Use of barium in evaluation of disorders of the upper gastrointestinal tract: current status

Biphasic contrast studies are generally advocated as the best current barium examination for the upper GI tract. Two recent prospective blinded trials compared the diagnostic results of a biphasic contrast examination--employing a medium-density barium suspension and glucagon--and endoscopy. Both methods appear to have nearly equal merit for the detection of peptic ulcer and gastric carcinoma. One of the trials demonstrated a relative inability of the barium examination to depict reflux esophagitis other than the severe variety, an inability that had been previously recognized. Earlier Japanese studies showed excellent results from biphasic studies in the detection of early and advanced gastric carcinoma. Because gastric carcinoma may present as a wide variety of lesions, ranging from minute alterations in mucosal relief through ulcers to masses, the values from these Japanese studies also test the sensitivity and specificity of the radiographic examination in demonstrating non-neoplastic lesions of the stomach. Ample data have shown that a radiographic examination compares favorably with endoscopy in the detection of esophageal carcinoma. The usefulness of a radiographic examination as a primary examination if disturbances of esophageal motor function are suspected is generally recognized. A state-of-the-art radiographic examination (ie, a biphasic examination, preferably with drug-induced hypotony) therefore appears to represent an appropriate initial examination in evaluation of most disorders of the upper GI tract. If this examination prompts the slightest suspicion of a malignant tumor, endoscopy should follow for the purpose of obtaining biopsy specimens. Endoscopy is not necessary if duodenal ulcers have been diagnosed by means of radiography; in typically benign gastric ulcers, radiographic follow-up without endoscopy may safely be considered. If in elderly patients multiple small gastric polyps have been detected, endoscopy is not needed. If complaints persist after negative results at radiographic examination, however, endoscopic intervention must be considered. If the complaints suggest reflux esophagitis, the clinician can choose between treatment and endoscopy. In a patient with acute upper GI bleeding, primary endoscopy may be preferred. This diagnostic approach in which endoscopy is employed as complementary to the barium examination is in most parts of the world a cost-effective one. It is also the safest possible option; although endoscopic complications are rare, their absolute number cannot be ignored if every patient had to undergo endoscopy. A biphasic approach with a medium-density barium suspension can be attempted in nearly every patient; if the patient proves unable to cooperate for an optimal double-contrast examination, a single-contrast examination can be performed with the same barium swallowed.     

Benign gastric ulcers: diagnosis and follow-up with double-contrast radiography

Double-contrast upper gastrointestinal examinations revealed 108 gastric ulcers at the authors' hospital during a recent 1-year period. With use of current double-contrast examination criteria for differentiating benign and malignant ulcers, the radiographic appearance was unequivocally benign in 68 patients, probably benign in 25, probably malignant in 12, and unequivocally malignant in three. Fifty-six patients with benign, probably benign, or probably malignant ulcers underwent endoscopy and biopsy. All 56 had benign ulcers. Another three patients with unequivocally malignant ulcers had endoscopically proved carcinomas. Thus, most suspicious ulcers were benign, but no benign-appearing ulcers were malignant. Follow-up double-contrast studies for 87 ulcers revealed complete ulcer healing in 68 (78%). A residual ulcer scar was observed in 61 of those 68 cases (90%). This experience suggests that double-contrast radiography is a valuable technique for diagnosing benign gastric ulcers and that once diagnosed, typically benign ulcers can be followed up radiographically until completely healed, without need for endoscopic intervention.     

Accuracy of radiologic and endoscopic diagnosis of gastric ulcer

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

Detection of gastric erosions: comparison of biphasic radiography with fiberoptic endoscopy

Biphasic radiography was compared with fiberoptic endoscopy in detecting gastric erosions in a prospective, blinded study of 385 patients with dyspepsia. Because no absolute standard was available for the comparison, since histologic confirmation of all erosions was not possible, the kappa statistic was used to compare results from both modalities. Flat (incomplete) erosions were detected with endoscopy only and were considered to be present in 42 patients (11.2%). Varioliform (complete) erosions were identified with both radiography and endoscopy in 12 patients (3.2%). For the detection of varioliform erosions, a substantial agreement beyond chance between both modalities was found (kappa = 0.73; standard error, 0.12). Thus, flat erosions were detected with endoscopy only, whereas state-of-the-art radiography and endoscopy were equally sensitive for detecting varioliform erosions. Histologic confirmation of erosions was obtained in only 75% of the patients. It is unknown whether the demonstration of erosions with radiography and/or endoscopy correlates with dyspepsia.     

The double-contrast barium meal: a correlation with endoscopy

The radiological and endoscopic findings are described in 214 patients with 252 lesions in whom endoscopy had been requested by a radiologist either to confirm or clarify a radiological opinion. There was radiological and endoscopic agreement about the presence or absence of oesophagitis in 73% of patients, but there was agreement about the presence or absence of duodenitis in only 48%. There were only two cases of early gastric cancer, and no early gastric cancers were found in a group of 43 patients on whom endoscopy had been specifically requested because of an abnormal gastric mucosal pattern. Endoscopy failed to detect 13% of gastric ulcers at the initial endoscopic examination.     

Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT

PURPOSE: To determine if multi-detector row computed tomography (CT) can replace conventional radiography and be performed alone in severe trauma patients for the depiction of thoracolumbar spine fractures. MATERIALS AND METHODS: One hundred consecutive severe trauma patients who underwent conventional radiography of the thoracolumbar spine as well as thoracoabdominal multi-detector row CT were prospectively identified. Conventional radiographs were reviewed independently by three radiologists and two orthopedic surgeons; CT images were reviewed by three radiologists. Reviewers were blinded both to one another's reviews and to the results of initial evaluation. Presence, location, and stability of fractures, as well as quality of reviewed images, were assessed. Statistical analysis was performed to determine sensitivity and interobserver agreement for each procedure, with results of clinical and radiologic follow-up as the standard of reference. The time to perform each examination and the radiation dose involved were evaluated. A resource cost analysis was performed. RESULTS: Sixty-seven fractured vertebrae were diagnosed in 26 patients. Twelve patients had unstable spine fractures. Mean sensitivity and interobserver agreement, respectively, for detection of unstable fractures were 97.2% and 0.951 for multi-detector row CT and 33.3% and 0.368 for conventional radiography. The median times to perform a conventional radiographic and a multi-detector row CT examination, respectively, were 33 and 40 minutes. Effective radiation doses at conventional radiography of the spine and thoracoabdominal multi-detector row CT, respectively, were 6.36 mSv and 19.42 mSv. Multi-detector row CT enabled identification of 146 associated traumatic lesions. The costs of conventional radiography and multi-detector row CT, respectively, were 145 and 880 US dollars per patient. CONCLUSION: Multi-detector row CT is a better examination for depicting spine fractures than conventional radiography. It can replace conventional radiography and be performed alone in patients who have sustained severe trauma.     

Radiologic evaluation of esophageal dysphagia

In patients with dysphagia, the radiographic examination evaluates both structural and functional abnormalities of the esophagus. Radiologic examination is more appropriate than endoscopy for initial screening of patients with dysphagia (Table 6). Endoscopy is more expensive, generally requires sedation, and is associated with a small but definite risk to the patient. Also, the endoscopic examination yields a poor evaluation of esophageal motor function and may fail to detect mucosal rings and peptic strictures, especially if smaller caliber instruments are used. The chief limitations of the radiographic examination are poor detection of mild cases of esophagitis and variable sensitivity and specificity in diagnosing esophageal motor disorders.     

David J. Ott

In patients with dysphagia, the radiographic examination evaluates both structural and functional abnormalities of the esophagus. Radiologic examination is more appropriate than endoscopy for initial screening of patients with dysphagia (Table 6). Endoscopy is more expensive, generally requires sedation, and is associated with a small but definite risk to the patient. Also, the endoscopic examination yields a poor evaluation of esophageal motor function and may fail to detect mucosal rings and peptic strictures, especially if smaller caliber instruments are used. The chief limitations of the radiographic examination are poor detection of mild cases of esophagitis and variable sensitivity and specificity in diagnosing esophageal motor disorders.     

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

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

Accuracy of direct digital radiography for detecting occlusal caries in primary teeth compared with conventional radiography and visual inspection: an in vitro study

Objectives

The diagnosis of caries lesions is still a matter of concern in dentistry. The diagnosis of dental caries by digital radiography has a number of advantages over conventional radiography; however, this method has not been explored fully in the field of paediatric dentistry. This in vitro research evaluated the accuracy of direct digital radiography compared with visual inspection and conventional radiography in the diagnosis of occlusal caries lesions in primary molars.

Methods

50 molars were selected and evaluated under standardized conditions by 2 previously calibrated examiners according to 3 diagnostic methods (visual inspection, conventional radiography and direct digital radiography). Direct digital radiographs were obtained with the Dixi3 system (Planmeca, Helsinki, Finland) and the conventional radiographs with InSight film (Kodak Eastman Co., Rochester, NY). The images were scored and a reference standard was obtained histologically. The interexaminer reliability was calculated using Cohen''s kappa test and the specificity, sensitivity and accuracy of the methods were calculated.

Results

Examiner reliability was good. For lesions limited to the enamel, visual inspection showed significantly higher sensitivity and accuracy than both radiographic methods, but no significant difference was found in specificity. For teeth with dentinal caries, no significant differences were found for any parameter when comparing visual and radiographic evaluation.

Conclusions

Although less accurate than the visual method for detecting caries lesions confined to the enamel, the direct digital radiographic method is as effective as conventional radiographic examination and visual inspection of primary teeth with occlusal caries when the dentine is involved.     

Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT--initial experience

PURPOSE: To prospectively compare the accuracy of ultrasonography (US) with that of supine chest radiography in the detection of traumatic pneumothoraces, with computed tomography (CT) as the reference standard. MATERIALS AND METHODS: Thoracic US, supine chest radiography, and CT were performed to assess for pneumothorax in 27 patients who sustained blunt thoracic trauma. US and radiographic findings were compared with CT findings, the reference standard, for pneumothorax detection. For the purpose of this study, the sonographers were blinded to the radiographic and CT findings. RESULTS: Eleven of 27 patients had pneumothorax at CT. All 11 of these pneumothoraces were detected at US, and four were seen at supine chest radiography. In the one false-positive US case, the patient was shown to have substantial bullous emphysema at CT. Sensitivity and negative predictive value of US were 100% (11 of 11 and 15 of 15 patients, respectively), specificity was 94% (15 of 16 patients), and positive predictive value was 92% (11 of 12 patients). Chest radiography had 36% (four of 11 patients) sensitivity, 100% (16 of 16 patients) specificity, a 100% (four of four patients) positive predictive value, and a 70% (16 of 23 patients) negative predictive value. CONCLUSION: In this study, US was more sensitive than supine chest radiography and as sensitive as CT in the detection of traumatic pneumothoraces.     

Detection of pulmonary edema in pigs: storage phosphor versus amorphous selenium-based flat-panel-detector radiography

PURPOSE: To compare diagnostic accuracy of soft-copy selenium-based digital radiographic images and soft-copy computed radiographic images obtained for detection of pulmonary edema in pigs. MATERIALS AND METHODS: Oleic acid was injected intraatrially into three pigs (weight, 20-25 kg) at doses of 0.04, 0.05, and 0.06 mL/kg to induce pulmonary edema. Thirty-seven sets of computed radiographic, digital radiographic, and thin-section computed tomographic (CT) scans were obtained every 20-30 minutes in three pigs over 4-6 hours. Images were masked for identity, randomly sorted, and displayed on a monitor. Four radiologists rated each image for presence of parenchymal opacities by using a dichotomous scoring system in two sessions. Presence of pulmonary edema was determined with thin-section CT and a severity scale. Intra- and interobserver variations were determined with the kappa statistic and the Z test and with the Cochran Q test and the McNemar test, respectively. True-positive, true-negative, false-positive, and false-negative rates were determined. McNemar test was used to determine statistical significance of differences in detection between computed and digital radiographic images. RESULTS: There was no significant intra- or interobserver variation, except for one pair of observers during the first interpretative session with computed radiographic images (P =.016, McNemar test). Overall sensitivity (92.1%) and diagnostic accuracy (90.2%) of digital radiography were significantly higher than those of computed radiography (79.6% and 83.4%, respectively) (P <.001 for sensitivity, P =.01 for diagnostic accuracy, McNemar test). In detection of minimal and mild pulmonary edema, sensitivity of digital radiography (84%) was significantly higher than that of computed radiography (58%) (P <.001). CONCLUSION: Soft-copy digital radiographic images are superior to soft-copy computed radiographic images obtained for detection of mild pulmonary edema in pigs.     

Improved radiographic detection of multiple gastric ulcers.

In more than 1,500 double contrast upper gastrointestinal examinations performed January through November 1974, 26 cases of multiple gastric ulcers were diagnosed. This represents 18.6% of the 140 patients who had a demonstrable gastric lesion, and 23.4% of the 111 patients who had either a single gastric ulcer or scar. This technique was developed in a country where gastric carcinoma is common, but in the United States its greatest usefulness will probably be in the detection of subtle mucosal defects such as multiple gastric ulcers, linear ulcers, and erosions. The sensitivity of the routine pharmacologically aided double contrast upper gastrointestinal examination is confirmed by the high incidence of multiple gastric ulcers found.     

Three-dimensional MDCT gastrography compared with axial CT for the detection of early gastric cancer

OBJECTIVE: To assess the diagnostic performance of multidetector-row computed tomography (CT) 3-dimensional CT gastrography (3-D CTG) to detect early gastric cancer (EGC) compared with axial CT images alone. METHODS: Contrast-enhanced multidetector-row CT scanning was performed on 39 patients with histopathologically proven EGC. By using volume-rendering technique, CTG images were created and interval reviews of both the axial images without and with 3-D CTG images were performed independently by 2 radiologists retrospectively. The stomach was divided into 4 segments (ie, the cardia or fundus, body, angle, and antrum). For 156 gastric segments, the radiologists determined the presence of the lesion using a 5-point confidence level. The radiologists' performance for the lesion detection was evaluated by means of receiver operating characteristic analysis. Interobserver agreement was also analyzed. The ability of CTG to reveal the extent and the morphological features of the lesions was also evaluated and compared with the results of conventional studies. RESULTS: Histopathologically, 41 EGCs were identified in 39 patients: 1 lesion was located in the fundus, 16 in the body, 9 in the angle, and 15 in the antrum. When 3-D CTG images were used, the receiver operating characteristic curve (AZ) analysis revealed a significant improvement in the diagnostic performance of both reviewers (AZ using axial CT images only, 0.608 and 0.602 for reviewers 1 and 2, respectively; AZ using CTG images, 0.821 and 0.822 for reviewers 1 and 2, respectively) (P < 0.05). The 3-D CTG also improved the sensitivity from 27% to 73% for reviewer 1 and from 29% to 76% for reviewer 2 (P < 0.05), as compared with the sensitivity when using axial CT images only. In addition, almost perfect agreement was achieved for CTG (weighted kappa, 0.836), whereas there was only moderate agreement for the axial CT images (weighted kappa, 0.445). The CTG provided information similar to that obtained by barium study and endoscopy in 51.6% and 59.5%, respectively, of the cases. CONCLUSIONS: The combined interpretation of axial and 3-D CTG was significantly better for detecting EGC, with a diagnostic confidence higher than that using axial CT imaging alone.     

胃溃疡B超诊断150例研究

报告了经手术、胃镜和病理证实的１５０例胃溃疡的Ｂ超检查结果。总检出符合率为８２％，其中溃疡直径＜０．５ｃｍ及≤１．５ｃｍ者良性溃疡分别占９１％和８１．８％；＞１．５ｃｍ者恶性溃疡为７９．２％。提出了小凹陷增厚型和大凹陷增厚型两种声像图类型。认为，Ｂ超诊断本病具有无创、无痛、简便、易行，且结果可靠的特点，值得推广应用。另外，作者对漏误诊原因进行了分析。对溃疡的性质，可根据凹陷的大小、形态、胃壁增厚的范围、胃蠕动变化程度及胃周有无淋巴结肿大和其它脏器有无浸润转移进行鉴别。     

Hypersensitivity pneumonitis: sensitivity of high-resolution CT in a population-based study.

OBJECTIVE. Hypersensitivity pneumonitis refers to a group of pulmonary disorders caused by inhalation of organic or inorganic particulates by sensitized persons. The diagnosis relies on a constellation of findings: exposure to an offending antigen, characteristic signs and symptoms, abnormal chest findings on physical examination, and abnormalities on pulmonary function tests and radiographic evaluation. In population-based studies, the sensitivity of chest radiography for detection of this disease is relatively low. The aim of this study was to determine the sensitivity of high-resolution CT (HRCT) for detection of hypersensitivity pneumonitis diagnosed in a population of swimming-pool employees. SUBJECTS AND METHODS. Thirty-one symptomatic employees of a recreation center who were referred because of possible hypersensitivity pneumonitis were examined by using chest radiography, HRCT, and fiberoptic bronchoscopy with bronchoalveolar lavage and transbronchial biopsy. Hypersensitivity pneumonitis was diagnosed in subjects who had two or more work-related signs or symptoms, abnormal results on transbronchial biopsies, and abnormal lymphocytosis as shown by examination of bronchoalveolar lavage fluid. The chest radiographs and HRCT scans were interpreted by consensus by two observers who were unaware of the clinical diagnosis. RESULTS. Only one of 11 subjects with a diagnosis of hypersensitivity pneumonitis had abnormal findings on a chest radiograph. Five had abnormal HRCT findings. The abnormality in each case consisted of small, poorly defined centrilobular nodules with variable profusion. No subject without the disease had abnormal HRCT findings. Those who had granulomas shown by lung biopsy were more likely to have abnormal HRCT findings than were those who had more subtle histologic abnormalities. CONCLUSION. The sensitivity of HRCT for the detection of hypersensitivity pneumonitis in a population-based study is greater than that of chest radiography. The finding of poorly defined centrilobular nodules on HRCT scans should prompt consideration of this disease.     

Film tomography compared with film and digital bitewing radiography for proximal caries detection

OBJECTIVES: The purpose of this study was to evaluate the efficiency of conventional tomography for proximal caries detection compared with conventional bitewing and digital intraoral radiography. METHODS: In this study, 48 extracted human posterior permanent teeth were used. Conventional bitewing radiographs, digital intraoral radiographs and conventional tomograms were obtained of the teeth. The presence or absence of caries was scored according to a five-point scale by two oral and maxillofacial radiologists. True caries depth was determined by histological examination. The diagnostic accuracy of each radiographic system was assessed by means of receiver operating characteristic (ROC) curve analysis. The mean of areas under the ROC curve (A(z)) was analysed by pairwise comparison of ROC curve. The interobserver agreement was evaluated using a t-test. RESULTS: The statistical analysis of A(z) scores has shown no significant difference for three imaging modalities (P>0.05). There was no statistically significant difference between interobserver agreement (P>0.05). CONCLUSIONS: This study has demonstrated that the diagnostic accuracy of conventional tomograms is comparable to that of conventional bitewing and digital intraoral radiographs for proximal caries detection.     

胃恶性肿瘤的影像学

近年胃肠道影像学诊断技术有了很大的进展,胃的影像学检查范畴已较前有了明显的扩大,CT,MR,US,EUS,DSA,SEPT和PET等检查技术已被广泛用于胃部影像学的诊断,并且在胃部肿瘤的诊断中取得了较大的发展,但胃的常规内镜和双对经造检查在胃部的检测中仍有重要的作用,CT和超声内镜在胃部肿瘤的检测和分期上有其独特的价值。MR作为一种无放射性的诊断技术技术可提供全方位的影像学资料。同时,随着多层CT和新型MR在技术上的进步和发展,仿真内镜技术将在胃肿瘤的检测中具有更多的突破。     

Radiographic efficacy in gastric ulcer: comparison of single-contrast and multiphasic examinations

The efficacies of single-contrast and multiphasic examinations of the stomach for gastric ulcer detection were compared in 90 patients with 102 gastric ulcers, and in a control group of 382 patients without gastric ulcer. Single-contrast and multiphasic sensitivities were 62% and 64%, respectively. Radiographic detection depended significantly on ulcer size: Only 24% of ulcers under 5 mm were detected, compared with 89% of ulcers 5 mm or larger. Radiographic specificities and positive predictive values were similar for both types of examination. Moderate variation of the sensitivities and specificities of the three radiologists was observed, with ranges of 53-69% and 90-98%, respectively. Results indicated that gastric ulcer detection is more related to ulcer size and to individual interpretive variations than to the type of examination.     

Individualized periapical radiography determined by clinical and panoramic examination.

The efficiency of panoramic radiography compared with full-mouth periapical examination is an unresolved problem. The diagnostic yield of periapical lesions when the clinical signs and symptoms and the findings from a panoramic radiograph served as the basis for an individualized periapical radiographic examination was studied. Two hundred patients were examined clinically and radiographically. The periapical status was assessed step by step with access to increasing numbers of radiographs. For the clinical examination, the sensitivity was 0.24, the positive predictive value 0.62, the specificity 0.98, the negative predictive value 0.90 and the likelihood ratio for the positive test result 12. For radiographs indicated by the clinical examination plus the panoramic radiograph and selected periapical radiographs, both the sensitivity and the positive predictive value were 0.91, the specificity and the negative predictive value 0.99 each and the likelihood ratio was 91. False findings were twice as frequent in the upper as in the lower arch and particularly found in the incisor and premolar regions. In 30% of the patients no periapical radiograph was needed to supplement the panoramic radiograph. In the other patients, two supplementary periapical radiographs were needed on average. We conclude that the information obtained from the clinical and panoramic examinations supplemented with no more than two periapical radiographs will result in a high diagnostic yield on the periapical status.