THE IMPORTANCE AND RELIABILITY OF THE ROENTGENOGRAPHIC EXAMINATION OF THE SMALL BOWEL IN PATIENTS WITH TROPICAL SPRUE.

Abstract

Tropical sprue, in certain parts of the world, is an important cause of significant morbidity. The 175 adult patients with tropical sprue who constitute the basis for this report represent less than half such cases studied at Rodriquez U. S. Army Hospital and the U. S. Army Tropical Research Medical Laboratory, San Juan, P. R., in the two and a half years under consideration (January 1961 to June 1963). An accurate estimate of the incidence in Puerto Rico is difficult because definitions of sprue vary (17, 33, 36), and numerous suspected cases, particularly from rural areas, are often treated empirically without benefit of refined diagnostic investigations. Numerous methods have been developed to diagnose and evaluate cases of intestinal malabsorption (21, 23, 33, 34, 35). These include stool fat determinations, xylose and vitamin A absorption studies, serum carotene levels, plasma folic acid levels, intestinal mucosal biopsies, and small bowel x-ray examinations. The purpose of this study is to assess the diagnostic value of a standard small bowel radiographic examination (6) in a large group of patients with either documented or suspected tropical sprue and to compare its reliability with the other parameters commonly used to investigate malabsorption. Material and Methods More than 800 small bowel x-ray studies, obtained during the period under consideration, were reviewed. Three hundred and twenty-two of these were selected for evaluation solely on the basis of availability of intestinal absorptive test data and/or intestinal biopsy performed within three weeks of the roentgenographic study. Pertinent clinical data were available in all cases. The case material evaluated is shown in Table I. Two hundred and twenty-eight of the examinations suitable for review were in patients with tropical sprue. The severity of the clinical signs and symptoms in the untreated sprue patients varied widely, from severe sprue with diarrhea, steatorrhea, weight loss, megaloblastic anemia, and glossitis, to mild disease manifested by abdominal discomfort, listlessness, slight weight loss, and mild malabsorption. The results of the various tests for malabsorption revealed a broad spectrum, but generally they were less abnormal in the patients with mild disease. The diagnosis was based on history, physical examination, and laboratory evidence of intestinal malabsorption, usually including steatorrhea. Jejunal biopsies were definitely abnormal in all but 3 patients with mild disease. Bone marrow aspirations were abnormal, indicating folic acid and/or vitamin B12 malabsorption in all patients so studied. Anemia, although present in most patients, was not required for the diagnosis of tropical sprue (17, 18). The group of patients with tropical sprue includes native Puerto Ricans as well as persons not indigenous to the island.