Diagnostic yield of barium enema examination after incomplete colonoscopy

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: Barium enema examination had a diagnostic yield of 3.2% for neoplastic lesions larger than 1 cm in the nonvisualized colon after incomplete colonoscopy.     

Colonic cleansing for radiographic detection of neoplasia: efficacy of the magnesium citrate-castor oil-cleansing enema regimen

To optimize detection of colonic polyps, we instituted a cleansing regimen of dietary restriction, hydration, magnesium citrate, castor oil, and a cleansing enema. We then conducted a review of serially performed barium enemas to determine the percentage of patients with clean colons in a mixed population of 500 inpatients and outpatients in whom this regimen had been used. The same regimen also was used before single- and double-contrast barium enemas were performed in 139 patients with 234 polyps, and radiologic-endoscopic correlation was used to determine the percentage of polypoid neoplasms detected. The review indicated that a clean colon had been achieved in 97% of the 500 cases. In an additional 1.4% of patients, fecal residue was limited to small amounts in the cecum or ascending colon. In only two cases (0.4%) did fecal material prevent an examination that was suitable for detection of large polypoid or circumferential lesions. The single- and double-contrast barium enemas detected 80% and 91%, respectively, of polypoid lesions of all sizes. Single-contrast examinations detected 94% of polyps 10 mm or larger and 72% of polyps 5-9 mm. Double-contrast studies detected 96% of polyps 10 mm or larger and 88% of those 5-9 mm. The results of this study indicate that with this regimen, fecal residue does not significantly interfere with the detection of colonic polyps via barium enema examination.     

Single-contrast vs double-contrast barium enema in the detection of colonic polyps

Radiographic and colonoscopic correlation in 139 patients with 234 colonic polyps compared the sensitivity of single- and double-contrast barium enema. Single-contrast barium enema detected 68 (80%) of polyps, with 72% of polyps under 1 cm and 94% of those 1 cm or over detected. Double-contrast barium enema detected 135 (91%) of 149 polyps, with 88% of polyps under 1 cm and 96% of larger polyps detected. Thus, the double-contrast barium enema was more effective than the single-contrast examination only for detection of polyps under 1 cm. The single-contrast barium enema was more likely performed on patients in poor physical condition and in those over 70 years old. The results suggest that for elderly patients, who may have difficulty in cooperating for a double-contrast enema, a properly performed single-contrast examination is an acceptable option.     

Giant hyperplastic polyps in the stomach: radiographic findings in seven patients

OBJECTIVE: We reassessed the radiographic findings of giant hyperplastic polyps in the stomach on double-contrast upper gastrointestinal examinations in seven patients. CONCLUSION: Giant hyperplastic polyps in the stomach may be manifested by distinctive findings on double-contrast barium studies, appearing as polypoid lesions with multiple lobulated components that form a conglomerate mass. Nevertheless, endoscopy and biopsy are required to rule out a polypoid carcinoma as the cause of these findings.     

Positive predictive value and posttest probability of diagnosis of colonic polyp on single- and double-contrast barium enema

The positive predictive value for a radiographic diagnosis of colonic polyp, the prevalence of polypoid disease, and posttest probability relative to patient age were studied. The positive predictive value for colonic polyp on single- and double-contrast barium enema was determined for 191 polyps found radiographically in 136 patients who also underwent colonoscopy for confirmation. Of 72 polyps seen in 54 patients on single-contrast examination, 59 were confirmed endoscopically; 110 of 119 polyps seen in 82 patients on double-contrast examination were confirmed similarly, giving positive predictive values of 82% and 92%, respectively. Positive predictive values per patient, disregarding the number of polyps present, were 87% (47/54) and 90% (74/82) for the single- and double-contrast examinations, respectively. False-positive errors were due to stool, air bubbles, haustration, and misinterpretation of an appendiceal stump. By using specificities derived from our prevalence of polypoid disease and previously reported sensitivities, we drew posttest probability curves showing that predictive values depend both on the chance of disease before the test is done and on the efficacy of the test used.     

Small flat umbilicated tumors of the colon: radiographic and pathologic findings

OBJECTIVE: We describe the radiographic and pathologic findings of small flat umbilicated tumors of the colon detected on double-contrast barium enema examinations performed in a Western population. CONCLUSION: Unlike those reported by Japanese authors, the small flat umbilicated tumors of the colon in our patients were usually hyperplastic polyps, previously called "inverted hyperplastic polyps." Nevertheless, colonoscopy with excisional biopsy is warranted for such tumors detected on double-contrast barium enema examinations because of the small possibility that these tumors represent adenoma or even early adenocarcinoma.     

Detection of colonic polyps on single-contrast barium enema study: emphasis on the elderly

A systems approach was employed to improve results of the single-contrast barium enema examination for detection of colonic polyps. Improvements were made in each of the following areas: radiographic-fluoroscopic equipment, fluoroscopic-television images, screen-film combinations, barium suspensions, examination techniques, imaging sequences, and quality controls. Radiologic-endoscopic correlation was undertaken for 137 colonic polyps seen endoscopically in 91 patients. The average age of the patients was 69 years. The sensitivity of the single-contrast examination for detection of all polyps was 80%. Polyps 5-9 mm in size were detected with 66% sensitivity, while 94% of polyps 10 mm or larger were detected. The results indicate that the sensitivity of a suitably performed single-contrast barium enema examination may approach that of the double-contrast study for the detection of colonic polyps, even in an elderly and infirm patient population.     

Role of ultrasonic diagnosis as a complementary method in contrast radiography of the intestines

This study was aimed at evaluating US reliability and sensitivity in identifying inflammatory or neoplastic bowel diseases in symptomatic patients. Two hundred and fifty patients who had been referred to our Unit for double-contrast barium enema of small bowel and colon, underwent panoramic and targeted abdominal US. According to well-known pathological criteria--i.e., intestinal wall thicker than 5 mm, and pseudo-kidney pattern--US had 61.7% sensitivity for inflammatory and neoplastic bowel diseases. The results indicate that US findings negative for intestinal disease are not reliable unless confirmed by contrastographic and endoscopic examinations. However, panoramic US occasionally demonstrated intestinal abnormalities and allowed collateral diseases to be observed in other organs or apparatuses. These abnormalities had been missed at contrastography, and were sometimes responsible for the symptoms the patients complained of. Targeted US emerged as a useful tool for detailing the lesions demonstrated by double-contrast barium enema, especially in case of expansive pathologies (size of the mass and relationship to adjacent organs).     

Internal hemorrhoids: diagnosis with double-contrast barium enema examinations

The authors retrospectively studied 43 patients suspected of having internal hemorrhoids at double-contrast barium enema examination. At endoscopy, 24 patients (56%) had internal hemorrhoids, four (9%) had other pathologic lesions in the rectum without evidence of hemorrhoids, and 15 (35%) had no reported abnormalities in the rectum. Internal hemorrhoids were found at endoscopy in 10 of 20 patients (50%) with lobulated folds extending 3 cm or less from the anorectal junction and 10 of 13 patients (77%) with multiple submucosal nodules. However, no patients with these characteristic radiographic findings were found to have other pathologic lesions in the rectum that had been mistaken for hemorrhoids at barium enema examination. Conversely, three of four patients with lobulated folds extending more than 3 cm from the anorectal junction and one of six patients with solitary nodules had proctitis or rectal neoplasms. Thus, specific criteria are suggested for the diagnosis of internal hemorrhoids on double-contrast barium enema examinations. Suspected hemorrhoids that do not fulfill these criteria should be evaluated endoscopically to rule out other more serious pathologic lesions in the rectum.     

Diagnosis of colorectal neoplasms at double-contrast barium enema examination

The double-contrast barium enema examination has been recognized as an option for colorectal cancer screening in Americans with average risk who are greater than 50 years of age. The purpose of this article is to review the principles for diagnosing colorectal neoplasms on double-contrast images and the spectrum of findings associated with these lesions. Colonic polyps can be sessile or pedunculated; their appearance depends on whether they are located on the dependent or nondependent wall of the bowel. Villous tumors may be flat, lobulated lesions, also known as "carpet" lesions, that are characterized by a finely nodular or reticular surface pattern, without a discrete mass. Colonic carcinomas may manifest as plaquelike, polypoid, semiannular ("saddle") or annular lesions. Colonic neoplasms sometimes are more difficult to detect in the region of the ileocecal valve or the distal rectum or in patients with severe diverticulosis. Careful double-contrast technique and meticulous scrutiny of the images therefore are required to optimize detection of these lesions.     

Barium enema and endoscopy for the detection of colorectal neoplasia: sensitivity, specificity, complications and its determinants

AIM: To analyse sensitivity, specificity and complication rate of endoscopy, and barium enema for the detection of colorectal neoplasia. MATERIALS AND METHODS: A MEDLINE search was performed (1980-2000) directed at the endoscopic and radiologic literature on barium enema. Articles were selected based on the type of study, availability of sensitivity and specificity values in sizeable patient groups, and reports on complications. Sixty articles were included in the analysis. RESULTS: Endoscopy proved to have superior sensitivity for polyps in patients at high-risk for colorectal neoplasia. The role of endoscopy and radiology in average-risk screening populations is not known. Sensitivity and specificity rates ranged widely, probably due to bias. For the detection of small polyps endoscopy has superior performance, whereas sensitivity is similar for endoscopy and barium enema for the detection of larger (>1 cm) polyps and tumours. Overall, endoscopy is associated with a higher complication rate. CONCLUSION: Endoscopy is the preferred detection method in high-risk patients. The role of endoscopy and radiology in a screening setting requires evaluation. This review provides the test characteristics of endoscopy and radiology which are relevant for a cost-effectiveness analysis. Double-contrast barium enema may play an important role for screening purposes, owing to its good sensitivity for detecting larger (>1 cm) polyps and its lack of major complications. de Zwart, I. M.et al. (2001). Clinical Radiology56, 401-409.     

Colon polyp morphology on double-contrast barium enema: its pathologic predictive value

The morphologic appearance of 96 polyps seen on double-contrast barium enema was reviewed to assess the predictive value of various signs described to diagnose malignancy. Size, surface contour, basal indentation, and pedunculation were studied. Sessile polyps had an appreciable incidence of malignancy, with size being the best indicator of that risk. Pedunculation was found to be a reliable sign of benignity in predicting the absence of malignant invasion into the adjacent colonic wall. Polyps under 1 cm and having a smooth contour were invariably benign. Conversely, polyps larger than 1 cm with a lobulated contour and basal indentation had a significant incidence of malignancy.     

Diverticular disease: imaging with post-double-contrast sigmoid flush

In a prospective study, the effect of infusion of a low-density contrast material was evaluated as an adjunct to high-density, double-contrast imaging of the sigmoid colon. After double-contrast barium enema (DCBE) study, 52 consecutive patients with sigmoid diverticulosis received an additional 500-750-mL enema either with water or a 1.5% barium suspension for computed tomography. Rectosigmoid radiographs were evaluated for luminal distention, visualization of the interhaustral space, definition of diverticula, and interpretation of polypoid defects. While double-contrast views were excellent in 21% of patients, improvement in multiple factors by water or 1.5% barium flush resulted in improved sigmoid images in 65% and 75% of patients, respectively. Polyps were confirmed and artifactual defects confidently excluded. Sigmoid flush, particularly with low-density barium, is a simple adjunct to DCBE study that improves visualization of the diverticular sigmoid and increases interpretive confidence.     

A retrospective 5-year study on the accuracy of the barium enema examination performed by radiographers

Barium enema examinations have been undertaken by radiographers at the Frenchay Hospital for more than 10 years. We have performed a retrospective study to assess the accuracy of this radiographer service by reviewing those patients who have been examined by both Barium enema and colonoscopy/flexible sigmoidoscopy to determine agreement, and reasons for disagreement. This paper does not attempt to compare the two techniques. In the 5 years between 1992 and 1996, 595 patients had both barium enema and colonoscopy or flexible sigmoidoscopy. In 488 (82%) of these patients the barium enema examination was performed by a radiographer. Comparisons with endoscopy indicate that 96% of polyps >1 cm, and 97% of carcinomas were detected radiologically. We conclude that radiographer performed barium enemas with double reporting produces a very high standard of examination with detection rates for significant lesions comparable with published data.     

Sensitivity of double-contrast barium study for left-colon polyps

A blinded, prospective study was conducted to determine the sensitivity of double-contrast barium enema examination (DCBE) in detecting left-colon polyps. Metal clips were endoscopically placed on normal mucosa either adjacent to polyps (in 65 study subjects with 92 polyps) or not adjacent to polyps (in 50 control subjects). DCBE had a high sensitivity for detection of polyps greater than or equal to 1 cm and 6-9 mm in size (100% and 83% detection, respectively) but was insensitive in detecting polyps in the 4 to 5-mm and 2 to 3-mm size ranges (56% and 22% detection, respectively). The factors contributing most commonly to false-negative interpretations were the presence of air bubbles, overlap of bowel loops, and luminal fecal debris. No error in radiographic technique was evident to account for false-negative interpretations in 14 (41%) of 34 polyps that were not detected by DCBE.     

Ileocecal valve: spectrum of normal findings at double-contrast barium enema examination

PURPOSE: To characterize the spectrum of normal findings of the ileocecal valve at double-contrast barium enema examination to allow differentiation between a normal valve and one infiltrated by tumor. MATERIALS AND METHODS: A search of radiology and endoscopy files showed 106 patients who underwent double-contrast barium enema examination and colonoscopy. The radiographic images were reviewed by two authors to determine the morphology of the ileocecal valve and to evaluate whether it appeared normal or abnormal. The radiographic data were then correlated with endoscopic and pathologic findings. RESULTS: The ileocecal valve was visible in 91 (86%) of 106 patients. It was round or ovoid in 71 patients (78%) and triangular in 20 (22%). In the 88 patients with a normal valve at colonoscopy, mean valve height was 1.7 cm, and mean width was 2.8 cm. The valve was smooth in 75 patients (85%) and smoothly lobulated in 13 (15%). The lips of the valve were symmetric in 77 patients (88%) and asymmetric in 11 (12%). All 87 patients with a normal valve at double-contrast barium enema examination had a normal valve at colonoscopy, whereas the two patients with a valve suspicious for tumor at barium enema examination had neoplasms (one carcinoma and one villous adenoma) at colonoscopy. CONCLUSION: The ileocecal valve may show a spectrum of normal findings at double-contrast barium enema examination and may appear as a round, ovoid, or triangular structure with a maximal height of nearly 4 cm. The valve may be large, asymmetric, or smoothly lobulated, even in the absence of tumor.     

早期结肠癌低张气钡双对比造影检查与纤维结肠镜对比分析

目的:对于早期结肠癌的检查,通过低张气钡双对比造影(DCBE)图像与纤维结肠镜检查图像对比观察,分析气钡双对比结肠造影在检出早期结肠癌中的价值。方法:20例经病理证实早期结肠癌病例,采用低张气钡双对比造影方法,实时点片。常规纤维结肠镜检查。结果:Ⅰ型11例,Ⅱa型6例,混合型1例,LST型2例,对比观察造影像及内镜像表现。结论:正确运用气钡双对比造影检查,对早期结肠癌的显示有较大价值。     

What happens to patients after upper and lower gastrointestinal tract barium studies?

We investigated the occurrence of new constipation, diarrhea, nausea, vomiting, visible blood in stool, abdominal pain, black stools, belching, and flatus in 324 outpatients following upper or lower gastrointestinal tract barium procedures. We also evaluated the roles of age, sex, patient mobility, and types of barium enema (single- or double-contrast). At least one new symptom was reported after 51% of all examinations. Constipation was the most frequently reported single symptom after barium meal or small bowel examinations. Fifty percent of all constipation occurred following upper gastrointestinal examinations. Abdominal pain was common in patients of the seventh decade, especially following barium enema. Nausea typically followed barium swallow or upper gastrointestinal series. Belching and passage of flatus were the most frequently reported symptoms after barium enema, both single- and double-contrast. No significant relationship between the frequency of symptoms and patient age, sex, or the type of barium enema was established.     

Radiologic recognition of colonic diverticula simulating polyps

The differentiation of colonic polyps and diverticula on the double-contrast barium enema is generally straightforward, using current diagnostic criteria. However, diverticula may be misinterpreted on the double-contrast barium enema as polyps when they appear uncommonly as filling defects within the barium pool. As a result of such erroneous interpretation, the patient may subsequently undergo costly and inconvenient repeat barium enema or colonoscopy. Carefully studied scout films, oblique views, compression spot images, and postevacuation films generally can differentiate these diverticula from polyps. The usual reason that a diverticulum assumes the appearance of a polyp is that it contains impacted stool.