Enema Radiography Research Articles

MRI diagnose post-operative anastomotic leak in patients with rectal cancer: preliminary experience

BackgroundAnastomotic leakage (AL) is one of the most serious postoperative complications after colorectal anastomosis. This study aims to evaluate the feasibility and diagnostic accuracy of magnetic resonance imaging (MRI) in the early detection of AL in patients with clinically suspected AL after rectal anterior resection.MethodsThis was a prospective study including patients who underwent anterior resection and postoperative MRI examination. AL was diagnosed by comprehensive indictors, which were mainly confirmed by clinical signs, symptoms, and retrograde contrast enema (RCE) radiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of diagnosing AL with MRI were calculated.ResultsIn total, 347 patients received anterior resection for rectal cancer, and 28 patients were suspected to have AL. Finally, 23 patients were included and received MRI examination. The median time interval from surgery to MRI was 10 days (3–21 days). The median distance from anastomosis to anal verge was 4.0 cm (2.0–10 cm), and 11 patients underwent diverted ileostomy. Eighteen patients had an anastomotic leak, including one patient who had a pelvic abscess and five patients who had no evidence of AL in the MRI examination. The overall sensitivity and specificity were 94.4% (95% CI 70.6% to 99.7%) and 80% (95% CI 29.8% to 98.9%), respectively. The PPV was 0.94 (95% CI 0.71 to 0.99) and the NPV was 0.80 (95% CI 0.29 to 0.99). For patients who had anastomosis less than 5 cm, the diagnostic accuracy of MRI was 93.7% (15/16). T2-weighted imaging with fat suppression can effectively reveal the leak track.ConclusionsThe accuracy of plain MRI examination in diagnosing AL was favorable for patients with a suspected AL. T2-weighted imaging with fat suppression was the best imaging modality to diagnose AL. A multicenter prospective study with more samples is needed to further determine the safety and feasibility of MRI in the diagnosis of AL.

Endoscopic Decompression with a Transanal Drainage Tube for the Treatment of Hirschsprung's Disease in Newborns

Background: To evaluate the effectiveness and safety of endoscopic decompression with a transanal drainage tube (ED-TDT) in the treatment of neonatal Hirschsprung's disease (HD). Materials and Methods: Six newborns (4 boys and 2 girls; age at operation 9-29 days, median 24 days) were admitted to our hospital due to the delayed passage of meconium after birth, abdominal distension, and vomiting. HD was diagnosed by the retrograde enema radiography. All patients underwent ED-TDT for decompression of the dilated colon. During the operation, an endoscope was inserted through the anus to the ascending colon or ileocecal region, which was then used to insert a guidewire to the ascending colon. The endoscope was then removed, and a colorectal drainage tube was introduced over the guidewire. This drainage was placed until a pull-through procedure was performed. Results: The ED-TDT was successfully performed in all newborns. The intraoperative rectal biopsy confirmed the diagnosis of HD. The duration of the operation was 25-70 minutes (median 52.5 minutes). There were no perforations, bleeding, or other complications after surgery. After surgery, the abdominal distention was significantly relieved, and the babies could be fed with milk after 6 hours. These babies were discharged after 2-11 days (median 2.5 days) and underwent a pull-through procedure after 1-3 months (median 3 months). Conclusions: ED-TDT is a safe and effective treatment for neonatal HD before a pull-through procedure. It could be used as an alternative therapy to colostomy.

Diagnosing Pediatric Intussusception Through Bedside Ultrasound by Novice Emergency Department Sonographers: A Case Report

Intussusception is a common cause of gastrointestinal emergency in the paediatric population and it is usually diagnosed through Barium enema radiography or ultrasound. The skill of using an ultrasound by a minimally trained medical officer in diagnosing this cases in the Emergency Department are very helpful and expedite the management. We present the case of a 7-month-old girl who presented to Emergency Department (ED) with the chief complaint of passing blood in stool. Clinically she was dehydrated, irritable and in compensated shock. There was generalised tenderness per abdomen but it was soft and not distended. There was no palpable mass and bowel sound normal. Immmediate fluid resuscitated commenced. Bedside abdominal ultrasound performed by ED medical officer showed a 1.8 cm x 2.5 cm mass of alternating hypo-echoic and hyper-echoic rings at the right lower quadrant, consistent with the ‘target’ sign of intussusception. Supine plain abdominal X-ray did not reveal any abnormality. The ultrasound finding of intussusception was later confirmed by the radiologist. She underwent immediate hydrostatic reduction and was discharged well.

Experience of Barium Enema Radiography in Mass Survey Procedure

大腸がん検診の二次検査に多くの施設では，全大腸内視鏡検査が実施されているが，私どもは注腸X線造影法を過去6年間用いて実施しており，その結果を比較報告する。 注腸X線造影法は精密検査受診率が内視鏡検査より極めて高く，放射線技師でも技術を磨くことで，医師にも勝るとも劣らないパワーを発揮することができるため，多数の地域住民検診希望者の需要に応じることが可能であった。また大腸がんの発見率が内視鏡検査に比べて落ちるのではないかという心配は，大腸がん発見率が新潟県平均よりはやや劣るが全国平均よりは高いこと，早期がんの割合が新潟県・全国と同程度の割合で検出されていることにより，また小さながんが見逃されるのではないかという心配は，種々の体位での撮影とガン好発部位の2回以上の撮影により払拭されている。 なお，私どもは注腸X線検査を精密検査，内視鏡検査をさらなる確定検査の手段と考えており，胃がん検診の直接X線撮影と同様に位置付けている。従って注腸X線造影法ではっきりとした所見が見いだされなくとも，痔などの出血源が見当たらない症例には積極的に内視鏡検査を奨めることにしている。

Rectosigmoid Ectasia Associated with Anorectal Anomaly Repair: Experience with Sigmoid Anterior Resection and Endorectal Pull-Through

Surgical treatment of anorectal anomalies may be followed by severe constipation with or without overflow incontinence secondary to dilation and ectasia of the rectosigmoid. The aim of this study is to evaluate the efficacy of anterior resection and endorectal pull-through for the treatment of rectosigmoid ectasia secondary to posterior sagittal anorectoplasty (PSARP). Seven patients with a history of PSARP presented with serious rectosigmoid ectasia and overflow incontinence of fecal impaction. Four were boys and 3 were girls aged from 16 months to 15 years. Preoperative diagnosis was based on physical examination, barium enema, MRI and rectal biopsy. Surgical treatment of the post-PSARP rectal ectasia was made by anterior resection of the ectatic segment of the sigmoid combined with pull-through of normal colon into the mucosectomized ectatic rectum. During a four-to ten-year follow-up period all of our patients had normal bowel movements. Postoperative barium enema radiography demonstrated a normal rectal caliber and manometry revealed normal anorectal motor function. The good postoperative results draw attention to the following. a) The aim of the surgical treatment of megarectum is to establish a neorectum with normal bowel. b) Resection of megasigmoid and pull-through of bowel with normal caliber into the mucosectomized ectatic rectum is an effective procedure in patients with post-PSARP rectosigmoid ectasia. c) The neorectum attains its reservoir function through a gradual process after resection and endorectal pull-through.

Longitudinal colonic torsion as a cause of tenesmus in an adult Irish Water Spaniel

CASE HISTORY: Torsion of the descending colon was diagnosed by barium enema radiography in an adult Irish Water Spaniel which had presented with tenesmus of 24 h duration. Treatment involved exploratory laparotomy, repositioning of the colon, colopexy and repair of a mesenteric rent. No definitive cause of the torsion could be established. The dog made an uneventful recovery from surgery. CLINICAL RELEVANCE: Animals presenting with constipation of undetermined cause should have large intestinal obstruction ruled out prior to administering bowel cleansing solutions per os and/or colonic enemas. Colonic obstruction by torsion should be considered as a possible differential diagnosis in all cases of tenesmus.

Colorectal Cancer Screening: A Community Case-Control Study of Proctosigmoidoscopy, Barium Enema Radiography, and Fecal Occult Blood Test Efficacy

To examine the effectiveness of screening proctosigmoidoscopy, barium enema radiography, and the fecal occult blood test (FOBT) in decreasing colorectal cancer mortality in a community setting. In this population-based case-control study, cases comprised 218 Rochester, Minn, residents who died of colorectal cancer between 1970 and 1993. Controls were 435 age- and sex-matched residents who did not have a diagnosis of colorectal cancer. Screening proctosigmoidoscopy, barium enema radiography, and FOBT results were documented for the 10 years prior to and including the date of diagnosis of fatal colorectal cancer in cases and for the same period in matched controls. History of general medical examinations and hospitalizations was also recorded. Within the 10 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening proctosigmoidoscopy were 23 (10.6%) of 218 cases vs 43 (9.9%) of 435 controls; at least 1 screening barium enema radiographic study was done in 12 (5.5%) of 218 vs 25 (5.7%) of 435. Within 3 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening FOBT were 27 (12.4%) of 218 vs 44 (10.1%) of 435. Adjusted odds ratios were 1.04 (95% confidence interval [CI], 0.21-5.13) for proctosigmoidoscopy (distal rectosigmoid cancers only), 0.67 (95% CI, 0.31-1.48) for barium enema radiography, and 0.83 (95% CI, 0.45-1.52) for FOBT over the above time periods. In this case-control study within a community setting, a colorectal cancer-specific mortality benefit could not be demonstrated for screening by FOBT, proctosigmoidoscopy, or barium enema radiography. Screening frequency was low, which may have contributed to the lack of measurable effects.

A man with a leg-vein clot and colonic ulcers

A 48-year-old man was admitted to hospital on May 28, 1995, with spasms of lower abdominal pain of variable intensity for 5 weeks, associated with weight loss. He had had a pulmonary embolism after a deep-vein thrombosis 15 years previously. 2 years before admission, he had had pancreatitis of unknown cause. 1 year before admission, colonoscopy had shown a segmental ulcer in the midtransverse colon. He had a segment of colon removed. Histological examination did not establish a cause for the ulcer. He continued to complain of recurrent lower abdominal pain and weight loss. Angiography of his mesenteric arteries was normal. Barium enema radiography of the colon showed a cicatricial stenosis in the mid-transverse colon at the site of the previous resection. This was removed at operation. Histological examination showed a segmental ulcer of unclear cause. After discharge from hospital he still had lower abdominal pain, especially after food. At our institution, physical examination showed he was 180 cm in height and weighed 60 kg. There was paraumbilical tenderness, but no other abnormalities. Repeated stool cultures were negative. Colonoscopy showed a segmental ulcer in the right side of the transverse colon. The ulcer was shallow and 10 cm in diameter. Colonic mucosa at the borders of the ulcer was friable and had petechial haemorrhages. The remainder of the colonic mucosa appeared normal (figure). Ten biopsy specimens were taken. The crypts were of normal height in three specimens and hyperplastic in one. The lamina propria contained normal numbers of lymphocytes and plasma cells and no granulocytes. Six specimens showed granulation tissue and inflammatory cells at the base of an ulcer. The lesion was consistent with an ischaemic ulcer. Histological slides from the second resection of his colon at another hospital showed similar findings. The diagnostic feature was thrombosis of small submucosal and mesenteric vessels, consistent with mesenteric thrombosis. An examination of the clotting system showed resistance to activated protein C, 1 caused

Use of air enema radiography to assess depth of ulceration during acute attacks of ulcerative colitis

Summary Background Acute colitis is usually assessed by means of plain abdominal radiographs, the diagnostic utility of which can be enhanced by barium enema. Colonoscopy can also be useful. The latter methods may be laborious and carry risk. We describe a radiographic technique using air as the contrast medium to show mucosal or deeper ulceration. Methods Of 60 patients undergoing colectomy for acute ulcerative colitis, 35 had air enema radiography and 14 had plain films with sufficient amount of spontaneously occurring gas to allow visualisation of the mucosa, during the 10 days before surgery. The degree of inflammation on air enema films and the extent of histopathological ulceration in colectomy specimens were independently graded and compared with each other. Depth of ulceration was compared with clinical data including a preoperative risk stratification, the APACHE II score. Findings The degree of inflammation on air enema radiography correlated significantly with depth of ulceration at histopathological examination (rs 0·61, p<0·001). Presence of mucosal changes had a close association with deep ulceration extending into the muscularis propria layer or beyond (p<0·001). Air enema radiography had a high sensitivity (0·91) for presence of and specificity (0·75) in the exclusion of deep ulceration, with positive and negative predictive values of 0·88 and 0·80. 42 of 49 patients were correctly classified as regards deep ulcers. The correlation between higher preoperative APACHE II scores and severity of histopathological colitis was weak (rs 0·30, p<0·05). Interpretation Air enema radiography reliably assesses the presence of colonic ulceration in patients with an acute attack of ulcerative colitis. It is a first-line investigation to assess the presence of deeper ulceration in acute colitis.

Mucosal Microcirculation in Juvenile Polyps in Children

To the Editor: Impairment of microcirculation in the gastrointestinal mucosa is known to play an important role in cases of mucosal injury, not only from local ischemia resulting in cellular hypoxia (1) but also from over-production of oxygen radicals, eicosanoids, and platelet-activating factor (2,3). Developments in spectrophotometric techniques have made possible in vivo, noninvasive assessment of the concentration of hemoglobin and levels of oxygenation in the gastrointestinal mucosa in adult patients using gastrointestinal fiberscopy (4-6). However, there have been no reports of this kind of evaluation in children. We measured the mucosal microcirculation in colonic polyps and in the normal surrounding colon using reflectance spectrophotometry during colonofiberscopy in four children with juvenile polyps. Four patients aged from 1.5 to 6 years were studied. The patients had melena, and barium enema radiography revealed colonic polyps. All patients had a single polyp of maximum diameter 12-30 mm located between the transverse colon and the rectum. Colonofiberscopy was used to perform polypectomy under systemic anesthesia. During this operation, the mucosal microcirculation in the polyp and in the normal surrounding colon was evaluated using reflectance spectrophotometry. The hemoglobin concentration and the levels of oxygenation were measured in the mucosa using a tissue spectrum analyzer (TS-200, Sumitomo Electric Industries, Osaka, Japan). This was done using a fine optic bundle, whose tip was passed through the biopsy channel until it gently contacted the mucosal surface, following the method of Kamada et al. (4). The concentration of mucosal hemoglobin in the polyp mucosa was significantly higher (p < 0.05) than that in the normal surrounding mucosa. In contrast, the amount of mucosal oxygen in the polyp mucosa was typically less (p < 0.1) than that in the normal surrounding mucosa (Fig. 1). Histological examination of the polyps showed typical findings of juvenile polyps. Reflectance spectrophotometry can evaluate the concentration of hemoglobin in the gastrointestinal mucosa and the levels of oxygenation during endoscopical examination (4-6). These microcirculatory parameters are known to be indicators of mucosal ischemia, congestion, and other disturbances of the gastrointestinal mucosal microcirculation that can cause mucosal injury of the gastrointestinal tract. Our findings showed that the mucosal hemoglobin concentration in the juvenile polyp was markedly more than normal but the levels of oxygenation were typically less than normal. These findings indicate congestion in the mucosal microcirculation in juvenile polyps. This is in accordance with our histological findings, which showed hypervascularity in the veins and capillaries of the polyps. Further, this study suggests that it is feasible to assess the relationship between mucosal microcirculation and mucosal injury in children, as well as adults, using in vivo measurement of the gastrointestinal mucosal microcirculation with reflectance spectrophotometry (4-6). Toshiaki Shimizu, Yuichiro Yamashiro, Atsushi Unno, Kaoru Obinata, Keijiro Yabuta, and *Tatsuo Ogihara Department of Pediatrics *Division of Gastroenterology Department of Internal Medicine Juntendo University School of Medicine Tokyo, JapanFIG. 1.: Index of mucosal blood volume (•) and oxygenation (○) in the mucosa of colonic polyps and of normal surrounding colon in four children with juvenile polyps. Means were compared using a paired t test.

The effects of distention of the colon during air-contrast barium enema on colonic morphology: anatomic correlation.

Radiologic and pathologic findings are snapshots of disease processes that may vary with a host of dynamic variables. This pictorial essay shows how the presence and visibility of the innominate grooves of the colon are a function of colonic distention. This article also shows how each layer of the colonic wall, including the epithelium, muscularis mucosae, and muscularis propria, changes dramatically in thickness with varying degrees of colonic distension. These anatomic changes are documented by barium enema radiography, specimen radiography, dissecting photomicrography, and histology. These observations have important implications for the interpretation of radiologic and pathologic findings in both normal and diseased states.

Intestinal Behçet disease: serial changes at radiography.

To clarify the characteristic radiographic findings and serial radiographic changes in nonsurgical cases of intestinal Behçet disease (BD), seven patients were followed up for an average of 4 1/2 years (range, 8 months to 11 years 4 months). They underwent repeated examination with barium meal studies and double-contrast barium enema meal studies and double-contrast barium enema radiography. Initial radiography revealed one to three deep ulcers in the terminal ileum or ileocecal region in five patients. The ulcers healed while patients were treated with medical therapy but recurred during the follow-up period. In four of these five patients, follow-up radiography demonstrated various changes within each case: At each examination, an enlarged ulcer or a newly developed ulcer was often found in conjunction with a healed ulcer. In the other two patients, multiple shallow ulcers or innumerable aphthoid ulcers were seen throughout the entire colon, and these ulcers showed a good response to medical treatment. These results indicate that serial radiographic changes in patients with intestinal BD may mimic those in patients with Crohn disease, with findings in the terminal ileum and colon that wax and wane with medical treatment.

410. 注腸 X 線写真評価基準の検討(X 線検査-10 上部消化管検査 大腸)

410. 注腸 X 線写真評価基準の検討(X 線検査-10 上部消化管検査 大腸)

Familial, recurrent hemolytic-uremic syndrome

Age (yr) 13 15 12 Sex M M F Duration of typical pain attack 1-2 min <3 min Few seconds Pain frequency (episodes/yr) 6 7-8 Unknown Character of pain Sudden, stabbing Sudden, crampy Sudden, crampy Associated GI symptoms None None None Past history of recurrent abdominal pain + + Familial irritable bowel syndrome + Physical examination Normal Normal Normal Barium enema radiography Normal Normal Normal Rectosigmoidoscopy Normal Not done Not done Multiple drug trials + +

Energy and rate dependence of diagnostic x-ray exposure meters.

Variations in x-ray exposure measurements among a variety of contemporary diagnostic exposure meters are investigated. Variations may result from systematic errors due to calibration, beam-quality dependence and exposure-rate dependence. It is concluded that the majority of general purpose diagnostic meters will agree to within 10% of each other if exposure rates are below 1.3 mC kg-1S-1 of air (5 R s-1) and beam qualities are typical for general purpose radiology, excluding mammography. For exposure rates comparable to those in barium enema radiography the variations can range up to 25% or more. Variations up to 40% were observed among general purpose exposure meters at mammographic beam qualities. In the mammographic range, mammographic (thin window) exposure meters varied by no more than 2%.

Computed tomographic distinction of submucosal lipoma and adenomatous polyp of the colon

Described here is a patient with 2 large pedunculated colonic tumors detected by barium enema radiography. By computed tomography (CT) 1 was found to be a submucosal lipoma characterized by oval shape, smooth demarcation, and homogeneous density with a CT number of -68 HU, whereas the other was an adenomatous polyp with slightly fuzzy outline and a much higher CT number. This case indicates that CT can be a definitive diagnostic modality for distinguishing between a colonic lipoma and other solid or cystic tumor of the colon.

Necrotising enterocolitis experience with 54 neonates.

Fifty-four neonates transferred to the neonatal surgical unit because of acute necrotising enterocolitis (N.E.C.) are presented. Eleven died (20.4%), of whom seven were treated conservatively and four by operation. Ten patients required surgical exploration because of intestinal perforation, obstruction or suspected perforation. Another five neonates presented with intestinal perforation and were treated by percutaneous catheter drainage of the peritoneal cavity because of their extreme prematurity. Nine patients developed a colonic stricture diagnosed between six weeks and a year after the onset of the disease. Another six patients showed a segment of colonic narrowing detected on barium enema radiography without clinical evidence of bowel obstruction. They were treated conservatively and showed complete resolution at follow up studies.

Postoperative evaluation of fecal continence after sphincter-preserving operations for rectal cancer.

Seventy-eight sphincter-preserving operations for rectal cancer were evaluated from the viewpoint of postoperative fecal continence. Operative procedures consisted of 39 anterior resections and 39 pull-through operations and Maunsell-Weir's operation. Postoperative fecal continence was evaluated by questionnaires and anorectal examinations including (1) the distance from the anal verge to the anastomosis, (2) the length of sensation to light touch in the anal canal, (3) electromyography of the sphincter, (4) internal sphincter reflex (5) pressure profile of the anal canal, and (6) barium enema radiography. Patients' evaluations of their continence were good when the distance of the anastomosis was over 5 cm from the anal verge, and mostly poor under 3 cm. Good or fair evaluations were obtained when the internal sphincter reflex or high pressure zone of the anal canal were preserved. Size of the reservoir was measured using a planimeter on the lateral view of the barium enema up to 6 cm from the upper margin of the anal canal. Good or fair evaluations were obtained when size was 30 cm2.

Clostridium difficile and cytotoxin in feces of patients with antimicrobial agent-associated pseudomembranous colitis.

Thirty patients with antimicrobial agent-associated pseudomembranous colitis (PMC) were studied for the presence of Clostridium difficile and its cytotoxin in feces. Either colonoscopy or barium enema radiography was required in three patients for the diagnosis of PMC because of nondiagnostic findings at sigmoidoscopy. Both the organism and cytotoxin were detected in 27 of the 30 patients; Staphylococcus aureus was excluded as the cause of PMC in two of the remaining patients. Eighteen of 19 patients with C. difficile-induced PMC who were treated with oral vancomycin had a salutary response; seven patients, however, had a relapse of colitis following the discontinuation of vancomycin. In general, relapses of colitis responded to retreatment with vancomycin. The implication of C. difficile as a cause of diarrhea is best achieved by the demonstration of colonic mucosal plaques or of a pseudomembrane. The value of fecal culture for C. difficile and cytotoxin assay is limited by the existence of asymptomatic carriers.