The small-bowel examination.

Abstract

Further experience with the reflux examination of the small intestine and the experience of others, a typical example of which is found elsewhere in this issue of Radiology (p. 1051), support our original enthusiasm for this method of examination and confirm our opinion that the complete reflux method, though relatively new, when properly used is an additional powerful weapon in our diagnostic arsenal. The procedure has been described elsewhere in detail (2). In brief, one should use large-bore tubing and an effective retention device. A 2,000 cc enema of precisely suspended barium sulfate is then followed by 2,500 cc of saline. This pushes the barium into the small bowel, and one can fill it as far as the site of obstruction or the duodenum. The colon is then drained. Two points are important—first, the patient is completely comfortable after drainage and the examiner should then fluoroscope and palpate the abdomen. Particular attention should be paid to any previous or present area of tenderness. Second, this author now uses 100 to 150 mg Demerol and 1 mg atropine ten minutes before the examination to make the patient more comfortable. The first reaction of many radiologists and clinicians to the procedure has been that this examination must be extremely painful. We make no claim that it is a pleasant experience for the patient. The addition of premedication with Demerol, however, has made the examination much easier. It should be emphasized that the period of discomfort is short, lasting only three to five minutes while the small bowel is being filled. As soon as the first film is taken and the bulk of fluid is drained, relief is immediate. Many examinations, including cystoscopy, sigmoidoscopy, esophagoscopy, and bronchoscopy, are more uncomfortable, but are repeatedly utilized when indicated. We do not feel that this method should completely replace the antegrade approach. Except for acute obstruction almost all of our patients have had antegrade studies first, and then the reflux examination has been performed either because no lesion was shown or because it was poorly defined. As a consequence of this selection of cases, disease has been demonstrated in about 50 per cent of those examined. To accomplish the reflux of barium through the ileocecal valve has been much easier than might be expected. Failure has occurred in only 4 per cent of our patients. Success depends partly upon the experience and diligence of the examiner. The contraindications to the reflux examination are the same as for any barium enema study. It has been performed in our department upon more than 150 patients, including the author, and we have had no complications.