Single-contrast Barium Enema Research Articles

Less barium enema, more colonoscopy: A 12-year nationwide population-based study in Taiwan.

Colorectal cancer (CRC) is the second most common and third most fatal cancer in Taiwan. To reduce incidence and mortality rates from cancer, including CRC, the Health Promotion Administration in Taiwan initiated the National Program on Cancer Prevention in 2005. For patients who have a positive fecal occult blood test, colonoscopy is recommended, and double-contrast barium enema (BE) is reserved as an alternative for those who cannot receive colonoscopy. In addition, single-contrast BE is sometimes used in pediatrics to evaluate colonic condition. This study evaluated the usage trends of BE and colonoscopy in Taiwan. Data from the National Health Insurance Research Database from 2001 to 2013 were used in this study. Patients who received BE and colonoscopy were identified using the procedure codes of the National Health Insurance program. Age-standardized, yearly rates of BE and colonoscopy procedures were calculated. According to the data, the total number of colonoscopies increased 3.7-fold from 2001 to 2013. The compound annual growth rates for BE and colonoscopy were -5.36% and 10.47%, respectively, during the same period. The compound annual growth rates for BE and colonoscopy were -3.89% and 11.64% from 2005 to 2009, and -11.36% and 9.82% from 2010 to 2013, respectively. BE was conducted significantly more frequently than colonoscopy in patients who were aged <12 years and in female patients. Professional association guidelines, national cancer prevention programs, patient and physician preferences, and increasing awareness and knowledge of CRC may all contribute to the increasing use of colonoscopy and the dramatic decline in the use of BE in Taiwan.

Value of 24-hour Delayed Film of Barium Enema for Evaluation of Colon Transit Function in Young Children with Constipation.

Background/AimsA colon transit time test using radio-opaque markers (CTTRM) is considered the gold standard for evaluating colon transit function. A 24-hour delayed film of barium enema (BE) has been used as a supplementary method in structural evaluations. The aim of this study was to evaluate the utility of a 24-hour delayed BE film for assessing colon transit function in young children with constipation.MethodsIn total, 93 children with constipation who performed both single-contrast BE and CTTRM were enrolled in this study. Of these, the data from 70 children were analyzed (males 33, females 37; mean age [range], 5.63 ± 2.94 [2–14] years). The basic principle of the study is “velocity = distance/time”. Time values were identified in both studies, and the colon length and distance of barium movement were measured on the 24-hour delayed BE film. Thus, colon transit velocity values could be calculated using both methods. The correlation between colon transit velocity using a 24-hour delayed BE film versus CTTRM was analyzed statistically.ResultsMedian value (interquartile range) of colon transit velocity using CTTRM was 1.57 (1.07–2.89) cm/hr, and that using BE of that was 1.58 (0.94–2.07) cm/hr. The Spearman correlation coefficient was 0.438 (P < 0.001) for the overall group. The correlation was strongest in children younger than 4 years (r = 0.537, P = 0.032).ConclusionsAlthough the correlation between BE and CTTRM was not very strong, the 24-hour delayed BE film could provide broad information about colon transit function in young children, especially those under 4 years who usually cannot undergo CTTRM.

History, evolution, and current status of radiologic imaging tests for colorectal cancer screening.

Colorectal cancer screening is thought to be an effective tool with which to reduce the mortality from colorectal cancer through early detection and removal of colonic adenomas and early colon cancers. In this article, we review the history, evolution, and current status of imaging tests of the colon-including single-contrast barium enema, double-contrast barium enema, computed tomographic (CT) colonography, and magnetic resonance (MR) colonography-for colorectal cancer screening. Despite its documented value in the detection of colonic polyps, the double-contrast barium enema has largely disappeared as a screening test because it is widely perceived as a labor-intensive, time-consuming, and technically demanding procedure. In the past decade, the barium enema has been supplanted by CT colonography as the major imaging test in colorectal cancer screening in the United States, with MR colonography emerging as another viable option in Europe. Although MR colonography does not require ionizing radiation, the radiation dose for CT colonography has decreased substantially, and regular screening with this technique has a high benefit-to-risk ratio. In recent years, CT colonography has been validated as an effective tool for use in colorectal cancer screening that is increasingly being disseminated.

ACR Appropriateness Criteria Colorectal Cancer Screening

Colorectal cancer is the third leading cause of cancer deaths in the United States. Most colorectal cancers can be prevented by detecting and removing the precursor adenomatous polyp. Individual risk factors for the development of colorectal cancer will influence the particular choice of screening tool. CT colonography (CTC) is the primary imaging test for colorectal cancer screening in average-risk individuals, whereas the double-contrast barium enema (DCBE) is now considered to be a test that may be appropriate, particularly in settings where CTC is unavailable. Single-contrast barium enema has a lower performance profile and is indicated for screening only when CTC and DCBE are not available. CTC is also the preferred test for colon evaluation following an incomplete colonoscopy. Imaging tests including CTC and DCBE are not indicated for colorectal cancer screening in high-risk patients with polyposis syndromes or inflammatory bowel disease. This paper presents the updated colorectal cancer imaging test ratings and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Gastrointestinal Imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Extramedullary Plasmacytoma of the Cecum: A Rare Cause of Iron Deficiency Anemia

Introduction: Plasmacytomas are solid myelomatous tumors composed of atypical plasma cells, which can be formed within bone or less commonly within soft tissue. Plasmacytomas are commonly associated with multiple myeloma (MM), however they may manifest outside the context of MM as solitary plasmacytomas. Extramedullary plasmacytomas are most commonly found in the aerodigestive tract, however they may present anywhere in the body. Here we present a rare case of a woman with iron deficiency anemia secondary to a cecal plasmacytoma not associated with MM. Case Report: A 73-year-old woman presented with iron deficiency anemia. Two years prior she had been diagnosed with a solitary extramedullary plasmacytoma in her right posterior mediastinum with intraspinal extension to T3. She underwent curative T2-T5 laminectomy and radiotherapy. Her disease was considered in remission at the time of presentation. After treatment of her profound iron deficiency anemia with intravenous iron, a single contrast barium enema was performed. It showed a large polypoid lesion in the lateral proximal ascending colon below the level of the ileocecal valve. These findings were indicative of colonic neoplasm and she was referred for colonoscopy. Colonoscopy confirmed the presence of a 4 cm fungating tumor at this location. This tumor was not amenable to endoscopic removal. Biopsies were taken for pathology which demonstrated plasmacytic infiltrate with frequent mitotic activity consistent with extramedullary plasmacytomas. Her β2 microglobulin level was elevated (282.5 nmol/L). She was referred back to oncology services where she was treated with concurrent prednisone and radiotherapy - 45 gray in 25 fractions. Discussion: Colonic extramedullary plasmacytomas are exceedingly rare with fewer than 25 cases reported in the literature. Any area of the gastrointestinal tract may be involved; however the most common site of involvement is the sigmoid colon. The most common presenting symptom of colonic plasmacytoma is abdominal pain; other symptoms have also been reported including overt bleeding, large bowel obstruction, and intussusception. We report a rare diagnosis of colonic extramedullary plasmacytoma from a history of iron deficiency anemia without presentation of the aforementioned symptoms. Treatment of plasmacytomas of the colon most commonly involve surgical resection. Radiotherapy and chemotherapy have only played a modest role in treatment. In our case the patient was felt to be a poor surgical candidate, and successful radiotherapy was performed.

SU‐E‐I‐100: Establishment of Local Diagnostic Reference Levels for Typical Fluoroscopic Procedures

Purpose: Diagnostic reference levels (DRLs) represent an efficient criterion for radiation protection of patients and for procedure optimization. The aim of our study was to establish local DRLs for typical fluoroscopic examinations in our institution. Methods: Three standard fluoroscopic procedures were considered in the survey: upper GI series, double contrast barium enema, and single contrast barium enema. The examinations were performed at four hospital sites in eight different rooms, including image‐ intensified systems and flat panel detector based rooms. The dose area product (DAP) was calculated from the recorded total fluoroscopy time, the FOV size, and the entrance exposure rate measured on the surface of the 20 cm water phantom. The survey included studies performed by seventeen radiologists on 280 average size patients. Local DRLs were determined as the third quartile (75th percentile) of the DAP distribution for each procedure. A one‐way ANOVA test was used to determine significance of the differences between the fluoroscopic systems and the radiologists. Results: Radiation dose to a patient in the rooms with flat panel detectors was up to 2.6 times lower than in the II‐based rooms. However, patient dose was affected not only by the performance of the system and total fluoroscopy time, but also by the chosen fluoroscopic mode. All differences between the rooms and the radiologists were significant at 95% confidence level. We had to accept the variations due to the fact that fluoroscopic examinations are patient and radiologist dependent. All local DRLs were below national values. Conclusions: We have established local diagnostic reference levels for standard fluoroscopic procedures in our institution. All values were lower than the national DRLs for those examinations. In order to implement ALARA in practice, it is important that all performing radiologists are familiar with the dose reduction options available on fluoroscopic systems existing in the institution.

Patient and staff doses for some complex x-ray examinations

The aim of this study was to measure patient and staff doses simultaneously for somecomplex x-ray examinations. Measurements of dose–area product (DAP) and entrance skindose (ESD) were carried out in a sample of 107 adult patients who underwent differentx-ray examinations such as double contrast barium enema (DCBE), single contrast bariumenema (SCBE), barium swallow, endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic cholangiography (PTC), and variousorthopaedic surgical procedures. Dose measurements were made separately foreach projection, and DAP, thermoluminescent dosimetry (TLD), film dosimetryand tube output measurement techniques were used. Staff doses were measuredsimultaneously with patient doses for these examinations, with the exception ofbarium procedures. The measured mean DAP values were found to be 8.33, 90.24,79.96 Gy cm2 for barium swallow, SCBE and DCBE procedures with the fluoroscopy timesof 3.1, 4.43 and 5.86 min, respectively. The calculated mean DAP was26.33 Gy cm2 for diagnosticand 89.76 Gy cm2 therapeutic ERCP examinations with the average fluoroscopy times of1.9 and 5.06 min respectively. Similarly, the calculated mean DAP was97.53 Gy cm2 with a corresponding fluoroscopy time of 6.1 min for PTC studies. The calculatedmean entrance skin dose (ESD) was 172 mGy for the orthopaedic surgical studies.Maximum skin doses were measured as 324, 891, 1218, 750, 819 and 1397 mGy forbarium swallow, SCBE, DCBE, ERCP, PTC and orthopaedic surgical procedures,respectively. The high number of radiographs taken during barium enema examinations,and the high x-ray outputs of the fluoroscopic units used in ERCP, were themain reasons for high doses, and some corrective actions were immediately taken.

Carcinoma of left colon presenting as mechanical obstruction in a patient with osteogenesis imperfecta type III

A 44-year-old premenopausal white woman with osteogen-esis imperfecta (OI) type III was admitted for signs of colonobstruction (Fig. 1). Plain abdominal radiographs revealeddilated loops of colon and small intestine. Single-contrastbarium enema (Fig. 2) delineated the anal canal and distalrectum with contrast stopping at the pelvic inlet. On oper-ation, dilated colon and rectum were identified up to theperitoneal fold with significant pelvic stenosis as a causeof obstruction. Further examination revealed a mass on thesplenicflexureofthecolon(Fig.3).TheHartmannprocedure(resection of the colon containing the tumour with forma-tion of a colostomy) was performed. Intraoperative bleed-ing was prominent and could have been due to underlyingconnective-tissue changes rather than a primary platelet dis-order (Hathaway and Solomons 1972). Wound healing wasnormal but stomal prolapse of 40 cm was observed. It wasunlikely to be attributable to surgical error because an ex-perienced colorectal surgeon undertook the initial operation.Prolapsecouldhavebeenduetolossoftensilestrengthoftheconnective tissue. Scott and Stris reported that surgical scarsin OI individuals tend to stretch under traction and are appar-ently weaker than those of normal individuals segment was

Successful management of a benign anastomotic colonic stricture with self-expanding metallic stents: A case report

To assess the effectiveness of and complications associated with metallic stent placement for treatment of anastomotic colonic strictures. A 46-year-old man undergoing two procedures of surgery for perforation of descending colon due to a traffic accident presented with pain, abdominal distention, and inability to defecate. Single-contrast barium enema radiograph showed a severe stenosis in the region of surgical anastomosis and the patient was too weak to accept another laparotomy. Under fluoroscopic and endoscopic guidance, we placed two metallic stents in the stenosis site of the anastomosis of the patient with anastomotic colonic strictures. In this case of postsurgical stenosis, the first stent relieved the symptoms of obstruction, but stent migration happened on the next day so an additional stent was required to deal with the stricture and relieve the symptoms. This case confirms that metallic stenting may represent an effective treatment for anastomotic colonic strictures in the absence of other therapeutic alternatives.

Peripheral blood eosinophilia associated with gastrointestinal administration of iodinated contrast media.

This study was designed to assess whether gastrointestinal administration of iodinated contrast media results in peripheral blood eosinophilia. We studied 110 patients in a retrospective review. Diatrizoate meglumine and diatrizoate sodium for abdominal CT were administered to 98 of these patients; 22 of the 98 had also been given the same contrast medium administered by enema. The remaining 12 patients were given diatrizoate sodium for gastrointestinal fluoroscopy. A control group of 65 patients underwent single-contrast barium upper gastrointestinal or enema examinations. WBC and eosinophil counts were determined approximately 24 hr before the examination and every 24 hr thereafter, through the ninth day. Eosinophilia was detected in 17 (15.5%) of 110 patients after gastrointestinal administration of iodinated contrast media. The prevalence of eosinophilia after administration of iodinated contrast media was statistically significantly different compared with that in the control group, in which none of the 65 patients had eosinophilia (p < 0.001). Eosinophilia was detected 48 hr after application of iodinated contrast agents and lasted through the sixth day, with a peak on the fifth day. The prevalence of eosinophilia was independent of route of application, dose, or type of iodinated contrast medium. Eosinophilia in all cases was clinically asymptomatic. Eosinophilia that is caused by gastrointestinal administration of iodinated contrast media is a transient, clinically silent phenomenon. It may lead to unnecessary workup for known conditions associated with eosinophilia.

Diagnostic yield of barium enema examination after incomplete colonoscopy.

To determine the diagnostic yield of barium enema examination for neoplastic lesions larger than 1 cm in diameter in the nonvisualized portion of the colon after incomplete colonoscopy. A review of computerized gastroenterology and radiology databases identified 355 patients who underwent incomplete colonoscopy; 158 (44.5%) underwent subsequent barium enema examination (125 double-contrast and 33 single-contrast barium enema examinations). The radiographic reports were reviewed and compared with the endoscopic reports by one author to identify neoplastic lesions larger than 1 cm in the nonvisualized colon after incomplete colonoscopy. Six such lesions were found. In all six cases, the images from the barium enema examinations were reviewed together by two authors to determine the size, location, and morphologic features (polypoid, ulcerated, or annular) of the lesions. Medical, endoscopic, and surgical records were subsequently reviewed by one author to determine whether these represented true- or false-positive radiographic findings. Barium enema examination depicted six possible lesions in the nonvisualized colon after incomplete colonoscopy; five were found to be true-positive radiographic findings, and one was found to be a false-positive finding. The five true-positive findings included two annular lesions (both adenocarcinomas) and three polypoid lesions (all tubulovillous adenomas, with high-grade dysplasia in one). Thus, neoplastic lesions larger than 1 cm were found on barium enema images in the nonvisualized colon in five (3.2%) of 158 patients after incomplete colonoscopy. Barium enema examination had a diagnostic yield of 3.2% for neoplastic lesions larger than 1 cm in the nonvisualized colon after incomplete colonoscopy.

Why barium enemas fail to identify colorectal cancers.

The aim of the present study was to determine the cause and clinicopathological factors associated with the failure of barium enemas to detect colorectal cancers. A histopathological database was used to identify all patients with a diagnosis of colorectal cancer between 1991 and 1995. These records were matched with the records from patients who underwent barium enema examinations between 1990 and 1995. Those patients who had a colorectal cancer histologically diagnosed within 24 months of a barium enema in which no carcinoma was seen, were identified. Where possible the radiology was reviewed. Failure to identify a carcinoma was then attributed to either simple failure, technical, interpretive or perceptive difficulties. There were 967 patients with colorectal cancers treated in Christchurch Hospital during the study period 1991-1995. Matching of these patient details with all barium enema records revealed 313 patients who had barium enemas and histologically proven colorectal cancer. There were 21 (6.7%) patients in whom a carcinoma was missed. Of these, 18 had a barium enema within 8 months of surgery, and three were performed outside this timespan (15, 18 and 28 months, respectively). On review, 11 carcinomas could not be identified (nine due to technical error: poor coating (n = 1), overlapping loops (n = 3), single-contrast enema (n = 4), faecal residue (n = 1)); and seven could be seen on review of the films (two interpretation errors, one technical and perceptive error, and four perceptive errors). In three cases films could not be found for review. In 16 of the 21 missed lesions the patient had a double-contrast barium enema (DCBE) while five patients had single-contrast barium enema (SCBE). The site and stage of missed tumours is presented. The most common reason for missed tumours was technical. The percentage of missed tumours in each region of the bowel correlates with the known incidence of tumours in each region and with a normal Dukes stage distribution, except in the caecum where the number of missed lesions was higher than expected.

Computed tomography of the colon in elderly people Single contrast barium study is adequate

EDITOR, - Michelle Fink and colleagues are presumably referring to the double contrast barium enema technique when they state that barium enema can be difficult, distressing, and unrewarding in frail elderly patients.1 We agree that the standard double contrast baruim enema can be unpleasant and unsuccessful in elderly people and that alternative techniques for examining the colon should be evaluated. The colon can be examined quickly, efficiently, and without distress by using a single contrast barium technique. For the past year it has been our policy to investigate the colon with a single contrast barium enema technique in frail elderly patients. The use of low viscosity barium suspension, often combined with smooth muscle relaxants, has proved successful in imaging the entire colon. The dilute barium suspension is infused into the rectum under gravity and flows rapidly through …

Intestinal tuberculosis: findings on double-contrast barium enema.

Seven cases of intestinal tuberculosis in an active stage were studied by the double-contrast barium enema (DCBE) method. Formerly, diagnosis of intestinal tuberculosis in the early stage by single-contrast barium enema (SCBE) and barium meals was based on functional phenomena, such as spasm and hypermotility of the ileocecal region. Presently, this can be better accomplished by DCBE. DCBE enables the detection of shallow ulcers with their characteristic elevated margins. These ulcers are frequently slim and transversally oriented. Confluence of ulcers may create whole girdle ulcers or affect entire segments. In more advanced stages, characteristic deformities, also evident by SCBE, such as symmetrical annular stenoses, shortening, retraction, pouch formation, and the frequently observed pathology of the ileocecal valve and the cecal region, acquire a new dimension with DCBE.

The role of barium enema in detecting colorectal disease. A radiologist's perspective.

The single-contrast barium enema examination remains useful for patients with acute diseases such as bowel obstruction, diverticulitis, appendicitis, and fistulas. It is also the procedure of choice for those patients who are too elderly, debilitated, or ill to cooperate with the maneuvers necessary for a double-contrast examination. The double-contrast technique is more sensitive than the single-contrast technique for detection of polyps, early inflammatory bowel disease, and lesions of the rectum. In the older population, there has been an increase in the incidence of colonic polyps and carcinomas in the right side of the colon. This emphasizes the need to examine the entire colon in these patients. The double-contrast barium enema is a safe, accurate, and cost-effective tool for accomplishing this. It is also recommended as the initial procedure in the examination of patients with positive results on fecal occult blood testing.

Barium enema versus colonoscopy for patients with polyps found during flexible sigmoidoscopy

This prospective study compares the accuracy of barium enema examination performed by experienced radiologists to colonoscopy performed by experienced gastroenterologists blinded to the radiographic findings to detect proximal, synchronous lesions in patients with polyps detected during fiberoptic sigmoidoscopy. Three thousand six patients were examined, of whom 147 (5%) had polyps larger than 0.5 cm in diameter. Of 114 patients who completed the protocol, 46 patients (40%) had synchronous, proximal colonic lesions. There were no radiographic false positives, but the single-contrast barium enema missed polyps in 13 while detecting polyps in 2 patients (sensitivity = 13%). The double-contrast barium enema missed proximal polyps in 23 patients while detecting them in 8 (sensitivity = 26%). We conclude that patients with neoplastic polyps found during fiberoptic sigmoidoscopy should have colonoscopy without barium enema. If the entire colon cannot be examined at colonoscopy, we advise double-contrast barium enema.

Endoscopic and radiographic evaluation of the murine colon

Endoscopic and radiographic techniques have not been widely applicable in the evaluation of chemically induced murine colon cancer. The authors investigated methods of cleansing the rat colon and refined endoscopic and radiographic techniques. They compared total colonoscopy (TC) and air-contrast (ACBE) and single-contrast barium enema (SCBE) findings with those obtained at necropsy in rats with 1,2-dimethylhydrazine (DMH)-induced colon cancer. Gastrograffin enemas with bisacodyl suppositiories showed complete evacuation of solid feces. Sprague-Dawley rats treated with DMH had their colons cleansed and then underwent TC (5.0-mm Olympus bronchoscope) and either SCBE or ACBE. Colonoscopy and ACBE were equally sensitive (81.5% and 76.3%, respectively), although SCBE was significantly insensitive in identifying lesions (P less than 0.001). This study demonstrates that: (1) mechanical cleansing of the rat colon is feasible, (2) TC and barium radiology can be done routinely after mechanical cleansing, and (3) TC and double-contrast BE are sensitive in identifying colon lesions. These techniques will provide a means for manipulation of murine tumors and in vivo surveillance.

Computed tomography of retroperitoneal perforation after barium enema

A case of retroperitoneal perforation of the rectum complicating a single contrast barium enema is presented. The appearances on computed tomography (CT) allowed accurate depiction of the extent of barium extravasation not appreciated on plain films. Although this is an unusual complication of the barium enema, CT may prove useful when the suspicion of perforation arises.

Fatal hypersensitivity reaction during a barium enema

Barium contrast examinations of the gastrointestinal tract are considered relatively innocuous procedures; most major complications result from perforation of the bowel. Allergic reactions to the contrast material have long been considered extremely rare, although there have been increasing reports of allergic complications due to the contrast material or glucagon [1 , 2]. Most reports have described fairly mild allergic reactions with pruritus, urticaria, and some edema [1 , 2]. Occasionally, the reactions have been more serious, and respiratory distress has occurred [3]. At least one well-substantiated death, which appeared to be due to an anaphylactoid response, has occurred during a barium enema [4]. We report a case of a woman with an extensive history of allergy who had a fatal anaphylactoid reaction during a single-contrast barium enema.

Pseudomembranous colitis with rectosigmoid sparing on barium studies.

The classic description of pseudomembranous colitis on barium enema studies is that of pancolitis with thickened haustral folds, a shaggy luminal contour, and/or mucosal plaques. However, the authors describe six patients with proved pseudomembranous colitis in whom barium studies (four double-contrast barium enema studies, one single-contrast barium enema study, and one peroral pneumocolon study) demonstrated rectosigmoid sparing with proximal colitis extending from the cecum to the sigmoid colon (three cases) or to the descending colon (three cases). In all six cases, endoscopy revealed a normal rectum or mild, nonspecific proctosigmoiditis without evidence of pseudomembranes in the rectosigmoid colon. Four patients had an atypical clinical presentation with bloody diarrhea (three cases) or minimal mucous diarrhea (one case). Thus, the diagnosis of pseudomembranous colitis may initially be suggested on barium studies in patients who have relative sparing of the rectosigmoid colon with characteristic findings more proximally in the colon.