Innocuous filling of the intestinal glands of the colon during barium enema (spiculation) simulating organic disease.

Abstract

Barium sulfate is occasionally seen in the intestinal glands of the colon following a barium enema and may simulate organic disease. When filled and opacified by barium sulfate, the glands form tiny spicules projecting from the margin of the colon. The morphologic pattern thus produced may be designated by the term “spiculation.” The x-ray appearance of the barium-filled glands, as seen in profile, simulates filling of tiny mucosal ulcers. It is important that spiculation be recognized as not abnormal, to avoid an erroneous diagnosis of a pathologic condition, especially early ulcerative colitis. Anatomy In man the large intestine is devoid of villi and has a smooth surface. The mucosa contains the glands of Lieberkühn (intestinal glands), which are straight tubules composed of columnar, goblet, and occasional argentaffin cells (1). A central crypt 0.5 to 0.7 mm. long is present in each gland. The glands are arranged perpendicularly to the surface and are regularly and profusely distributed over the mucosa of the colon. Review Sasson (2) reported the first case in which barium was demonstrated roentgenologically in the intestinal glands of the colon and conclusively explained this finding. His patient, a young man with clinical symptoms suggesting a mild irritable colon syndrome, showed multiple small opaque spicules projecting perpendicularly from the colon on a post-evacuation x-ray film. Proctosigmoidoscopy showed normal mucosa except for second-degree hemorrhoids. A biopsy three weeks after the barium enema was negative, nor were any spicules seen following a barium enema nine months after the first examination. Sasson demonstrated crystals of barium sulfate within the intestinal glands by examining rectal mucosa with a microscope illuminated by polarized light. A punch biopsy of mucosa was obtained through a sigmoidoscope immediately following a barium enema. In one case there were destructive changes of epithelial cells in contact with the crystals. It was proposed that this is the mechanism of formation of barium granuloma. For several years we have recorded cases showing prominent spiculation of the colon. Our x-ray diagnoses of early ulcerative colitis were proved wrong in a few cases by a normal sigmoidoscopic examination and a negative clinical history. This led us to recognize empirically that the finding of spiculation in only the post-evacuation film must be disregarded and considered as a normal finding. Roentgenologic findings An intestinal gland filled with barium forms a tiny hairline spicule which may be seen projecting perpendicularly from the colon on the post-evacuation film (Figs. 1 and 2). The length varies from 0.5 to 2.0 mm. and the maximum diameter is 1.0 mm., as seen in the profile view. Filled intestinal glands seen “on end” form a polka-dot pattern of tiny dots and ovals. Spicules of barium appear to be super-imposed upon a normal colon pattern. Within a cluster they are usually of about equal size.