Double-contrast Research Articles

A perforated duodenal ulcer presenting as inferior lead ST elevation following amphetamine use

Typical symptoms of duodenal ulcers include epigastric pain, nausea, vomiting, chest pain and shortness of breath. Here we present the case of a 39-year-old man who had a sudden onset of chest and epigastric pain following the use of recreational amphetamines. There were ST changes in the inferior leads of his electrocardiogram, indicating the possibility of a myocardial infarction. Following double contrast computed tomography of the abdomen and an urgent laparotomy, a diagnosis of a perforated duodenal ulcer was made. We discuss the aetiologies, presentation, investigation and treatment of the disorder, and make recommendations on the management.

Colorectal Cancer Screening by Double Contrast Barium Enema in Thai People

The incidence of colorectal cancer (CRC) has been increasing in Asian countries including Thailand. Double contrast barium enema (DCBE) is one of the investigation tools used in CRC screening. This study aimed to determine the incidence of colorectal neoplasm detected at screening by DCBE in Thai people. The computerized radiology database of screening DCBE in Thai adults between June 2009 and October 2011 at the Faculty of Medicine, Siriraj Hospital, was reviewed. DCBE examination performed in a surveillance program after curative CRC resection or the removal of colorectal polyps was also considered as a screening DCBE. A total of 819 screening DCBEs performed during this 28-month period were analyzed. The mean age of patients was 59.8 ∓ 13.6 years. Of the total, 467 (57%) were male. A family history of CRC and a previous history of curative CRC resection or polyp removal were noted in 34 patients (4%) and 124 patients (15%), respectively. A total of 31 patients (3.8%; 95%CI = 2.7%-5.3%) were reported to have colorectal polyp or mass demonstrated on DCBE. Of these, follow-up endoscopy was performed in 20 cases (65%). According to pathological results, the incidence of advanced adenoma and CRC detected at screening DCBE was 0.7% (95%CI = 0.3%-1.6%; n=6) and 0.4% (95%CI = 0.1%-1.1%; n=3), respectively. The screening DCBE performed in Thai adults had a diagnostic yield of 0.7% for advanced adenoma and 0.4% for CRC.

Cáncer de colon y recto

Colorectal cancer (CRC) is today the most frequent type of cancer, with a higher incidence in men. 90% of cases are diagnosed over the fifth decade of life. Positive familial history (familial CRC, Lynch syndrome or familial adenomatous polyposis [FAP]) as well as personal previous CRC, colonic adenomas or colonic inflammatory bowel disease (IBD) represent the main risk factors for CRC. Adenoma-adenocarcinoma sequence, along with APC gene mutations, is the best known colorectal carcinogenetic pathway, although there are other pathways implicated namely DNA mismatch repairing genes mutations, in Lynch syndrome, or hypermetilation epigenetic phenomenons characteristic of serrated lesions. Clinical symptoms depend on anatomic localization of CRC, being rectal bleeding the most frequent one. Colonoscopy is considered the gold standard for colorectal pathology and has a higher performance than virtual colonoscopy or double contrast barium enema. Screening programs allow early CRC detection but also removal of premalignant colonic lesions such as adenomas, decreasing CRC incidence. Biennial fecal occult blood test (FOBT) or colonoscopy every ten years are the most accepted screening methods although there are others.

Diagnostic yield of flexible sigmoidoscopy and CTC

A recent study demonstrates that concurrent flexible sigmoidoscopy in conjunction with CT colonography (CTC) does not improve the diagnostic yield for left-sided colorectal neoplasia compared with CTC alone. This study provides further evidence that CTC is not only more sensitive than the double contrast barium enema, but could be superior to endoscopy for initial evaluation.

Chronic diverticulitis vs. colorectal cancer: findings on CT colonography

The purpose of this update article is to evaluate findings on CT colonography in patients with chronic diverticulitis and to compare the findings in patients with colorectal carcinoma. Different morphological criteria retrieved from a literature review were retrospectively analyzed in a series of 13 patients with proven chronic diverticulitis. The findings were compared with a series of 10 patients with colorectal carcinoma. Overall, the findings in chronic diverticulitis resemble the findings in acute diverticulitis. The advantage of virtual CT colonography in differentiating both entities relies in the combination of morphological features previously described on axial computed tomography and double contrast barium enema. The single strongest morphological feature pointing towards the diagnosis of chronic diverticulitis is the presence of diverticula in the affected segment. In the presence of diverticula in the affected segment, a long segment (≥10cm), thick fascia sign without adenopathies, mild bowel wall thickening, tapered margins, and distorted but preserved mucosal folds are likely to further improve accuracy of diagnosing chronic diverticulitis. The single strongest morphological sign to differentiate chronic diverticulitis from colorectal cancer is the presence of diverticula in the affected segment.

Imaging the temporomandibular joint by double contrast cone-beam computed arthrotomography

Cone-beam computed tomography (CBCT) has developed as a newly computerized radiographic technique in dentistry and this offers non-distorted computer aided imaging of maxillofacial region. This new technique was applied for the temporomandibular joint (TMJ) imaging with encouraging results. CBCT showed high radiological performance to detect intra-articular lesion of the TMJ, providing significant differences in the comparison with conventional transcranial arthrogram. Those clear images of TMJ can help clinicians to understand the lesion of the TMJ and its reliable information will have added greatly positive impact on the treatment modalities. In this paper, the new technique to visualize intra-articular region in the TMJ is introduced comparing the results with those by conventional method. Fibrous adhesion in the superior joint space was the most frequently observed finding by CBCT.

A novel, cost-effective strategy for the screening of colorectal cancer with higher patient compliance.

407 Background: Routine screening methods for colorectal cancer (CRC) have poor patient compliance and low sensitivity for early stages. The sensitivity rates are 19, 71, 76, and 83% for Fecal Occult Blood test (FOBT), stool DNA test, colonoscopy/sigmoidoscopy, and double-contrast barium enema; respectively. Biological markers have also been tested including CEA (sensitivity of 38.7%); however, its utility in CRC screening is limited due to low sensitivity. Onko-Sure is an FDA-cleared blood test for monitoring of CRC treatment/recurrence. It measures the accumulation of Fibrin/Fibrinogen Degradation products in the serum using anti-DR-70 antibody. The objective was to determine whether DR-70 and CEA combination can improve the sensitivity such that it can be used as a cost-effective alternative to current screening methods yet with a higher patient compliance. Methods: A total of 564 serum samples were retrospectively obtained from a serum bank in two arms: confirmed healthy control (n=298) and biopsy-confirmed CRC (n=266) groups. The samples were tested for DR-70 and CEA. Results: The results showed sensitivity of 58.2% and specificity of 59.83% for DR-70 and CEA combined. The sensitivity for the combined test was 55.5% higher than that of CEA alone. A consistent improvement of sensitivity for the combined usage relative to CEA alone was observed with an increase of 73%, 108%, 58% and 18% in CRC stage I, II, III and IV; respectively. The sensitivity of the combined test was 48%, 47%, 57% and 98% for stages I, II, III and IV. Conclusions: Combining DR-70 and CEA tests showed a significant clinical advantage in CRC screening over using each marker alone. The sensitivity improvement was highest for stages I/II, which has important implications in patient treatment options, prognosis and survival rate due to this early detection. With a 3 times higher sensitivity for early stage CRC compared to using FOBT, this approach should improve the CRC early stage diagnosis. Such early stage detection is less likely using routine approaches for CRC screening because of low sensitivity and low patient compliance.

Core/Shell Magnetite/Bismuth Oxide Nanocrystals with Tunable Size, Colloidal, and Magnetic Properties

New inorganic hybrid nanoparticles integrating different materials in a core/shell structure of iron and bismuth oxides have been synthesized by a simple aqueous route. The method is based on the precipitation of an Fe(II) salt in the presence of bismuth(III) cations in a mild oxidant and leads to highly uniform and crystalline magnetic nanoparticles with sizes in the range between 8 and 30 nm. Bismuth in proportions between 1 and 20% atomic ratio of Bi to Fe acts as surfactant being accumulated at the nanoparticle surface, controlling particle size and colloidal properties. Evidence of a core/shell structure is revealed by X-ray photoelectron spectroscopy analysis with bismuth enrichment in an outer shell. This robust material with very long chemical stability and resistance to degradation, good magnetic properties, and high density due to the presence of bismuth ions is expected to have important applications in diagnosis as a new double contrast agent for both magnetic resonance imaging and computed tomography.

Comparison between CT Colonography and Double-Contrast Barium Enema for Colonic Evaluation in Patients with Renal Insufficiency

ObjectiveTo compare the CT colonography (CTC) and double-contrast barium enema (DCBE) for colonic evaluation in patients with renal insufficiency.Materials and MethodsTwo sequential groups of consecutive patients with renal insufficiency who had a similar risk for colorectal cancer, were examined by DCBE (n = 182; mean ± SD in age, 51 ± 6.4 years) and CTC (n = 176; 50 ± 6.7 years), respectively. CTC was performed after colon cleansing with 250-mL magnesium citrate (n = 87) or 4-L polyethylene glycol (n = 89) and fecal tagging. DCBE was performed after preparation with 250-mL magnesium citrate. Patients with colonic polyps/masses of ≥ 6 mm were subsequently recommended to undergo a colonoscopy. Diagnostic yield and positive predictive value (PPV) for colonic polyps/masses, examination quality, and examination-related serum electrolyte change were retrospectively compared between the two groups.ResultsBoth the CTC and DCBE were positive for colonic polyps/masses in 28 (16%) of 176 and 11 (6%) of 182 patients, respectively (p = 0.004). Among patients with positive findings, 17 CTC and six DCBE patients subsequently underwent a colonoscopy and yielded a PPV of 88% (15 of 17 patients) and 50% (3 of 6 patients), respectively (p = 0.089). Thirteen patients with adenomatous lesions were detected in the CTC group (adenocarcinoma [n = 1], advanced adenoma [n = 6], and non-advanced adenoma [n = 6]), as compared with two patients (each with adenocarcinoma and advanced adenoma) in the DCBE group (p = 0.003). Six (3%) of 176 CTC and 16 (9%) of 182 DCBE examinations deemed to be inadequate (p = 0.046). Electrolyte changes were similar in the two groups.ConclusionIn patients with renal insufficiency, CTC has a higher diagnostic yield and a marginally higher PPV for detecting colorectal neoplasia, despite a similar diagnostic yield for adenocarcinoma, and a lower rate of inadequate examinations as compared with DCBE.

Fatal Rectal Perforation Following Double Contrast Barium Enema

Double-contrast barium enema (DCBE) is a widely used diagnostic tool for colorectal disorders, providing a relatively cheap and less invasive alternative to invasive procedures such as colonoscopy. Complications due to DCBE can be fatal in a small number of cases. Rectal perforations to the intra-peritoneal or retro-peritoneal space are the most severe and life-threatening complications where immediate diagnosis and treatment are essential. We report the case of a 72-year-old male admitted to the emergency department with dyspnea, altered mental status and swelling in the neck 15 minutes after DCBE. Upright chest X-ray revealed sub-diaphragmatic air with subcutaneous emphysema, and computed tomography revealed air in the deep neck tissue and abdominal cavity, accompanied by pneumothorax and pneumomediastinum. This case demonstrates the importance of chest pain, neck swelling and neurological symptoms after DCBE as signs of possible serious complications that should alert emergency physicians.

Factors Associated with Colorectal Cancer Screening of Blue-Color Workers

Purpose: Even though the incidence of colorectal cancer (CRC) has increased in Korea, the colorectal cancer screening (CRCS) is lower than that of other cancer screenings. The purpose of this study was to identify CRCS rate and to predict factors in blue-color workers. Methods: A descriptive survey design was employed. Data were collected with 327 workers, recruited from 32 companies, aged 40 and over using questionnaire from August 2010 to January 2011. Collected information included CRCS, demographic characteristics, job characteristics, health behaviors, and interpersonal relationship. The definition of CRCS included fecal occult blood test (FOBT), colonoscopy, or double contrast barium enema (DCBE). Results: Among 94 workers receiving CRCS, workers having FOBT were 37, colonoscopy were 28, and DCBE was 6 in the past. Workers who aged over 50 (OR=2.30, 95% CI=1.11-4.77), middle school educated (OR=0.30, 95% CI=0.14-0.65), less working hours (OR=0.98, 95% CI=0.96-0.99), and had family members who carried out regular cancer screening (OR=1.89, 95% CI=1.01-3.55) were more likely to perform CRCS. Conclusion: The findings suggest that the information and notice about CRCS to increase screening uptake, providing the accessible screening method, and involving company administrators or health managers might be useful to increase the CRCS rate in workers.

Flexible Sigmoidoscopy Does Not Significantly Increase Polyp and Cancer Detection Yield when Used to Supplement CT Colonography

Background and Aims: Flexible sigmoidoscopy (FS) increases polyp and carcinoma detection in addition to double contrast barium enema (DCBE). However, CT colonography (CTC) is now the preferred technique. Our aim was to explore whether FS increases polyp and carcinoma detection rates when used in addition to CTC. Methods: Patients who underwent FS and CTC between 2007 and 2009 were included and data were collected from patient records. Yields of polyp, adenoma and carcinoma detection were calculated for FS and CTC. Results: In a cohort of 294 patients, CTC detected 36 patients with carcinomas while FS detected 28. One rectal cancer not seen on CTC was diagnosed by FS. Polyps were seen by CTC in 66 and FS in 45 patients. In 5 patients FS found polyps that were not detected by CTC; 3 of which were small adenomas. FS detected extra adenomas or carcinomas in 1.36% (4/294). Adding FS to CTC neither increased the cancer nor the polyp detection yield significantly. Conclusions: This first study investigating the use of FS in addition to CTC detected little additional pathology. The routine use of FS as a supplement to CTC for adenoma and carcinoma detection is of questionable utility.

Magnesium sulfate as an oral contrast medium in magnetic resonance imaging of the small intestine

To explore the use of magnesium sulfate (MgSO4) as an oral contrast medium (CM) in MRI of the small intestine. By comparing MgSO4 SNRs at different concentrations, we determined that 2.5% MgSO4 is the ideal concentration for small bowel MRI. Twenty volunteers underwent MRI after drinking 2.5% MgSO4. Thirty-one patients with clinical suspicion of small intestinal pathology underwent both MRI and the air-barium contrast examination. The patient's tolerance, side effects and complications were noted. 2.5% MgSO4 can decrease the absorption of water and fully fill the enteric cavity, thereby increasing the contrast between the intestinal wall and lumen and facilitating radiographic examination of the small bowel. The mean diameter of the small intestine was 19.8±1.21 mm in the 20 volunteers consuming 2.5% MgSO4 and 12.7±0.84 mm in the 20 volunteers given water. There was a significant difference (P<0.05) between the diameters of the small intestine of the two groups. But there were no significant differences (P>0.05) in side effects between MgSO4 and water groups. Small intestinal MRI was successfully performed in all 31 patients, who were also examined by the double contrast barium, which gave almost identical diagnoses to MRI in all cases except for 1 patient with small intestinal hemorrhage. MRI with 2.5% MgSO4 can demonstrate intestinal abnormalities. Therefore, 2.5% MgSO4 solution is an ideal oral CM for small bowel MRI.

Equivalence of double and single wave vector diffusion contrast at low diffusion weighting

Multiple pulsed field gradient diffusion sequences have received renewed interest in recent years as a potentially new type of MRI contrast. This attention is largely a result of the ability to measure pore sizes using low-amplitude diffusion gradients, and to distinguish between macroscopically isotropic systems of anisotropic pores and systems of isotropic pores. In this article, it is shown that, under many circumstances, the same type of information can be obtained by combining two or more standard single pulse diffusion-weighted experiments acquired at different diffusion times. Similarly, information from multiple pulsed field gradient diffusion can be reconstructed from several single pulsed diffusion experiments. This possibility is rooted in the information contained in the time dependence of the diffusion tensor, which provides a complete description of the diffusion-weighted MR signal at low gradient amplitudes. The new information arising at the fourth order in the cumulant expansion is discussed. The coupling of the wave vectors at long mixing times is found to be controlled by the variance of the single pore mean displacement tensor. In particular, a discussion is given concerning the way in which the sensitivity of the fourth-order term to the pore shape anisotropy is modulated by pore orientation anisotropy and vanishes in coherently oriented homogeneous ensembles. For macroscopically isotropic systems, a new index of pore shape anisotropy is proposed.

C-A5-02: Is Tailored Screening for Colorectal Cancer based on Gender and Race Cost-Effective?

Thomas Flottemesch, PhD1 and the Prevention Priorities Study Team1 1HealthPartners

Comparison of transvaginal sonography and double‐contrast barium enema for diagnosing deep infiltrating endometriosis of the posterior compartment

To compare the diagnostic accuracy of transvaginal sonography (TVS) and double-contrast barium enema (DCBE) in the preoperative detection of deep infiltrating endometriosis (DIE) of the posterior compartment. This was a prospective study of 69 consecutive patients with results of pelvic examination or symptoms suggestive of DIE of the posterior compartment. TVS and DCBE were performed before surgery by two groups of physicians specialized in endometriosis, each blinded to the results of the other technique. Imaging data were compared with histopathologic analysis of the resected specimen (gold standard). Sensitivity, specificity, positive and negative predictive values and test accuracies were calculated for both imaging modalities. Sixty seven of the 69 women had a nodule of DIE confirmed at laparoscopy and histopathologic examination. TVS diagnosed DIE in 57 (85%) of these patients, while DCBE revealed the presence of the lesion in 24 (36%) women. For the diagnosis of posterior DIE, TVS and DCBE had, respectively, a sensitivity of 85% and 36%, specificity of 100% and 100%, positive predictive value of 100% and 100%, negative predictive value of 17% and 4% and accuracy of 85.5% and 38%. In patients with pure bowel DIE the sensitivity was 91% and 43%, specificity was 100% and 100%, positive predictive value was 100% and 100%, negative predictive value was 29% and 6% and accuracy was 91% and 45%, respectively. TVS has a much higher sensitivity than does DCBE in detecting the presence of posterior DIE and should thus be regarded as the imaging modality of choice when there is clinical suspicion of the disease.

Two-year Trends in Colorectal Cancer Screening After Switch to a High-deductible Health Plan

Recent health reform laws might accelerate high-deductible health plan (HDHP) growth. The impact of HDHPs on long-term colorectal cancer screening rates and low socioeconomic status (SES) members is unknown. We studied colorectal cancer screening rates among 1306 Health Maintenance Organization (HMO) members for 1 year before and 2 years after an employer-mandated switch to HDHPs, compared with 1306 propensity score-matched controls who remained in HMOs by employer choice. HDHP members had full coverage of fecal occult blood testing (FOBT) but colonoscopy, flexible sigmoidoscopy, and double-contrast barium enema were subject to $500 to $2000 annual deductibles. HMO members had full coverage of these tests. We used generalized estimating equations to adjust screening rates for member characteristics. We stratified analyses by SES. Overall colorectal cancer screening rates in the HDHP group relative to the control group trended down from baseline to the first and second follow-up years [ratios of change, 0.88, (95% confidence interval, 0.73 to 1.06) and 0.83, (0.69 to 1.00), respectively]. Low SES HDHP members experienced a statistically significant relative decrease in colonoscopy in both follow-up years [0.65, (0.48 to 0.88) and 0.59, (0.42 to 0.84), respectively] and a trend toward increased FOBT [1.26, (0.92 to 1.72) and 1.30, (0.95 to 1.77), respectively] to maintain stable overall colorectal cancer screening rates [1.01, (0.77 to 1.32) and 0.93, (0.71 to 1.22), respectively]. High SES members experienced less pronounced decrease in colonoscopy [0.89, (0.67 to 1.18) and 0.87, (0.62 to 1.21), respectively] but FOBT rates did not increase [0.83, (0.62 to 1.11 and 0.81), (0.60 to 1.11), respectively]. Switching to a HDHP was associated with a downward trend in overall colorectal cancer screening rates after 2 years. Low SES HDHP members maintained stable rates, but substituted FOBT for colonoscopy and other tests now more widely recommended. Further research should investigate whether such reduced adherence to screening guidelines adversely affects health outcomes.

Double contrast–enhanced ultrasonography for the preoperative evaluation of gastric cancer: A comparison to endoscopic ultrasonography with respect to histopathology

Background This study was designed to compare the accuracy of endoscopic ultrasound (EUS) with double contrast–enhanced ultrasound (DCUS) in the staging of gastric malignancies. DCUS is a transabdominal ultrasound technique using both intravenous and intraluminal contrast to enhance sonographic visualization. Methods This retrospective study included 162 patients with biopsy-proven gastric cancer who underwent DCUS and EUS preoperatively with the ultrasound results compared with the pathologic findings of the resected specimens. Results The overall accuracy of DCUS and EUS for tumor (T) staging was 77.2% and 74.7%, respectively . Comparison of ultrasound techniques for T staging revealed that DCUS was superior to EUS only for a tumor depth of T3 (chi-square, P = .025). Lymph nodes were staged correctly with DCUS and EUS in 78.4% and 57.4% of cases, respectively (chi-square, P = .001). Conclusions DCUS offers a noninvasive approach for the staging of gastric cancer. DCUS was comparable to EUS in tumor depth evaluation but offered an advantage in lymph node detection.

The Future of Radiology

It has been my good fortune to live and practice radiology during a long period of momentous change – to see the transformation of the discipline from a supportive service into a mainstream, essential branch of clinical medicine. I remember wearing red goggles to adapt my vision before performing fluoroscopy; observing the horrible, now thankfully obsolete, practice of ventriculography, which was considered advanced neuroradiology; and performing other, now rarely prescribed procedures, such as double-contrast barium enemas and intravenous pyelography. Witnessing the beginnings of interventional radiology, I suggested its name in an editorial.1 I also had the good fortune to see the introduction of computed tomography (CT) and a technology first known as nuclear magnetic resonance imaging. Together with fellow members of a committee of the American College of Radiology and editors of prestigious radiological journals, I took part in changing the name of the latter modality to MRI, freeing it from threatening implications. Looking back on these experiences, one lesson stands out above all: Innovation and transformation never cease. Looking forward, it is clear that radiology, along with the rest of medicine, is now undergoing further momentous changes that will affect the future of all those already practicing as well as those yet to start their careers.2

Manganese kinetics demonstrated double contrast in acute but not in chronic infarction in a mouse model of myocardial occlusion reperfusion

Manganese (Mn(2+)) is considered as a specific MRI contrast agent that enters viable cardiomyocytes through calcium pathways. Compared to extracellular gadolinium based contrast agents, it has the potential to assess cell viability. To date, only information from the washout phase after recirculation has been used for the detection and characterization of myocardial infarct. This study showed for the first time that in a mouse model of coronary occlusion-reperfusion, Mn(2+) wash-in kinetics are different at 24 h after surgery (acute infarction) than at eight days after surgery (chronic infarction). A fast but transient entry of Mn(2+) into the acute infarct area led to a double contrast between infarct and remote areas, whereas entry of Mn(2+) into the chronic infarct area remained reduced compared to remote regions during both wash-in and washout phases. The main hypothesis is that extracellular space is largely enhanced in acute infarction due to cell membrane rupture and interstitial edema, whereas scar tissue is densely composed of collagen fibers that reduce the distribution volume of free Mn(2+) ions. In addition to its ability to accurately depict the infarct area during the redistribution phase, Mn(2+) is also able to discriminate acute versus chronic injury by the observation of double-contrast kinetics in a mouse model of ischemia reperfusion.