studies in 4 patients, and inferior in 1 patient ( p<0.05). The addition of multiplanar reformatted images to axial spiral CT scans significantly improved observers' confidence in image interpretation ( p<0.05) but did not reveal additional abnormalities. Multiplanar spiral CT enterography with Mucofalk excellently provides information in patients with Crohn's disease. This technique accurately depicts the level of small bowel obstruction and the extent of inflammatory small bowel disease and its extraluminal complications.     

Chronic diverticulitis: clinical, radiographic, and pathologic findings

OBJECTIVE: The purpose of our study is to present a series of 14 patients with chronic diverticulitis on barium enema examinations and to correlate the radiographic findings with the clinical and pathologic findings in these patients. CONCLUSION: Chronic diverticulitis is a distinct pathologic entity characterized by the frequent development of chronic obstructive symptoms and abdominal pain rather than the classic clinical findings of acute sigmoid diverticulitis. Barium enema examinations usually reveal a relatively long segment of circumferential narrowing in the sigmoid colon with a spiculated contour and tapered margins, sometimes associated with retrograde obstruction. Our experience suggests that chronic diverticulitis can often be diagnosed on the basis of the characteristic clinical and radiographic findings in these patients.     

Usefulness of CT colonography in the preoperative evaluation of patients with distal occlusive colorectal carcinoma

PURPOSE: To evaluate the role of preoperative virtual colonoscopy to study the proximal colon in patients with distal occlusive carcinomas, diagnosed by conventional colonoscopy. MATERIAL AND METHODS: We examined 19 patients aged 46 to 83 years (13 men and 6 women) with distal occlusive colorectal carcinomas diagnosed by conventional colonoscopy, who were preoperatively studied with virtual colonoscopy. Patients with acute bowel obstruction were excluded. Results were compared with the findings of preoperative conventional colonoscopy and barium enema examination, intraoperative colon palpation, histopathologic outcome, postoperative conventional colonoscopy and barium enema examination. RESULTS: Virtual colonoscopy identified all 19 distal occlusive colon carcinomas and 22 synchronous lesions, 2 cancers (prevalence 10,6%) and 20 polyps (prevalence 68,4%). Both synchronous cancers were confirmed intraoperatively by direct palpation. Postoperative conventional colonoscopy, which was performed in 18 patients, confirmed the presence of 15 polyps in 12 patients. Three subcentimeter polyps were removed during conventional colonoscopy and were missed at virtual colonoscopy. Two polyps shown by virtual colonoscopy were not found at conventional colonoscopy. Postoperative barium enema was performed in three patients and confirmed three polyps identified at virtual colonoscopy. Preoperative barium enema was performed in five patients and failed to adequately demonstrate the proximal colon. Virtual colonoscopy showed a sensitivity of 87% and a specificity of 75%. CONCLUSIONS: Virtual CT colonoscopy can be considered an important diagnostic technique to evaluate preoperatively the proximal colon in patients with distal occlusive carcinomas,as it gives better results than barium enema or conventional colonoscopy, as well as being well tolerated and less invasive.     

小肠不全性梗阻的钡剂造影(附23例分析)

目的　探讨钡剂造影对小肠病变所致梗阻的诊断价值。方法　对 2 3例经手术证实的因小肠病变所致不全性梗阻患者行钡餐及小肠插管注钡造影进行回顾性分析。结果　 2 3例小肠梗阻患者中 ,恶性病变 14例 ,良性病变 9例。结论　对小肠病变所致不全性梗阻 ,钡餐及小肠插管气钡双重造影检查均有重要的诊断价值。     

CT of prominent pericolic or perienteric vasculature in patients with Crohn's disease: correlation with clinical disease activity and findings on barium studies

OBJECTIVE. The purpose of this study was to correlate CT findings of prominent pericolic or perienteric vasculature with clinical disease activity, treatment methods, and barium enema study findings in patients with Crohn's disease. MATERIALS AND METHODS: We retrospectively analyzed 33 patients with Crohn's disease who had undergone both barium enema study and abdominal CT. CT scans were evaluated for the presence and location of prominent vasculature. On the basis of the Crohn's disease activity index, the patients were assigned to one of three categories--active, intermediate, or quiescent disease groups--and the frequency of prominent vasculature was compared among them. Thereafter, erythrocyte sedimentation rates, C-reactive protein levels, treatment methods, and radiographic findings were compared in groups with and without prominent vasculature. RESULTS: Prominent vasculature was more frequently found in patients with active disease (81%) than in those with intermediate (33%) and quiescent disease (0%) (p < 0.001). The erythrocyte sedimentation rates and C-reactive protein levels were higher in patients with prominent vasculature (but not at a statistically significant rate). Patients with prominent vasculature were more frequently admitted to the hospital (p = 0.024) and received more aggressive treatment (p = 0.049) than patients without prominent vasculature. The main differences of radiographic findings between the group with prominent vasculature and the group without prominent vasculature included the common occurrence of longitudinal and perpendicular ulceration (p = 0.017 for small bowel; p = 0.041 for colon) and the extensive length of organ involvement (p = 0.004 for small bowel; p = 0.036 for colon). CONCLUSION: Prominent pericolic or perienteric vasculature seen on CT in patients with Crohn's disease suggests that the disease is clinically active, advanced, and extensive and that these patients require more aggressive treatment than patients without this CT finding.     

Rectal involvement by prostatic carcinoma: barium enema findings

A retrospective study was performed to determine the radiographic features of prostatic carcinoma invading the rectum on double-contrast barium enemas. In 11 such patients, these examinations revealed localized narrowing and/or speculation of the rectum (four cases); a smooth, extrinsic mass impression on the rectosigmoid colon (two cases); an umbilicated submucosal mass in the rectosigmoid colon (one case); and rectosigmoid narrowing with spiculated, pleated mucosal folds in the narrowed segment of bowel (four cases). Thus, most patients (64%) had localized involvement of the rectosigmoid colon with sparing of the distal rectum. The anatomic-pathologic basis for the localized spread of prostatic carcinoma to the rectosigmoid colon is illustrated on MR scans. Thus, prostatic carcinoma invading the rectum may be manifested on double-contrast barium enema by a spectrum of radiographic findings, and most patients have localized rectosigmoid involvement with sparing of the distal rectum.     

Role of ultrasonic diagnosis as a complementary method in contrast radiography of the intestines

This study was aimed at evaluating US reliability and sensitivity in identifying inflammatory or neoplastic bowel diseases in symptomatic patients. Two hundred and fifty patients who had been referred to our Unit for double-contrast barium enema of small bowel and colon, underwent panoramic and targeted abdominal US. According to well-known pathological criteria--i.e., intestinal wall thicker than 5 mm, and pseudo-kidney pattern--US had 61.7% sensitivity for inflammatory and neoplastic bowel diseases. The results indicate that US findings negative for intestinal disease are not reliable unless confirmed by contrastographic and endoscopic examinations. However, panoramic US occasionally demonstrated intestinal abnormalities and allowed collateral diseases to be observed in other organs or apparatuses. These abnormalities had been missed at contrastography, and were sometimes responsible for the symptoms the patients complained of. Targeted US emerged as a useful tool for detailing the lesions demonstrated by double-contrast barium enema, especially in case of expansive pathologies (size of the mass and relationship to adjacent organs).     

Occlusive colon carcinoma: virtual colonoscopy in the preoperative evaluation of the proximal colon

PURPOSE: To evaluate the use of preoperative virtual colonoscopy to examine the proximal colon in patients with distal occlusive carcinomas, defined as cancers that cannot be traversed endoscopically. MATERIALS AND METHODS: Twenty-nine patients with occlusive colorectal carcinomas underwent preoperative virtual colonoscopy with use of a standard protocol. Patients with acute bowel obstruction were excluded. Results of virtual colonoscopy were compared with the findings of preoperative colonoscopy, preoperative barium enema examination, intraoperative colon palpation, histopathologic outcome, and postoperative colonoscopy and barium enema examination, where possible. RESULTS: Virtual colonoscopy helped identify all 29 occlusive carcinomas and demonstrated two cancers and 24 polyps in the proximal colon. Both synchronous cancers were confirmed intraoperatively and resected. Postoperative conventional colonoscopy in 12 patients confirmed 16 polyps identified at virtual colonoscopy and demonstrated two subcentimeter polyps missed at virtual colonoscopy. Postoperative barium enema examination was performed in two patients and helped confirm two polyps identified at virtual colonoscopy. Virtual colonoscopy successfully demonstrated the proximal colon in 26 of 29 patients examined compared with preoperative barium enema examination, which failed to adequately demonstrate the proximal colon in any patient examined. CONCLUSION: Virtual colonoscopy is a feasible and useful method for evaluating the entire colon before surgery in patients with occlusive carcinomas.     

Double-contrast study of the small intestine using enteroclysis. Considerations on the results in 250 patients

The value of double contrast small bowel enema via duodenal intubation using barium sulphate and methylcellulose as contrast media was assessed in 250 patients. In cases of small bowel obstruction it represented the first-line investigation after a plain abdominal film. It was performed electively in patients of painful bowel syndrome, in cases of malabsorption, in cases of endoscopically or radiologically diagnosed colitis and in patients with Crohn's disease. On the basis of our results we believe double contrast small bowel enema to be the most reliable investigation in the localization and identification of small bowel lesions.     

A comparison of Golytely and standard preparation for barium enema

A randomized prospective trial was performed comparing Golytely (with bisacodyl) with our standard two-day catharsis and bowel washout regimen as colon preparation for double-contrast barium enema examinations. Of the 107 patients who participated, 50 received the standard preparation and 57 Golytely. Two radiologists reviewed the enema films without knowledge of which preparation had been used. No significant difference was detected either in the number of failed preparations or in the quality. We conclude that routine use of Golytely is preferable to methods involving catharsis and standard tap water enemas for barium enema examination, on the grounds that it is equally effective, yet more convenient for patients and for the radiology department, and reduces total costs.     

Intraperitoneal carcinomatosis: incidence of its radiographic findings and description of a new sign

Forty documented cases of intraperitoneal carcinomatosis were studied to examine the incidence of common consistently useful radiographic signs. Twenty-four (60%) were radiographically positive. Ten of 19 barium enema examinations (53%) revealed metastatic implant(s) on the colon. This proved to be the most common finding of intraperitoneal carcinomatosis. Other radiographic findings included ascites in 14 patients (35%) and small bowel obstruction in five (13%). A new sign of intraperitoneal carcinomatosis termed "fixed colon" sign is discussed. Seven of 19 cases (37%) with lower GI series demonstrated this sign. Barium enema examination has a high yield in demonstrating intraperitoneal carcinomatosis.     

Evaluation of tiny abnormal mucosal findings on double contrast barium enema study

Tiny abnormal mucosal findings on double contrast barium enema studies in 104 cases were classified into 5 patterns, as follows 1) small elevation, 2) elevation with barium fleck, 3) spotty barium fleck, 4) ill defined barium fleck and 5) barium fleck with halo. Each mucosal pattern was correlated with age, sex and symptoms, as well as the coexistence of the fine network pattern. They were compared with those of 86 control cases. 44 histologically proven cases were reviewed in order to clarify the clinical significance of the above 5 patterns. Incidence of the tiny mucosal findings was 4.8% (104/2186). 1) small elevation, 2) spotty barium fleck, 3) ill defined barium fleck and 4) barium fleck with halo were suggested the possibility of inflammatory bowel diseases.     

Small intestine ischemia simulating primary colonic disease

Clinical and radiographic findings were reviewed for four patients in whom colonic diverticulitis was suspected clinically but in whom small intestine ischemia was proved surgically. In each patient the initial diagnostic studies--plain abdominal radiography and barium enema examination--revealed generalized small intestine distention and non-specific colonic abnormalities, respectively. The latter findings consisted of an extrinsic impression on the superior or inferior aspect of the sigmoid colon with associated thumbprinting or spiculation. In each patient serosal inflammation of the sigmoid colon produced by an adherent segment of the ischemic small intestine was confirmed at laparotomy. In two patients, delay in surgical intervention resulted in small intestine necrosis. In a patient who has clinical signs and symptoms of colonic ischemia, diverticulitis, or small intestine obstruction but nonspecific findings on barium studies, the diagnosis of small intestine ischemia should be considered and further diagnostic imaging, such as angiography or small intestine follow-through examination, should be performed.