Adult Crohn disease: can ileoscopy replace small bowel radiology?

Background: This study aimed to document the radiological features and distribution of small bowel Crohn disease (CD) in adults by using a barium follow-through (BaFT) technique and to determine whether disease would be missed or its distribution underestimated if only colonoscopy with ileoscopy were performed. Methods: The BaFT examinations of 121 adults with proven CD were reviewed retrospectively with respect to the stage and distribution of disease. Colonoscopy with attempted ileoscopy was performed in 37 of these subjects, and the results were compared with radiological findings. Results: A normal villous pattern was visualized in 89 studies (74%). BaFT showed small bowel CD in 71 (59%) of 121 patients studied. The terminal ileum (TI) was the most common site of disease, affecting 62 (87%) of patients with small bowel CD. Forty-six patients (65%) had more proximal small bowel disease, including nine (13%) with a normal TI. BaFT showed early mucosal changes of CD in 52 subjects (73%), which was the sole manifestation in 15 (21%). Ileoscopy was possible in the majority of patients colonoscoped but was not achieved in 14 (38%), nine of whom had CD on BaFT. Of the 23 patients in whom ileoscopy was performed, findings agreed with BaFT assessment of the TI in 22. Conclusion: BaFT adequately demonstrates the stage and extent of small bowel CD. The majority of patients with small bowel CD have disease proximal to the TI, which cannot be diagnosed by ileoscopy. Received: 27 August 1996/Accepted: 16 October 1996     

Double contrast examination of the small bowel

The technique for contrast examination of the small bowel has been considerably elaborated during recent years by the reintroduction of duodenal intubation by Sellink. A double contrast method for the small bowelvia duodenal intubation is presented based on a propective study of 202 patients. When the injected contrast medium had reached the cecum, air was introduced and double contrast views were obtained of the terminal ileum and cecum. It was noted that air passed very rapidly through the bowel but did not seem to influence the transit of the positive contrast medium. The duration of the examination in 75% of the cases was less than 45 min.     

Spiral CT of the abdomen after distention of small bowel loops with transparent enema in patients with Crohn's disease

Background: To evaluate the capability of a computed tomographic (CT) technique that combines distention of the small bowel loops with a transparent enema with contrast-enhanced spiral CT of the abdomen in patients with Crohn's disease. Methods: We evaluated the abdomen with spiral CT after distention of the small bowel loops with a transparent enema of methylcellulose in 40 patients consecutively referred for radiologic evaluation of Crohn's disease of the small bowel. Fluid was infused through a nasojejunal catheter with a peristaltic pump. Ultrasonography was used to prevent bowel overdistention and detect arrival of methylcellulose to the cecum. Contrast-enhanced spiral CT of the abdomen was then performed, and the degree of contrast enhancement and the thickness of the walls of the involved loops were evaluated. A series of 10 patients with retrograde distention of the last ileal loop from large bowel water enema was used as a control. The results of the CT were compared with those of conventional radiographic small bowel studies. Results: The normal small bowel wall was 1.9–2.5 mm thick (mean = 2.1 mm); density values of the normal enhanced wall varied between 25 and 60 HU (mean = 32 HU) and presented a homogeneous structure. Bowel segments involved by the disease were 4–12.5 mm thick (mean = 9.2 mm), had density values of 75–150 HU (mean = 105 HU), and showed a multilayered appearance. Compared with conventional radiography, CT detected longer lesions or additional segments involved by the disease process in 14 cases, 11 additional fistulas, two abscesses, and mesenteric changes in 21 cases. Conclusions: The small bowel CT enema technique provides good results in the study of patients with Crohn's disease and can be used to evaluate patients with advanced lesions. Received: 24 June 1998/Revision accepted: 27 January 1999     

Current status of small bowel radiography

Background: In the past, small bowel examinations were usually ordered for the sake of ``completeness.' As a result, small bowel radiography was performed casually and without attention to detail. This review examines pertinent clinical issues and the recent contribution of small bowel radiography to the evaluation and management of the patient with suspected small bowel disease. Recommendations for the clinical utilization of small bowel radiography are discussed. Methods: Analysis of pertinent citations addressing valid indications for, and technique of, small bowel radiography from 1980 to July 1995 through a computerized bibliographic search (Medline and Current Contents). Results: Accepted clinical indications for small bowel radiography include (1) unexplained gastrointestinal bleeding, (2) possible small bowel tumor, (3) small bowel obstruction, (4) Crohn disease, and (5) malabsorption. The current literature reflects the limitations of the conventional small bowel follow-through, various modifications to improve its clinical yield, the important contribution of enteroclysis in the workup, and subsequent management of patients with possible small bowel disease. A controversy in the radiology literature exists as to whether to use the small bowel follow-through or enteroclysis as the primary method of examining the small bowel. Conclusion: The thoughtful selection of patients by clinicians for small bowel radiography is essential to make radiologic evaluation cost effective. The incidence of disease of the small intestine is low and is associated with nonspecific symptoms. Because of the inherent difficulty of visualizing numerous loops of an actively peristalsing bowel, a reliable imaging method is needed that not only detects small or early structural abnormality but also accurately documents normalcy. The yield of information provided by enteroclysis and its high negative predictive value suggests that it should be the primary method for small bowel examination. The ``overhead'-based conventional small bowel follow-through should be abandoned. The ``fluoroscopy'-based small bowel follow-through augmented when necessary by the peroral pneumocolon or the gas-enhanced double-contrast follow-through method is an acceptable alternative when enteroclysis is not possible. Received: 0/0/00Accepted: 0/0/00     

Cisapride or metoclopramide to accelerate small bowel transit during barium follow-through examination?

Background: Metoclopramide is commonly used to accelerate small bowel transit during barium follow-through (BaFT) examinations, but its action is unpredictable. Cisapride, commonly used to treat gastroesophageal reflux disease, also accelerates small bowel transit and may be a viable alternative. The two were compared in a prospective, randomized, blind study. Methods: Patients attending for BaFT were randomized to receive either 10 mg cisapride or 20 mg metoclopramide orally 1 h before the barium suspension. BaFT was performed by using a standard technique, and small bowel transit and study quality were compared. Patients also noted any side effects experienced. Results: Of 45 patients recruited, 27 received cisapride and 18 metoclopramide. Median transit time for the cisapride group was 30 min (range = 10–130 min) versus 67.5 min (range = 30–290 min) for the metoclopramide group (p= 0.019). Study quality was comparable. However, nine patients (33%) receiving cisapride experienced nausea versus only one subject (6%) receiving metoclopramide (p= 0.034). Conclusions: This study suggests that cisapride is a more effective prokinetic agent than metoclopramide, but this benefit is offset by a higher incidence of side effects. Received: 17 August 1999/Revision accepted: 3 November 1999     

CT of small bowel obstruction in adults

The increasing use of computed tomography in evaluating patients with acute abdominal pain has revolutionized the diagnosis of small bowel obstruction in adults. Computed tomography is incontestably the most useful and powerful tool to make positive, topographic, and etiologic diagnoses of small bowel obstruction. Good knowledge of some key signs and rigorous analysis of computed tomographic images by radiologists should lead to improved diagnosis and appropriate treatment.     

Primary small bowel tumors: a radiologic-pathologic correlation

Background: Primary small bowel tumors are rare and their preoperative diagnosis is unsatisfactory. The cornerstone of diagnosis remains contrast radiography. The present study was done to evaluate the radiologic findings of primary small bowel tumors as shown on enteroclysis and to correlate these observations with surgical and histopathologic findings. Methods: Seventy two patients with primary small bowel tumors identified by enteroclysis were evaluated. All the patients were subjected to jejunal biopsy or surgery. The diagnosis was established by histopathologic examination in all cases. Results: Radiologic findings were suggestive of benign tumors in 19 patients and malignant tumors in 31 patients. Nonspecific findings in the form of diffuse involvement of the small bowel were noted in 22 patients. There was 100% radiologic–surgical correlation. Leiomyomas and lymphomas were the most common benign and malignant tumors, respectively. Tumor specificities were 89.5% for benign tumors and 41.5% for malignant tumors. Conclusion: Distinctive morphologic patterns as shown on enteroclysis are highly suggestive of specific tumor types in the majority of cases. Received: 25 April 2000/Revision accepted: 20 September 2000     

Acute diverticulitis of the small bowel: CT findings

We present the computed tomographic (CT) findings in two cases of small bowel diverticulitis, one affecting the jejunum and the other a Meckel's diverticulum. The main CT finding was that of a mass with an air–fluid collection in contiguity with small bowel loops. Received: 18 September 1998/Accepted: 2 December 1998     

Vaginal opacification during defecography: direction of vaginal migration aids in diagnosis of pelvic floor pathology

Background: To determine whether direction of vaginal displacement during defecography aids in diagnosing pelvic floor pathology. Methods: Ninety patients underwent defecography over a 2-year period. Each study was retrospectively reviewed by three radiologists who recorded whether the vagina was displaced cephalad, caudad, or nondisplaced in relation to the urogenital hiatus. This information was then correlated with radiologic diagnosis rendered for the study. Results: Of the 26 patients with normal defecograms, 19 (73%; p < 0.001) demonstrated no vaginal displacement during the procedure. Comparatively, 10 (83%; p < 0.001) of the 12 patients with cystoceles showed caudad vaginal displacement, and no patients with cystoceles showed cephalad displacement of the vagina. Of the 17 patients with rectoceles, 10 (58%) showed cephalad displacement, one (6%) showed caudad displacement, and six (35%) patients showed no vaginal displacement. Thirteen (46%) of 28 patients with enteroceles showed cephalad vaginal displacement, nine (32%) showed no vaginal displacement, and six (21%) demonstrated caudad displacement. Conclusions: Caudad displacement of the opacified vagina suggests the presence of a cystocele. Cephalad vaginal displacement is suggestive of the presence of an enterocele or rectocele. Received: 4 December 1998/Revision accepted: 10 March 1999     

Crohn's disease of the small bowel examined by double contrast technique: A comparison with oral technique

The combination of orally administered bartion is an old method which has come into use again. The technique is simple to perform and the examination is of short duration. In order to evaluate the applicability of this method it was compared with the oral technique in 43 patients with Crohn's disease of the small bowel who were examined by both methods. The tube technique revealed more clearly all pathologic changes except fistulas. The proximal extension of the changes and their demarcation from healthy intestine appeared more distinctly with the tube technique.     

Vaginal opacification during defecography: utility of placing a folded gauze square at the introitus

We evaluated the value of placement of a folded gauze square into the urogenital introitus to improve vaginal opacification in 90 patients who underwent defecography. Of the 50 patients who retained the gauze in the introitus, 96% demonstrated excellent or good vaginal opacification. By contrast, only 75% of the 40 patients who lost the gauze during the study were able to achieve the same level of opacification. This difference was shown to be statistically significant (p < 0.002), suggesting that placement of a folded gauze square in the introitus limits loss of contrast from the vagina, which improves vaginal opacification. Received: 12 October 1998/Revision accepted: 27 January 1999     

Intestinal tuberculosis with abdominal complications: radiologic and pathologic features

Background: To investigate radiologic and pathological features of intestinal tuberculosis with abdominal complications. Methods: Twenty-two patients with 23 surgically proven complications (nine intestinal obstructions, eight perforations, three fistulae, and three intestinal bleeds) were analyzed. Medical records, radiologic studies, and pathologic examinations were reviewed with special emphasis on searching for the common features in each group of complication. Results: The most important single feature in seven of the nine patients with intestinal obstruction was the presence of stricture. In the remaining two patients, bowel adhesion was a primary cause of obstruction. In eight patients with intestinal perforation, both obstruction and ulcerations in the dilated proximal loop were the important features in six, and multiple deep ulcerations without obstruction was a primary cause in the remaining two. The common features in three patients with fistulae were focal or multiple strictures, severe adhesions, and fibrotic bowel wall. Intestinal bleeding originated from diffuse mucosal ulcerations. The abdominal complications occurred during antituberculous therapy in 10 of the 22 patients. Conclusion: Understanding the radiologic and pathologic features of intestinal tuberculosis with complications help in making an appropriate clinical decision for the treatment strategy. Close observation is necessary, especially in those patients who are acutely ill during antituberculous medical therapy. Received: 30 June 1997/Accepted 20 August 1997     

Laxatives prior to small bowel follow-through: Are they necessary for a rapid and good-quality examination?

Fifty-six patients undergoing small bowel follow-through examination were randomly allocated to two groups to assess the effect of preparation with laxative on the speed and quality of the examination. We found that laxative had no effect on either speed of the examination or quality of visualization of small bowel. However, the latter was dependent on the degree of supervision and technique of the examining radiologist.     

Helical CT of the small bowel with an alternative oral contrast material in patients with Crohn disease

Background: We assessed the usefulness of helical computed tomography (CT) with a negative oral contrast material for detecting Crohn disease. Methods: Thirty-eight patients with proven Crohn disease were examined. We administered a large volume of a new negative oral contrast material (Mucofalk suspended in water) and then proceeded with helical CT scanning. This technique is an alternative to CT and conventional enteroclyses that use a nasojejunal tube. Two radiologists interpreted the scans, and patients were interviewed about their tolerance of the procedure. We created multiplanar reformatted images in all cases. Potential of small bowel distention by Mucofalk was evaluated by two observers on a three-point scale, and interobserver agreement was calculated with κ statistics. Results: All patients who underwent enteroclysis stated that CT was the more comfortable method, the taste of the peroral contrast medium was considered good by 52.6% and acceptable by 47.4%. Small bowel distention was excellent in 55% of cases, moderate in 26%, and poor in 19%, with an interoberserver agreement of 78%. CT findings correlated with enteroclysis in 27 patients who underwent both methods. Analysis of CT versus enteroclysis showed a sensitivity of 89% for CT versus 78% for small bowel enteroclysis. Conclusion: Mucofalk CT is a simple, rapid, noninvasive, and accurate method of evaluating extramucosal manifestations of Crohn disease. The tubeless procedure improved patients' comfort and decreased time, cost, and radiation exposure.     

Ultrasound examination of the small bowel: comparison with enteroclysis in patients with Crohn disease

Background Screening for inflammatory small bowel disease has hereto relied on barium examination, usually performed after duodenal intubation. A noninvasive technique for imaging of the small bowel in such patients would be preferable.Methods A total of 59 patients were included in the study. A small bowel barium examination (SBE) was performed after duodenal intubation using a barium and air double-contrast technique. Ultrasound (US) of the right lower quadrant was performed with a 3.5- or 5-MHz transducer. The patients fasted overnight.Results In 37 of 39 patients with a normal SBE, US was also normal. In 20 patients, SBE showed lesions compatible with Crohn disease and in 18 of these the US study showed thickening of the bowel wall. One of these patients later tested positive for Yersinia enterocolitica. There were two false-positive and two false-negative US examinations.For detection of inflammatory disease of the small bowel, US was calculated to have a sensitivity of 0.95, specificity of 0.93, accuracy of 0.93, predictive value of a positive test was 0.90, and a predictive value of a negative test was 0.95.Conclusions US, therefore, seems to be a reliable method in the workup of patients suspected of having inflammatory small bowel disease. Thereby, US probably can select patients for SBE.     

Enteroclysis: The small bowel enema

Enteroclysis, the infusion of contrast medium directly into the small bowel, is a precise, rapid method for thorough small bowel examination. This technique demonstrates far more pathology than any other method when it is properly executed. However, the examination is sure to fail with poor techniques, thereby discrediting a superb method. Experience has shown that failures are usually due to inadequate technique or poor judgment or both during the examination. This article covers the proper and improper techniques of the examination and gives examples of each. The most common problems that arise during the examination are discussed in the order in which they usually develop.     

Eosinophilic gastroenteritis: percutaneous biopsy under ultrasound guidance

Eosinophilic gastroenteritis (EG) is an unusual disorder that is characterized by diffuse or scattered eosinophilic infiltration of the digestive tract. The diagnosis is based on histology obtained by capsule, endoscopic, laparoscopic, or laparotomy biopsy. The eosinophilic infiltration produces thickening of the small bowel wall that can be observed by using sonography. The appearance produces the pseudokidney sign that can be used to guide biopsy. We report the first case of EG diagnosed by percutaneous biopsy under ultrasound guidance. Received: 11/14/96/Accepted after revision: 2/19/97     

CT findings of isolated small bowel angioedema due to iodinated radiographic contrast medium reaction

We report three cases of small bowel angioedema that showed circumferential wall thickening of the small bowel loops during infusion of iodinated contrast media. Follow-up small bowel series or computed tomography confirmed the normalized small bowel loops. When significant wall thickening of the long segment of the small bowel during infusion of contrast media is seen, radiologists should consider the possibility of isolated small bowel angioedema in spite of its rarity. Received: 4 February 1998/Accepted: 11 March 1998     

CT differentiation between necrotic and nonnecrotic small bowel in closed loop and strangulating obstruction

Background: The purpose of this study was to evaluate computed tomographic (CT) findings for predicting the presence of intestinal necrosis in patients with closed loop and strangulating obstruction of the small bowel. Methods: Twenty-five patients with surgically confirmed closed loop and strangulating obstruction were divided into two groups with (n= 16) and without (n= 9) intestinal necrosis. By using univariate and multivariate statistical procedures, we evaluated the differences in CT findings between the two groups on the basis of the following six findings: bowel dilatation of strangulated loops (bowel dilatation), wall thickening of strangulated intestines (wall thickening), ascites, vascular dilatation of affected mesenteries (vascular dilatation), elevation of mesenteric attenuation (mesenteric attenuation), and radial distribution of the mesenteric vessels (radial distribution). Results: Of the six findings, ascites, vascular dilatation, mesenteric attenuation, and radial distribution provided significant discriminating findings between the two groups on univariate analysis. On multivariate analysis, mesenteric attenuation was the most important discriminative factor, followed by radial distribution and ascites. Using these three parameters, the CT was correlated with the surgical findings in 15 of the 16 patients in the necrosis group (sensitivity = 93.8%) and in eight of the nine patients in the nonnecrosis group (specificity = 88.9%). The overall accuracy was 92.0%. Conclusions: Mesenteric attenuation, radial distribution, and ascites, depicted on CT differentiate well between necrosis and nonnecrosis of the small bowelin patients with closed loop and strangulating obstruction. Received 5 December 1997/Accepted: 14 January 1998     

Computed tomographic appearance of sigmoid volvulus

The computed tomographic (CT) appearance of two cases of sigmoid colon volvulus is described. Both underwent plain abdominal radiographs, contrast enema, and CT. The findings of sigmoid volvulus at CT were characteristic, having a whirl pattern of the dilated sigmoid loop around mesocolon and vessels and a bird-beak aspect of the afferent and efferent segments. CT may be valuable in a case of unusual clinical or plain film presentation as an alternative to contrast enema. Received: 24 March 1995/Accepted: 3 May 1995