Barium Paste Research Articles

Computed Tomography Guidance for Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia.

Percutaneous glycerol rhizotomy (PGR) is a well-described treatment for trigeminal neuralgia; however, the technique in using surface landmarks and fluoroscopy has not drastically changed since being first introduced. In this paper, we describe a protocol for PGR using computed tomography (CT) guidance based on an experience of over 7 yr and 200 patients. To introduce an approach for PGR using CT guidance and, in doing so, demonstrate possible benefits over the traditional fluoroscopic technique. Using a standard CT scanner, patients are placed supine with head in extension. Barium paste and a CT scout image are used to identify and plan a trajectory to the foramen ovale. A laser localization system built into the CT scanner helps to guide placement of the spinal needle into the foramen ovale. The needle position in the foramen is confirmed with a short-sequence CT scan. CT-guided PGR provides multiple benefits over standard fluoroscopy, including improved visualization of the skull base and significant reduction in radiation exposure to the surgeon and staff. Side benefits include improved procedure efficiency, definitive imaging evidence of correct needle placement, and potentially increased patient safety. We have had no significant complications in over 200 patients. CT-guided PGR is a useful technique for treating trigeminal neuralgia based on better imaging of the skull base, better efficiency of the procedure, and elimination of radiation exposure for the surgeon and staff compared to traditional fluoroscopic based techniques.

A new defecographic parameter for assessing rectal emptying

PurposeTo validate a new defecographic parameter to assess rectal empyting correlating the percentage of weight reduction of barium paste and the variation in the percentage of area reduction of rectum compared before and after defecation during cinedefecography. MethodThirty-two consecutive female patients with dyschezia who had clinical indication for cinedefecography were selected. Their median age was 58 years old (18–78 years, mean=55 years). During cinedefecography, we calculated the cross-sectional sagittal area of the rectum before and after defecation and, thus, the percentage of area reduction of the rectum. The percentage of weight reduction of barium paste was calculated after weighing the contrast injected into the rectum and the amount of contrast evacuated, in grams, using a scale. Finally, both percentages were compared and checked for a correlation between them. Pearson's correlation (r) and Student's t test were used for statistical analysis. ResultsA correlation between evacuated barium paste and cross-sectional sagittal area of the rectum at the end of defecation was demonstrated (r=0.668 and p<0.0001). ConclusionIt is possible to estimate how much barium paste is evacuated based on the variations in cross-sectional sagittal area of the rectum before and after defecation, in cinedefecography.

Interobserver reliability of computed tomographic contouring of canine tonsils in radiation therapy treatment planning.

In radiation therapy (RT) treatment planning for canine head and neck cancer, the tonsils may be included as part of the treated volume. Delineation of tonsils on computed tomography (CT) scans is difficult. Error or uncertainty in the volume and location of contoured structures may result in treatment failure. The purpose of this prospective, observer agreement study was to assess the interobserver agreement of tonsillar contouring by two groups of trained observers. Thirty dogs undergoing pre- and post-contrast CT studies of the head were included. After the pre- and postcontrast CT scans, the tonsils were identified via direct visualization, barium paste was applied bilaterally to the visible tonsils, and a third CT scan was acquired. Data from each of the three CT scans were registered in an RT treatment planning system. Two groups of observers (one veterinary radiologist and one veterinary radiation oncologist in each group) contoured bilateral tonsils by consensus, obtaining three sets of contours. Tonsil volume and location data were obtained from both groups. The contour volumes and locations were compared between groups using mixed (fixed and random effect) linear models. There was no significant difference between each group's contours in terms of three-dimensional coordinates. However there was a significant difference between each group's contours in terms of the tonsillar volume (P<0.0001). Pre- and postcontrast CT can be used to identify the location of canine tonsils with reasonable agreement between trained observers. Discrepancy in tonsillar volume between groups of trained observers may affect RT treatment outcome.

How Do We Evacuate Stool? Insights From Combined High-Resolution Anorectal Manometry With Defecography

Introduction: The sense of incomplete evacuation is a feature of a defecatory disorder- however the mechanism of evacuation is not well understood. The aim of this study was to use simultaneous barium defecography and high resolution anorectal manometry (HRAM) to elucidate the mechanism of defecation in patients and controls Methods: Simultaneous seated HRAM and defecography (using180ml barium paste) were performed in 26 constipated women and 22 asymptomatic controls. Anal diameter and rectal pressures during evacuation and percentage of barium emptied, and the rectoanal pressure gradient during evacuation were calculated. Values less than 25th percentile for controls was considered abnormal. Results: Healthy women evacuated 80% of barium paste (median, IQ range-18-90%) while patients evacuated 21% (0-70%). Five controls and 12 patients evacuated < 18% of barium (25th percentile for controls). They were classified as “poor-evacuators” or PE); of these 9 had an abnormal balloon expulsion test (>60 seconds). The rest were classified as “adequate evacuators” (AE). Rectal and anal pressures increased initially during evacuation in all women. Thereafter, anal pressures declined, but the rectoanal pressure gradient exceeded 0 mm Hg only in AEs, enabling evacuation in this group. Rectal pressure at the onset of evacuation (median 87 vs 47mmHg, p=0.1) and anal diameter during evacuation (13 vs 0mm, p=0.002) was greater in AEs than PEs. Among AEs, a moving average of recto-anal pressure gradients (median = 4.2 mmHg) was positive (>0 mm Hg) for a median duration of 5s, which is 60% of the median duration of evacuation (8.5s). Among constipated PEs, disturbances were inadequate rectal pressure (4 patients) or impaired anal relaxation (8 patients). In a multivariate linear regression model, the rectoanal gradient, average anal canal diameter, and duration of anal relaxation during evacuation explained 40% of the variation in percent of barium emptied (p=0.0001). Conclusion: Adequate evacuation of barium (≥18%) is characterized by an initial simultaneous increase in rectal and anal pressure followed by anal relaxation. Conversely, either an inadequate increase in rectal pressure or in anal diameter during evacuation leads to incomplete evacuation. Not all women who have poor evacuation are symptomatic. The simultaneous increase in rectal and anal pressures during evacuation may be mediated by a reflex induced by increased abdominal pressure. Simultaneous defecography with HRAM may be useful in the clinical evaluation of chronic constipation.

Radiographic localisation of the entheses of the equine stifle

Injury to the tendons and ligaments of the equine stifle is a common cause of lameness in horses. Individual radiographic localisation of each tendon and ligament of the stifle has not been previously reported or demonstrated in multiple radiographic projections. To create a series of radiographs identifying the origins and/or insertions of the tendons and ligaments of the equine stifle. Descriptive study of radiographic anatomy. The location of all entheses were determined by gross dissection. The proximal tibia and fibula, distal femur, patella and menisci were isolated from one horse and used as a template. A series of 4 radiographs was obtained with each enthesis identified with barium paste. The radiographic landmarks for each enthesis were described and the best projection(s) for evaluation of each structure of interest identified. Forty-eight radiographic images were produced that demonstrated the best radiographic projections to define each enthesis. Radiography is the imaging modality most frequently used to evaluate the equine stifle. The images presented here will serve as a guide for evaluating radiographs of the equine stifle, particularly identifying avulsions and enthesopathies of ligamentous and tendinous origins and insertions.

Influence of body posture on defecation: a prospective study of "The Thinker" position.

We hypothesized that bending the upper body into what we have termed "The Thinker" position facilitates defecation.This study aimed to assess the influence of "The Thinker" position on defecation. This is the prospective single-group study. Patients who could not evacuate the paste in normal sitting position on cinedefecography between January and June 2013 were enrolled in this study. Cinedefecography was first performed in the sitting position; if the patient was unable to evacuate the paste, images were obtained in "The Thinker" position. Patients who were able to evacuate the paste were excluded from the study. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining in both positions were measured from the radiographs. Twenty-two patients unable to evacuate the barium paste underwent cinedefecography in "The Thinker" position. Seventeen patients were female, average age of 56 (range 22-76) years. "The Thinker" position had significantly wider ARA than the sitting position (113° vs. 134°, respectively; p=0.03), larger PPD (7.1 vs. 9.3cm, respectively; p=0.02), and longer PRL (12.9 vs. 15.2cm, respectively; p=0.005) during straining. Eleven patients could evacuate completely in "The Thinker" position. "The Thinker" position seems to be a more efficient method for defecation than the sitting position. This technique may be helpful when retraining patients with constipation.

Swallowing outcomes following primary surgical resection and primary free flap reconstruction for oral and oropharyngeal squamous cell carcinomas: a systematic review protocol

Swallowing outcomes following primary surgical resection and primary free flap reconstruction for oral and oropharyngeal squamous cell carcinomas: a systematic review protocol

Clinical Use of Computed Tomography and Surface Markers to Assist Internal Fixation Within the Equine Hoof

To describe clinical use of computed tomography (CT) and hoof surface markers to facilitate internal fixation within the confines of the hoof wall. Retrospective case series. Horses (n = 16) that had CT-guided internal fixation of the distal phalanx (DP) or distal sesamoid bone (DSB). Drill bit entry point and direction were planned from CT image series performed on hooves with grids of barium paste dots at proposed entry and projected exit sites. Post-implantation CT images were obtained to check screw position and length as well as fracture reduction. Imaging, reduction, and surgical and general anesthesia times were evaluated. Outcome was recorded. Screw position and length were considered near optimal in all horses, with no consequential malposition of bits or screws. Fracture reduction was evident in all cases. Preoperative planning times (at least 2 CT image acquisitions and grid creation) ranged from 10 to 20 minutes. Surgery time ranged from 45 to 90 minutes (mean, 61 minutes) and general anesthesia time ranged from 115 to 220 minutes (mean, 171 minutes). The combination of CT and surface marker grids allowed accurate positioning of screws in clinical DP and DSB fractures. The technique was simple and rapid. An aiming device is useful for the technique.

Balloon Dilation in Sporadic Inclusion Body Myositis Patients with Dysphagia

Here, we describe balloon catheter dilation at the upper esophageal sphincter (UES) in three sporadic inclusion body myositis (s-IBM) patients with dysphagia. Initially, we performed IVIg therapy, and, three months later, switched to balloon dilation therapy. A 12-Fr balloon catheter was inserted from the mouth under fluoroscopy and the balloon inflated at the UES. The catheter was pulled back and re-inserted several times. We examined videofluoroscopy (VF) and pressure at the oropharynx, hypopharynx and UES using computed pharyngoesophageal manometry (CPM). Before both therapies, the VF study revealed a very small amount of barium paste passing through the UES. After balloon dilation therapy, as well as IVIg, subjective complaints of dysphagia disappeared and the VF study revealed an increased amount of barium paste passing through the UES. We conclude that balloon dilation therapy is a complementary method for conventional dysphagia therapies in s-IBM patients with dysphagia.

Variability of Oral and Pharyngeal Transit Between Two Consecutive Swallows in Chagas' Disease.

BackgroundChagas’ disease causes dysphagia, regurgitation and retention of food in the esophageal body. Patients have longer pharyngeal clearance, which might be consequent of the involvement of the central nervous system or an adaptation to the esophageal transit impairment. If there is central nervous system involvement by the disease, we expect a larger difference in the oral and pharyngeal phases of swallowing between two consecutive swallows than that seen in controls. Our objective was to evaluate the difference of oral and pharyngeal transit duration between two consecutive swallows in patients with Chagas’ disease compared with controls.MethodsBy videofluoroscopy, the duration of oral and pharyngeal transit, pharyngeal clearance, upper esophageal sphincter transit, hyoid movement and oropharyngeal transit was measured in 17 patients with Chagas’ disease and 15 asymptomatic volunteers. Each subject swallowed in duplicate and in sequence 5 mL and 10 mL of barium liquid and 5 mL and 10 mL of barium paste boluses. The differences were calculated between the two swallows of each volume and consistency in patients and controls.ResultsThere were no differences between controls and patients in the values of the differences between the two consecutive swallows, except for the hyoid movement duration of the 5 mL liquid bolus, causing a higher difference in controls than in patients.ConclusionOral and pharyngeal transit variation between two consecutive swallows is similar between patients with Chagas’ disease and controls, which suggests that the longer pharyngeal clearance duration previously described is not a consequence of impairment of the central nervous system control of swallowing.

Successful radiofrequency ablation of long-standing persistent atrial fibrillation in a patient with esophageal achalasia

A 54-year-old man was referred for ablation of symptomatic drug-refractory long-lasting persistent atrial fibrillation. His past medical history was negative for cardiac disease but included a diagnosis of esophageal achalasia. The patient underwent an ablation procedure, guided by barium esophagram, including isolation of the pulmonary veins, ablation of complex fractionated left atrial electrograms recorded on the sep-tal wall and, finally, linear ablation of the cavo-tricuspid isthmus. The ablation procedure was performed with multielectrode ablation catheters using duty-cycled bipolar/unipolar radiofrequency energy. During 6 months of follow-up no recurrences of atrial fibrillation were documented. The reported case demonstrates how an ablation procedure for long-standing persistent AF may be safely performed even in a patient presenting with a achalasia, outlining the mega-esophagus position with a simple barium paste.

How to Interpret a Functional or Motility Test - Defecography

Defecography evaluates in real time the morphology of rectum and anal canal in a physiologic setting by injection of a thick barium paste into the rectum and its subsequent evacuation. Because of its ability of structural and functional evaluation, defecography is primarily performed for work up of patients with longstanding constipation, unexplained anal or rectal pain, residual sensation after defecation or suspected prolapse. Technique and interpretation of this examination are outlined in this review.

Prospective Multicenter Trial Comparing Echodefecography With Defecography in the Assessment of Anorectal Dysfunction in Patients With Obstructed Defecation

Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations. This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation. Multicenter, prospective observational study. Women with symptoms of obstructed defecation. Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela). Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans. The κ statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele. Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6-23); median age, 53.4 (range, 26-77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; κ = 0.61; 95% CI = 0.48-0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (κ = 0.79; 95% CI = 0.57-1.0). Intussusception was associated with rectocele in 28 patients for both methods (κ = 0.62; 95% CI = 0.41-0.83). There was substantial agreement for anismus (κ = 0.61; 95% CI = 0.40-0.81) and for rectocele combined with anismus (κ = 0.61; 95% CI = 0.40-0.82). Agreement for grade III enterocele was classified as almost perfect (κ = 0.87; 95% CI = 0.66-1.0). Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used. Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

Immediate Effects of Thermal–Tactile Stimulation on Timing of Swallow in Idiopathic Parkinson’s Disease

Oropharyngeal dysphagia frequently presents in people with idiopathic Parkinson's disease (IPD). Clinical sequelae of dysphagia in this group include weight loss and aspiration pneumonia, the latter of which is the leading cause of hospital admissions and death in IPD. Thermal-tactile stimulation (TTS) is a sensory technique whereby stimulation is provided to the anterior faucial pillars to speed up the pharyngeal swallow. The effects of TTS on swallowing have not yet been investigated in IPD. The aim of this study was to investigate the immediate effects of TTS on the timing of swallow in a cohort of people with IPD and known oropharyngeal dysphagia. Thirteen participants with IPD and known dysphagia attended for videofluoroscopy during which standardised volumes of liquid barium and barium paste were administered preceding and immediately subsequent to TTS. The immediate effects of TTS on swallowing were examined using oral, pharyngeal, and total transit times and pharyngeal delay times as outcome measures. TTS significantly reduced median pharyngeal transit time on fluids (0.20 s, 95% CI = 0.12-0.28, p = 0.004) and on paste (0.3 s, 95% CI = 0.08-0.66, p = 0.01). Median total transit time was also reduced on fluids (0.48 s, 95% CI = 0.00-1.17, p = 0.049) and on paste (0.52 s, 95% CI = 0.08-1.46, p = 0.033). Median pharyngeal delay time was reduced on fluids (0.20 s, 95% CI = 0.12-0.34, p = 0.002). TTS did not significantly alter median oral transit time on either fluid or paste consistency. TTS significantly reduced temporal measures of the pharyngeal phase of swallowing in the IPD population. Significant results may be attributed to the role of sensory stimulation in improving motor function in IPD, with emphasis on the impaired glossopharyngeal and vagus nerves in this population. It is still unclear whether these findings will translate into a clinically beneficial effect.

Colonic total and segmental transit times in healthy Italian adults

This study was done to determine colonic transit times in healthy Italian adults. Institutional review board approval and informed patient consent were obtained. Colonic segmental radiopaque markers were counted and transit times calculated in 36 healthy subjects studied using a technique involving daily radiopaque marker ingestion and single radiological visit, with oral administration of 8-10 ml of a thick barium paste as a colonic trace for the marker count. Two independent radiologists counted the marker twice. Observer agreement was assessed using comparison analysis. There was very good observer agreement for the segmental marker counts. The upper limit for colonic transit times was: 45.6 h in the colon as a whole, 31.2 h in the right colon, 19.2 h in the left colon and 16.8 h in the rectosigmoid. Colonic transit times were not gender-related. In healthy subjects, a barium trace affords optimal visibility of the different colonic segments, enabling accurate location of all markers and thus providing an anatomy-related, repeatable and reproducible fluoroscopic segmental marker count. We suggest that the reference values for normal colonic transit times could be adopted for Italian people irrespective of gender.

Massive Hiatal Hernia and Thoracic Stomach Illustrated by Barium Swallow During Left Atrial Catheter Ablation for Atrial Fibrillation

Left atrial radiofrequency catheter ablation was planned in a 68-year-old man with chronic atrial fibrillation refractory to medical therapy and cardioversion. After the transseptal puncture and before conscious sedation, the patient was asked to swallow 5 mL of barium paste (E-Z-EM, Lake Success, NY) so that the location of the esophagus in relation to the left atrium could be visualized.1 The esophagogram delineated a massive hiatal hernia that resulted in an intrathoracic stomach that was in apposition to the entire posterior left atrium (Figure 1). Because of this …

Radiographic Measurements of the Intercondylar Notch: Are They Accurate?

The purpose of this study was to evaluate the accuracy of radiographic measurements of the intercondylar notch. Radiographs of 10 cadaveric knees were obtained via the 3 methods reported in the literature (Holmblad 45 degree, Holmblad 70 degree, and Rosenberg views), after removal of the patella and surrounding soft tissues. The anterior outlet of the intercondylar notch of each knee was then outlined with barium paste, and radiography was repeated. A total of 1,770 radiographs were obtained for the 10 knees. Six measurements of the anterior outlet of the intercondylar notch were made from each radiograph and corrected for magnification. Finally, the notch width index was calculated. Caliper measurements were subsequently made of each knee to compare the size of the anterior outlet of the notch with the radiographic measurements with and without barium. There were statistically significant differences in caliper measurements compared with all but one radiographic measurement obtained from the Holmblad 45 degree, Holmblad 70 degree, and Rosenberg views. The radiographs taken with barium outlining the intercondylar notch clearly showed the inability to accurately identify the anterior outlet on radiographs. Even under optimal conditions, correcting for technique, projection, and magnification, most of the radiographic measurements of the anterior outlet of the intercondylar notch were inaccurate. The notch width index calculated from the Holmblad 70 degree view appears to be the only accurate radiographic measurement. This controlled laboratory study shows that clinicians should use caution when basing conclusions on radiographic measurements of the intercondylar notch.

Esophageal Diverticulum Illustrated by Barium Swallow During Left Atrial Catheter Ablation for Atrial Fibrillation

Left atrial radiofrequency catheter ablation guided by a 3-dimensional electroanatomic mapping system (CARTO, Biosense-Webster, Diamond Bar, Calif) was performed in a 67-year-old woman with paroxysmal atrial fibrillation. To avoid delivery of radiofrequency energy near the esophagus, the patient was asked to swallow 5 cm3 of barium paste (E-Z-EM, Lake Success, NY) before conscious sedation, as described previously.1 …

Dysphagia and Hoarseness Associated with Painless Aortic Dissection: A Rare Case of Cardiovocal Syndrome

Cardiovocal syndrome (Ortner's syndrome) is characterized by left recurrent laryngeal nerve palsy due to cardiovascular disease, but in rare cases it can also be caused by aortic dissection. An 81-year-old man with hypertension was admitted to the hospital with aspiration pneumonia. He had been developing progressive dysphagia and hoarseness for several months before admission. A videofluoroscopic swallowing study showed supraglottic penetration with barium paste and liquid. Laryngoscopy and electromyography revealed left vocal cord palsy caused by left recurrent laryngeal neuropathy, and a contrast-enhanced chest CT revealed dissection of the aortic arch.

Prediction of Findings at Defecography in Patients with Genital Prolapse

This study was designed to investigate the ability of defecography to identify abnormalities of the anterior and posterior compartments that might be associated with genital prolapse and require repair during prolapse surgery. Defecography is a technique that assesses the defecation process by recording the expulsion of a barium paste used as a substitute for feces. Study subjects were 82 patients with descensus uteri stages 2-4 who were enrolled in a trial comparing vaginal and abdominal prolapse surgery. All patients underwent a preoperative evaluation, including urogynecologic interview, physical examination, an assessment of genital prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q), and a rectal examination. In addition, 1 to 3 weeks before surgery, study subjects completed a questionnaire about defecation and micturition symptoms. One to 3 months before surgery, defecography was performed according to standard techniques. The rectum is filled with barium paste, which is expelled while the patient is sitting on a radiolucent commode. The process of defecation is recorded on video. The results of defecography were analyzed by 2 physicians and were considered abnormal when an enterocele or rectal intussusception was identified. In this study, an enterocele was defined as a peritoneal sac that is herniated along the anterior rectal wall below the vaginal apex. A rectal intussusception was defined as the presence of a ring pocket formed by the rectal wall folding in toward the rectal lumen. The results of preoperative evaluation, including physical findings at pelvic examination, reported defecation and micturition symptoms, and patient history, were examined for their ability to predict the presence of abnormalities in defecography. Abnormal defecography results were seen in 26 (32%) of the 82 study subjects. Both an enterocele and rectal intussusception were found in 6 (7%) patients. Univariate analysis was performed of variables associated with the presence of rectocele or rectal intussusception, including details of the patient's medical history, results of genital prolapse assessment, and reported defecation and micturition symptoms. A history of pelvic surgery, the degree of genital prolapse as measured by POP-Q (Ap), and a history of constipation emerged as predictors of abnormal defecography. The results were similar after multivariate analysis. Using these 3 variables, the authors developed a model for predicting an abnormal defecography. With the model, a score is assigned to each variable and the total computed using the formula: 3 + 3 X history of abdominal or pelvic surgery + Ap (in centimeters) + 3 X constipation. As an example, for an imaginary patient with no history of pelvic surgery, with a rectocele descending to 1 cm above the hymen (Ap = -1 cm), who reports constipation, the formula would give a score of(3+3×0+-1+3×1). Table 1 shows the results from this series of patients using this model.