Double-contrast Barium Examination Research Articles

Clinicopathological characteristics of clinical early gastric cancer in the upper-third stomach

To elucidate the clinicopathological characteristics of clinically early gastric cancer in the upper-third stomach and to clarify treatment precautions. A total of 683 patients with clinical early gastric cancer were enrolled in this retrospective study, 128 of whom had gastric cancer in the upper-third stomach (U group). All patients underwent a double contrast barium examination, endoscopy, and computed tomography (CT), and were diagnosed preoperatively based on the findings obtained. The clinicopathological features of these patients were compared with those of patients with gastric cancer in the middle- and lower-third stomach (ML group). We also compared clinicopathological factors between accurate-diagnosis and under-diagnosis groups in order to identify factors affecting the accuracy of a preoperative diagnosis of tumor depth. Patients in the U group were older (P = 0.029), had a higher ratio of males to females (P = 0.015), and had more histologically differentiated tumors (P = 0.007) than patients in the ML group. A clinical under-diagnosis occurred in 57 out of 683 patients (8.3%), and was more frequent in the U group than in the ML group (16.4% vs 6.3%, P < 0.0001). Therefore, the rates of lymph node metastasis and lymphatic invasion were slightly higher in the U group than in the ML group (P = 0.071 and 0.082, respectively). An under-diagnosis was more frequent in histologically undifferentiated tumors (P = 0.094) and in those larger than 4 cm (P = 0.024). The median follow-up period after surgery was 56 mo (range, 1-186 mo). Overall, survival and disease-specific survival rates were significantly lower in the U group than in the ML group (P = 0.016 and 0.020, respectively). However, limited operation-related cancer recurrence was not detected in the U group in the present study. Clinical early gastric cancer in the upper-third stomach has distinguishable characteristics that increase the risk of a clinical under-diagnosis, especially in patients with larger or undifferentiated tumors.

A New Anastomotic Leakage Model in Circular Double Stapled Colorectal Anastomosis After Low Anterior Rectum Resection in Pigs

ABSTRACTBackground: A high incidence of anastomotic leakage (37.5%) is reported after low anterior rectal resection (LAR) and circular double-stapled anastomosis without protective ileostoma. Since the pathomechanism of anastomosis leakage is still unclear, a suitable animal model would be most desirable. Methods: The objective was to assess the incidence of clinically apparent and inapparent leakage after LAR in pigs (n = 20). Endpoints were radiological, clinical, macroscopic, and histologic proof of anastomotic leakage on the 9th postoperative day. Integrity of anastomosis was assessed by double-contrast barium examination on 9th postoperative day. Animals were sacrificed and anastomoses were resected for histopathological investigation. In case of earlier clinical apparent anastomotic leakage, radiologic double-contrast barium was performed immediately. Results: LAR with a circular double-stapled anastomosis without protective ileostoma was performed in 20 pigs (m:f = 8:12). Length of resection was 10–20 cm, anastomosis was performed 7 cm ab ano. Five animals (25%) developed clinical apparent anastomotic leakage (no appetite, fever, inactivity, tachypnea, discomfort, pain) between the 6th (n = 1) and 9th (n = 4) postoperative day, proven by double-contrast barium radiographs. Additionally in 1 animal clinical inapparent anastomotic insufficiency was observed radiologically. Total rate of leakage was 30% (n = 6). These results were confirmed by leucocytosis, low potassium levels, in two cases high ALT and AST and local peritonitis in all cases. Conclusion: Including one additional case of clinical inapparent leakage, total rate of anastomotic leakage was 30% (6/20). Thus we managed to establish a new experimental model of anastomotic leakage after low rectal resection comparable to the human situation.

Usefulness of the water-drinking method in preparing for the double-contrast barium examination of the stomach

Usefulness of the water-drinking method in preparing for the double-contrast barium examination of the stomach

Barium appendicitis

This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration. A 75-year-old woman presented with a history of hypertension, gastrointestinal polyposis, and a 1-year history of protein losing syndrome. She had received double contrast barium examination of her colon 6 months previously related to the protein losing syndrome. The barium exam revealed multiple and varied sizes of polypoid lesions along the whole colon. Endoscopy confirmed the gastrointestinal polyposis and suspected lymphangiectasia-related protein losing syndrome. She presented to our emergency department with a primary complaint of severe right lower quadrant pain of 24 hours duration. Physical examination revealed a focal Larp memorydrant disorder, tenderness in the right lower abdominal quadrant with positive McBurney's sign. The white blood cell count was 16,300/μl with 87.8% neutrophils. A plain film abdominal radiography disclosed a densely radio-opaque tubular lesion in the right lower quadrant of the abdomen (Fig 1). Computed tomography scans identified a dense barium retention in the appendix with surrounding prominent fatty infiltration indicating acute appendicitis (Fig 2). A diagnosis of barium appendicitis was suspected. The patient underwent an open appendectomy, which identified an enlarged and erythematous appendix with a focal perforation near the base. Post-operatively, the abdominal pain resolved and the patient was discharged 5 days later. This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration. This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration.

Diagnostic Yield of Double-Balloon Enteroscopy in Patients with Various Ulcerative Diseases of the Small Intestine: Present Status and Problems Concerning Endoscopic Diagnosis

Diagnostic Yield of Double-Balloon Enteroscopy in Patients with Various Ulcerative Diseases of the Small Intestine: Present Status and Problems Concerning Endoscopic Diagnosis Noriaki Manabe, Shinji Tanaka, Akira Fukumoto, Yoshiaki Matsumoto, Toshiki Yamaguchi, Madoka Nakao, Yutaka Mitsuoka, Jiro Hata, Ken Haruma, Kazuaki Chayama Background and Aims: Various diseases of the small intestine are now detected by double-balloon enteroscopy (DBE), which has revolutionized endoscopy of the small intestine. One of the most common DBE findings is ulcerative lesion. The etiology of ulcerative lesions varies. It is a matter of great importance to diagnose these lesions, including etiology, accurately. The aim of this investigation was to evaluate the diagnostic yield of DBE in patients with ulcerative lesions of the small intestine. Subjects and Methods: Between August 1, 2003, and October 31, 2005, 118 patients underwent DBE, and 52 patients (30 men, 22 women; mean age, 52.8 years) in whom a total of 159 ulcerative lesions in the small intestine were detected were enrolled in this study. After detailed endoscopic observation, biopsy specimens were obtained, and double-contrast barium examination was performed as deemed necessary. Final diagnosis was made comprehensively on the basis of endoscopic findings, pathologic findings and clinical course. Results: The most common indication for DBE in these patients was gastrointestinal bleeding (n Z 31, 59.6%). There were 12 patients (23.1%) with ulcerative lesions related to tumor (Ul-tm) and 40 patients (76.9%) with ulcerative lesions related to chronic inflammation (Ul-inf). Ten patients (83.3%) with Ul-tm had lesions located in the upper small intestine; 29 patients (72.5%) with Ul-inf had lesions located in the lower small intestine. Small (3-4 mm), circular, scattered ulcerations were commonly detected endoscopically. Twelve patients showed stenotic lesions caused by Crohn’s disease (n Z 5), tuberculosis (n Z 4) and other causes (n Z 3). A definitive diagnosis was obtained by DBE in 17 patients (42.5%). A definitive diagnosis was obtained by double-contrast barium examination after DBE in 4 patients (10%) and by consideration of DBE findings and the clinical course in 8 patients (20%). Seven cases (17.5%) remained undiagnosed. Thus, most lesions of the small intestine could be diagnosed definitively from characteristic endoscopic findings. However, some ulcerative lesions, especially those related to chronic inflammation, could not be diagnosed on the basis of a single DBE examination because configurations of the lesions varied easily according to disease stage or treatment. Conclusions: Our results suggest that about half ulcerative lesions in about 50% of patients cannot be diagnosed definitively on the basis of a single endoscopic observation.

An unusual cause for a colonic stricture: a case of Mycobacterium xenopi mimicking malignancy

Abstract Colonic strictures are very common and are a frequent finding on double contrast barium examination; they very often reflect the presence of malignancy, diverticular disease, ischaemia, inflammatory bowel disease, and rarely mycobacterial disease. A case of mycobacterial disease mimicking malignancy is presented; this was due to a rare mycobacterial subtype and there was complete resolution of symptoms with antimycobacterial therapy.

Double-contrast barium examination of the upper gastrointestinal tract with nonendoscopic biopsy: findings in 100 patients.

To evaluate the performance of double-contrast barium examination of the upper gastrointestinal tract augmented with nonendoscopic gastric mucosal biopsy. One hundred twenty-six patients (aged 9-81 years) underwent double-contrast barium examination of the upper gastrointestinal tract and nasogastric biopsy. Pathology reports were recovered for 100 patients. These patients' records were searched for procedural complications, sufficiency of biopsy tissue, diagnoses among various age groups, and radiographic findings. Forty-nine (49%) of the 100 patients had biopsy-proved Helicobacter pylori infection with chronic active gastritis. Twenty-one patients (21%) with H pylori-negative biopsy specimens had chronic gastritis. One patient with eosinophilic gastritis and one with granulomatous gastritis were identified. Twenty-nine patients (29%) had negative biopsy results. Nineteen (30%) of the patients with negative barium studies had a positive biopsy specimen, and four (6%) of the patients with positive barium studies had negative biopsy specimens. Eight patients (8%) had a second diagnosis of intestinal metaplasia. Use of double-contrast barium examination of the upper gastrointestinal tract combined with nonendoscopic biopsy is quick and safe and can provide reliable histologic information to the primary care physician.

Referrals for double-contrast barium examination. Factors influencing the probability of finding polyps or cancer.

Predictors of the radiologic detection of colorectal polyps or cancer were studied in 1852 patients referred from primary health care for a double-contrast barium enema. Significant polyp predictors were age 40-79 years (odds ratio (OR), 2.4-5.0) and rectal bleeding (OR, 1.8). Previous colorectal neoplasm, familial history of cancer in general, and male sex were nearly significant predictors of polyps. Significant cancer predictors were age > or = 60 years (OR, 8.6-27.8), rectal bleeding (OR, 2.7), loss of weight (OR, 2.6), and male sex (OR, 2.2). Fatigue and abdominal pain were nearly significant negative predictors for cancer. No association was found between patient delay and the detection of polyps or cancer. Physician delay was significantly shorter in patients with cancer than in cancer-free patients. Age was the most important predictor for the detection of both polyps and cancer, more important than symptoms and history, including family history.

Amyloidosis of the small intestine: findings on double-contrast radiographs.

The appearance of the small intestinal mucosa on double-contrast barium examinations was studied in 26 patients with proved intestinal amyloidosis. Findings included innumerable fine granular densities 1-3 mm in diameter (16 patients), multiple nodular densities 3-4 mm in diameter (four patients), multiple polypoid protrusions 4-10 mm in diameter (three patients), irregularities of Kerckring folds (12 patients), and multiple erosions (eight patients). The multiple nodular densities and erosions disappeared after the patients were treated with total parenteral nutrition. The other abnormalities remained unchanged on follow-up examinations. Our results indicate that double-contrast radiographic findings of the small intestine in patients with amyloidosis include mucosal abnormalities that vary according to the pathologic type of amyloid deposition.

Visualization of the mucosal villi on double-contrast barium studies of the small intestine by using a high molecular fraction of guaran

Guaran is a water-soluble polysaccharide from the seed endosperm of Cyanopsis tetragonolobus. A high molecular fraction of guaran, when added to barium, enhances barium coating of the intestinal mucosa. This study reports its use to demonstrate the mucosal villi of the small intestine during double-contrast barium examination in the rat and in the human. In the animal model, individual villi were identified surrounded by pools of barium. In the human, a granular pattern caused by the villi was seen. Individual villi were visible with high-definition radiography. This was confirmed by microscopic studies of biopsy specimens in which the villi were shown to have the same diameters as the structures seen on high-definition radiography.

The relationship between the radiological and clinical features in patients with crohn's disease

A study has been made of 93 Japanese patients with Crohn's disease who had not undergone bowel resection at the time of diagnosis during the years 1969 to 1983. Ninety had longitudinal ulcers or a cobblestone appearance or both of the small intestine or colon or both on double contrast barium examination. The incidence of longitudinal ulcers in the small intestine was significantly higher than in the colon (P less than 0.001). Conversely the incidence of cobblestoning was higher in the colon than in the small intestine (P = 0.065). In patients with longitudinal ulceration, there was significantly lower Crohn's disease activity index (CDAI), ESR, and C-reactive protein. Patients with cobblestoning had a significantly higher CDAI, ESR and C-reactive protein, and significantly lower values of albumin, cholesterol in serum, serum iron, haemoglobin, and relative body weight. Our findings indicate that cobblestoning closely correlates with the disease activity of Crohn's disease, and that longitudinal ulceration has a negative correlation. Moreover, our results suggest that the high incidence of cobblestoning and low incidence of longitudinal ulcers in the colon and the reverse in the small intestine reflects the fact that colonic involvement renders the disease more severe than small intestine involvement only.

Accuracy of Radiologic and Endoscopic Diagnosis of Gastric Ulcer

Patients with upper abdominal pain are often examined with both double contrast study of the stomach and endoscopy. On the basis of the results of the two examinations four diagnostic criteria of an ulcer can be formed: 1) radiography reveals an ulcer, 2) endoscopy reveals an ulcer, 3) both radiography and endoscopy reveal an ulcer, and 4) radiography and/or endoscopy reveals an ulcer. In a prospective study the accuracy of each of the four diagnostic criteria was examined. Eighty-two randomly selected outpatients had a double contrast barium examination and an upper gastrointestinal endoscopy performed by staff personnel. The diagnosis of a specialist in upper gastrointestinal endoscopy was used as the standard. For the four diagnostic criteria the overall accuracy ranged from 0.80 to 0.88. The predictive value of a positive test result was around 0.70 and the predictive value of a negative test result ranged from 0.81 to 0.96. The specificity ranged from 0.87 to 0.95, and the sensitivity from 0.38 to 0.90. It is concluded that from a clinical point of view, the accuracy of the four diagnostic criteria does not differ to an extent that justifies recommendation of one diagnostic criterion of gastric ulcer rather than the other.

Accuracy of Radiologic and Endoscopic Diagnosis of Gastric Ulcer

Patients with upper abdominal pain are often examined with both double contrast study of the stomach and endoscopy. On the basis of the results of the two examinations four diagnostic criteria of an ulcer can be formed: 1) radiography reveals an ulcer, 2) endoscopy reveals an ulcer, 3) both radiography and endoscopy reveal an ulcer, and 4) radiography and/or endoscopy reveals an ulcer. In a prospective study the accuracy of each of the four diagnostic criteria was examined. Eighty-two randomly selected outpatients had a double contrast barium examination and an upper gastrointestinal endoscopy performed by staff personnel. The diagnosis of a specialist in upper gastrointestinal endoscopy was used as the standard. For the four diagnostic criteria the overall accuracy ranged from 0.80 to 0.88. The predictive value of a positive test result was around 0.70 and the predictive value of a negative test result ranged from 0.81 to 0.96. The specificity ranged from 0.87 to 0.95, and the sensitivity from 0.38 to 0.90. It is concluded that from a clinical point of view, the accuracy of the four diagnostic criteria does not differ to an extent that justifies recommendation of one diagnostic criterion of gastric ulcer rather than the other.

Interobserver variation in the radiographic diagnosis of duodenal ulcer disease.

Interobserver variation was estimated in radiologists' detection of duodenal ulcer and deformity of the duodenal bulb. A consecutive series of 156 patients with upper abdominal pain had a double contrast barium examination. The films were first read by routine by a specialist in radiology. A second reading was performed by another specialist who did not know the result of the first reading. Overall agreement between the two readings in the detection of duodenal ulcer and deformity of the duodenal bulb was 0.91 and 0.94, respectively. The overall agreement was adjusted for the expected chance agreement and kappa values were calculated. Kappa was 0.63 for the detection of duodenal ulcer and 0.85 for the detection of deformity of the duodenal bulb.

Interobserver variation in the radiographic diagnosis of gastric ulcer. Gastroenterologists' guesses as to level of interobserver variation.

A total of 156 double contrast barium examinations were independently interpreted by two observers for the presence of gastric ulcer. The observed agreement between the two readings was 93 per cent, and after adjusting for the expected chance agreement a kappa value of 0.73 was obtained. At the first reading 4 ulcers, and at the second reading 8 ulcers were interpreted as malignant. None of these interpretations agreed. In a questionnaire study it was demonstrated that gastroenterologists had a realistic impression of the level of agreement in the radiographic detection of gastric ulcer.

Mucosal surface patterns of the duodenal bulb. Subject review.

While the duodenal mucosa usually exhibits a smooth, featureless surface on the double-contrast barium examination, on occasion a fine mucosal pattern can be demonstrated. Several pathological processes, including erosive duodenitis, Crohn disease, and celiac disease, may produce subtle alterations in the normal surface pattern. Various normal and abnormal mucosal patterns are illustrated.

Benign greater curve gastric ulcer: the "sump-ulcer".

Twenty-six cases of greater curve gastric ulcers are presented, of which all but one were benign. There appears to have been an increased occurrence of benign greater curve gastric ulcers in our institution. By using a double contrast barium examination diagnostic accuracy was high, although endoscopy and biopsy are required for confirmation. Greater curve gastric ulcers were commonest in elderly patients with concomitant disease and a high intake or oral drugs, particularly analgesics, potassium chloride supplements and steroids. The constant location of the ulceration in the most dependent part of the stomach suggests a causal relationship with drug ingestion in these patients. The term "sump-ulcer" is suggested. A relatively high incidence of perforation and gastrocolic fistulae was found. It would appear that gastrocolic fistulae from benign peptic ulcer disease, previously thought to be excessively rare, are becoming more commonly recognized.

Glucagon in barium examinations in infants and children: special reference to dosage.

The dose of intravenous glucagon which will produce a predictable, short and useful period of gastro-intestinal atony during double contrast barium examinations in infants and children has been established. A dose of 0.5-1.0 micrograms/kg body weight will produce an atonic period of three to five minutes which is satisfactory for double contrast meals. A larger dose of 0.8-1.25 micrograms/kg is recommended for barium enemas for which an atonic period of five to ten minutes was found to be satisfactory. These doses have been derived from data obtained during 20 barium examinations in infants and children. In barium meals the glucagon is given after the duodenal cap has opacified. In barium enemas it is recommended to give the drug at the beginning of the examination. Benefits of the use of these small doses of i.v. glucagon are: (1) atony permitting good double contrast examination; (2) rapid return to normal permitting motility to be examined; (3) relief of painful and obstructive spasm in barium enemas; (4) quietening of angry, hungry infants; (5) probable shortening of the total examination time. No undesirable side effect was observed.

8 - Newer Radiological Techniques in the Diagnosis of Gastrointestinal Cancer

SUMMARY 1. A review of improved standard techniques as well as newer radiological methods for the evaluation of gastrointestinal cancer is presented. 2. Double contrast barium examinations of the oesophagus, stomach, duodenum, and colon increase the capability for diagnosing and characterising small gastrointestinal mass lesions. Commercial products are available so that excellent double contrast examinations may be performed in any institution. 3. Diagnostic applications of angiography to the liver, pancreas, and alimentary canal are presented. The importance of assessing extent of disease by angiographic means is stressed. Therapeutic angiography, particularly in the control of gastrointestinal haemorrhage, is considered. 4. A number of newer interventional techniques including ‘skinny needle' percutaneous transhepatic cholangiography, transjugular liver biopsy, and percutaneous aspiration pancreatic biopsy are discussed. 5. In the evaluation of patients with gastrointestinal cancer, present radiological techniques allow for more accurate diagnosis, staging of disease, and even therapeutic assistance.

Double contrast barium meal examination — A comparison of techniques for introducing gas

A comparison made between five techniques for introducing additional gas to the stomach for double contrast barium examination showed effervescent tablets to be associated with significant improvement in gastric mucosal coating with significantly less bubble formation. A proprietary effervescent health salt on the other hand was associated with significantly greater bubble formation.