Diagnosis and treatment of bleeding colonic diverticula.

BACKGROUND/AIMS: Colonic diverticula are the most frequent cause of major lower intestinal bleeding and pose a diagnostic and therapeutic challenge to the attending physician. Emergency surgical resection is associated with a high mortality and morbidity and patients who will stop bleeding spontaneously cannot be distinguished from those who will continue to bleed. Our aim was to evaluate the efficacy of barium enema as a sole less invasive treatment option for severe diverticular bleeding. METHODOLOGY: We evaluated 102 patients admitted with colonic diverticular bleeding, from 1993 to 1997, who needed transfusion of 2 or more units of blood. We compared the clinical efficacy of surgical resection, conservative treatment, and therapeutic barium enema with regard to the cessation of bleeding, morbidity, mortality, and rebleeding rate. The therapeutic strategies used after further episodes of bleeding were also registered. RESULTS: Transfusion requirements were highest in patients who underwent surgical treatment, while the least amount of blood was required by the barium enema group (6.9 +/- 3.1 vs. 3.6 +/- 1.5 units of blood). However, the quantity of transfused blood did not correlate with the initial hemoglobin level, which was highest in the conservative treatment group and lowest in the operative group (9.0 +/- 1.2 vs. 8.1 +/- 1.3 g/dL). These data support the fact that the most severe bleeding would necessitate surgical resection and that therapeutic barium enema may be considered more effective than conservative treatments. With regard to the outcome of treatment, conservative treatment led to a rebleeding rate of 43.3%, which differed significantly from a 15.9% rebleeding rate after therapeutic barium enema (P = 0.009). No rebleeding was registered in surgically treated patients. Sixty percent of patients in whom therapeutic barium enema failed were treated by colonic resection without mortality, while 77% of patients who had rebleeding after conservative treatment were successfully treated with barium enema. Overall, barium enema was the most frequently applied second-line treatment (56.5%). The mortality after surgery was significantly higher than that after other treatment modalities (33% vs. 1%; P = 0.0001). CONCLUSIONS: If diverticular bleeding is clinically suspected as the cause of major lower intestinal hemorrhage, barium enema is a more promising alternative than conservative treatment because of diagnostic and therapeutic importance in the long-term. In the event of urgent secondary surgery following the failure of barium enema to stop bleeding, we recommend a sigmoidoscopy and, optionally, an angiography before surgery in order to first localize the bleeding. We conclude that therapeutic barium enema is the treatment of choice for the first bleeding episode, while surgical resection should be performed if rebleeding occurs.     

Prospective comparison of double contrast barium enema plus flexible sigmoidoscopy v colonoscopy in rectal bleeding: barium enema v colonoscopy in rectal bleeding.

Rectal bleeding often heralds serious colonic disease. The literature suggests that colonoscopy is superior to barium enema plus sigmoidoscopy, although no good comparative studies exist. Seventy one patients with overt rectal bleeding had prospectively flexible sigmoidoscopy, double contrast barium enema and colonoscopy completed independently. Against the gold standard, the sensitivity and specificity of colonoscopy were 0.69 and 0.78 respectively for a spectrum of colonic lesions, while for combined flexible sigmoidoscopy and double contrast barium enema these values were 0.80 and 0.56, respectively. When assessing adenoma or carcinoma, colonoscopy was more sensitive at 0.82 v 0.73, while flexible sigmoidoscopy plus double contrast barium enema was superior for detecting diverticular disease. The positive predictive value for colonoscopy was 0.87 against 0.81 for flexible sigmoidoscopy and double contrast barium enema. This study confirms that colonoscopy should be a first line investigation in subjects likely to require biopsy or therapeutic intervention.     

Therapeutic barium enema for bleeding colonic diverticula： Four case series and review of the literature

The prevalence of diverticular diseases of the colon, including severe and persistent bleeding in Eastern countries, has increased in the last decades. The bleeding from colonic diverticula is the most common cause of acute lower gastrointestinal bleeding. Herein, we report four cases of severe and persistent bleeding of colonic diverticular disease that could be treated with a high concentration barium enema. These four cases showed a similar pattern of bleeding whose source could not be identified. Colonoscopy revealed fresh blood in the entire colon and many diverticula were noted throughout the colon. No active bleeding source was identified, but large adherent clots in some diverticula were noted. After endoscopic and angiographic therapies failed, therapeutic barium enema stopped the severe bleeding. These patients remained free of re-bleeding in the follow-up period （range 17-35 mo） after the therapy. We report the four case series of therapeutic barium enema and reviewed the literature pertinent to this procedure.     

Carbon dioxide-insufflated colonoscopy: an ignored superior technique

Colonoscopy and barium enema are complementary studies in the diagnosis of the cause of lower intestinal bleeding. The air usually insufflated during colonoscopy often makes it impossible to perform a good barium enema on the same day. As a possible solution to this problem, we studied the quality of barium enemas performed immediately following carbon dioxide-insufflated colonoscopy. All 15 patients who underwent unsuccessful total colonoscopies using carbon dioxide insufflation were able to have barium enemas performed the same day in contrast to only one out of 15 patients who had air-insufflated colonoscopy. In a survey of all hospitals in Illinois with 150 beds or more, we found only 15 of 146 hospitals used carbon dioxide for colonoscopy insufflation. We recommend the routine use of carbon dioxide for colonoscopic insufflation not only for greater safety and comfort for the patient, but also for the convenience and cost savings.     

Colonoscopic polypectomy

A total of 137 polyps were removed during 106 colonoscopies on 100 patients. In one patient there was significant colonic bleeding. Another patient was hospitalized with the delayed onset of abdominal pain in the general area of the polypectomy. This complication has not been reported previously and was presumed to be serositis due to a transmural burn. Average age of the patients was 57 years. Most were men. Twenty-four procedures were multiple polypectomies. Most polyps were in the sigmoid or descending colon. At microscopy 116 polyps showed a variety of pathologic types, including one invasive and nine superficial carcinomas. Several small polyps disclosed superficial cancer. Nine patients had histories of colon cancer of “malignant polyp.” Presenting features included bleeding or polyp(s) found at routine sigmoidoscopy or barium enema. The accuracy of barium enema in detecting polyps was 76%.     

Prospective comparison of air-contrast barium enema and colonoscopy in patients with fecal occult blood: a pilot study

BACKGROUND: The utility of air-contrast barium enema and colonoscopy for evaluation of the colon has been debated. Air-contrast barium enema is less expensive and invasive than colonoscopy, but it also is less sensitive and specific. Further, although air-contrast barium enema may be less painful than colonoscopy, it often is poorly tolerated by patients. Thus, this study compared the sensitivity and the specificity of air-contrast barium enema and colonoscopy for detection of colonic lesions in patients with fecal occult blood. METHODS: Over a 30-month period, patients with fecal occult blood were recruited. Patients underwent standard air-contrast barium enema, followed by colonoscopy 7 to 14 days later. Colonoscopists were blinded to the results of air-contrast barium enema until the colonoscopy was completed, after which the results were disclosed. If the findings were discrepant, colonoscopy was repeated. RESULTS: A total of 100 patients were evaluated. Nine air-contrast barium enemas were reported to be inadequate, and the cecum was not intubated at colonoscopy in two patients. In the remaining patients, 5 cancers were identified (1 each cecum, transverse colon, descending colon, sigmoid colon, and rectum) by both studies. Sixty-six polypoid lesions were identified in 30 patients. Diverticula were identified in 42 patients by air-contrast barium enema and in 18 patients by colonoscopy. Air-contrast barium enema detected 3 of 36 polypoid lesions 5 mm or less in diameter, 5 of 15 adenomas 6 to 9 mm in size, and 4 of 15 adenomas 10 mm or greater in diameter (sensitivity 8%, 33%, and 27%, respectively). After excluding patients with diverticula, air-contrast barium enema detected 3 of 7 adenomas 10 mm or greater in size. Overall, 12 polypoid lesions or filling defects were identified by air-contrast barium enema that could not be verified by colonoscopy. The specificity of air-contrast barium enema for lesions 1.0 cm or greater in size was 100%; for those 6 mm or greater, it was 97%. CONCLUSIONS: Air-contrast barium enema accurately detects colon cancer and diverticula. Its sensitivity for detection of polypoid lesions or adenomas is poor and was confounded by the presence of diverticula.     

Effectiveness of therapeutic barium enema for diverticular hemorrhage

AIM:To evaluate the effectiveness of barium impaction therapy for patients with colonic diverticular bleeding.METHODS:We reviewed the clinical charts of patients in whom therapeutic barium enema was performed for the control of diverticular bleeding between August2010 and March 2012 at Yokohama Rosai Hospital.Twenty patients were included in the review,consisting of 14 men and 6 women.The median age of the patients was 73.5 years.The duration of the followup period ranged from 1 to 19 mo(median:9.8 mo).Among the 20 patients were 11 patients who required the procedure for re-bleeding during hospitalization,6patients who required it for re-bleeding that developed after the patient left the hospital,and 3 patients who required the procedure for the prevention of rebleeding.Barium(concentration:150 w%/v%)was administered per the rectum,and the leading edge of the contrast medium was followed up to the cecum by fluoroscopy.After confirmation that the ascending colon and cecum were filled with barium,the enema tube was withdrawn,and the patient’s position was changed every 20 min for 3 h.RESULTS:Twelve patients remained free of rebleeding during the follow-up period(range:1-19mo)after the therapeutic barium enema,including 9men and 3 women with a median age of 72.0 years.Re-bleeding occurred in 8 patients including 5 men and 3 women with a median age of 68.5 years:4developed early re-bleeding,defined as re-bleeding that occurs within one week after the procedure,and the remaining 4 developed late re-bleeding.The DFI(disease-free interval)decreased 0.4 for 12 mo.Only one patient developed a complication from therapeutic barium enema(colonic perforation).CONCLUSION:Therapeutic barium enema is effective for the control of diverticular hemorrhage in cases where the active bleeding site cannot be identified by colonoscopy.     

Radionuclide enemas for localization of gastrointestinal bleeding sites

The anatomical site of gastrointestinal bleeding may not be determined accurately with a scintigraphic bleeding scan. A case in which a radionuclide enema following a positive scintigraphic bleeding scan helped to guide the surgeon to the appropriate bleeding site, is presented. The radionuclide enema also obviates the need for barium examinations that would interfere with subsequent angiography.     

Endoscopic diagnosis of lower intestinal lesions of leukaemia and malignant lymphoma

There have been only a few endoscopic studies with respect to lower intestinal lesions of leukaemia and malignant lymphoma, although there have been many autopsy studies of these lesions. The aim of this study was to clarify these lesions using endoscopy. Colonoscopy was performed on 11 of 341 patients with leukaemia and on 32 of 105 patients with malignant lymphoma for frequent diarrhoea, anal bleeding or abnormal findings on barium enema examination, between April 1984 and September 1994. In eight of the 11 patients with leukaemia on whom endoscopy was performed, nine lesions were found; aphthoid ulcers, small ulcers or large tumours due to leukaemic infiltration were found in five, and colorectal adenoma was found in only one patient. Antibiotic-associated haemorrhagic colitis or pseudomembranous colitis was found in one patient each. In 10 of the 32 patients with malignant lymphoma, 11 lesions were found. The following were found in one patient each: large lymphomatous tumours, a large lymphomatous ulcer, multiple small polypoid lesions, multiple lymphomatous polyposis; and colorectal cancer or adenoma in six patients. However, the autopsy findings in patients with both diseases were mostly pseudomembrane formation or ulcers due to fungal and/or bacterial infection. It is concluded that accurate endoscopic diagnosis of lower intestinal lesions in patients with leukaemia or malignant lymphoma is essential for staging and treatment of these diseases and for determining their prognosis. Most lesions in leukaemia are aphthoid and small ulcers are due to leukaemic infiltration or antibiotics; most lesions in malignant lymphoma are elevated lesions such as cancer, adenoma or lymphomatous lesions as determined by endoscopy. This is in contrast to pseudomembrane formation or ulcers due to fungal and/or bacterial infection which are detected at autopsy.     

The investigation of anorectal dysfunction in the solitary rectal ulcer syndrome

To investigate anorectal function in solitary rectal ulcer syndrome 22 patients were studied by means of balloon expulsion, intestinal transit time, barium enema and evacuation proctography. Half of the patients tested had difficulty in expelling a water filled balloon. Delay in intestinal transit was noted in only three patients. Barium enema was of little benefit in diagnosing the condition. Evacuation proctography was the investigation of choise in that it showed at least one abnormality of pelvic floor function in all of the patients and can help select patients for surgery.     

Flexible sigmoidoscopy plus air contrast barium enema versus colonoscopy for suspected lower gastrointestinal bleeding

A randomized, controlled trial was performed to compare the diagnostic yields and cost-effectiveness of two strategies for the evaluation of nonemergent lower gastrointestinal bleeding. Three hundred eighty patients aged greater than or equal to 40 yr were randomized to undergo initial flexible sigmoidoscopy plus air contrast barium enema or colonoscopy; 332 completed the initial studies. Initial colonoscopy detected more cases of polyps less than 9 mm in size, adenomas, and arteriovenous malformations but fewer cases of diverticulosis. No significant difference was found between strategies in the number of patients detected with cancers or polyps greater than or equal to 9 mm in size. In both strategies, cancers were more common in subjects aged greater than or equal to 55 yr (8% overall) than in those aged less than 55 yr (1%). Among patients aged less than 55 yr with suspected lower gastrointestinal bleeding, initial flexible sigmoidoscopy plus air contrast barium enema is a more cost-effective strategy for the detection of colonic neoplasms than initial colonoscopy. However, initial colonoscopy is more cost effective for those aged greater than or equal to 55 yr.     

Fused Epiploic Appendages Simulating Carcinoma of the Left Colon

A 60-year old male with a history of rectal bleeding was operated upon because of the finding of a filling defect on barium enema examination. At operation it was found that the defect was produced by the fusion of two epiploic appendages. Following release of the adhesion the colon regained its normal appearance and postoperative barium enema showed no pathological findings.     

Multilocular colorectal tuberculosis and hypogammaglobulinemia

We present the case of a young male patient admitted for weight loss, diarrhea and rectal bleeding. The patient belonged to a low social class and had associated hypogammaglobulinemia. The endoscopy revealed different localized ulcerations of he rectum and a stenosis. By barium enema and hydrosonography multiple stenotic lesions were observed. The pathological examinations detected lesions suggestive for intestinal tuberculosis. A specific therapy led to the improvement of his general state and to the disappearance of diarrhea and rectal bleeding.     

Limitations of Barium Enema Performed as an Adjunct to Incomplete Colonoscopy

PURPOSE Colonoscopy is believed to be inadequate in 4 to 24 percent of procedures. Barium enema often is utilized to complete the examination. In radiology literature, a successful barium enema in this setting requires only that the cecum has been reached. In this study, completion barium enema was assessed for both completeness and quality of proximal visualization. METHODS The charts of 16,216 patients undergoing colonoscopy at Saint Vincent Health Center from July 1995 to July 2003 were reviewed to identify patients who underwent barium enema within six months of an incomplete colonoscopy. Incomplete colonoscopies were audited for history of previous abdominal/pelvic surgery, level of colon attained, and apparent reasons for failure. Corresponding barium enema reports were evaluated in a similar fashion. RESULTS In 485 patients (2.9 percent), colonoscopy was incomplete. One hundred eighteen patients underwent barium enema after incomplete colonoscopy. In these patients, sharp angulation (42 percent) or redundancy/looping (31 percent) most often limited endoscopy. Among the barium enema studies, 91 (77 percent) were technically adequate. Twenty-seven studies were suboptimal (poor preparation/intolerance = 7, redundancy = 6, poor filling = 6, stricture/narrowing = 6, severe diverticulosis = 2). Two patients demonstrated additional polyps. There was no correlation between reasons for endoscopic failure and inadequacy of barium enema. Completeness of barium enema was not affected by previous pelvic surgery. Immediate barium enema was no less complete than a delayed study. CONCLUSIONS The reliability of barium enema after incomplete colonoscopy is less than previously reported. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. Reprints are not available.     

Pelvic lipomatosis: diagnosis by computerized tomography scan.

Pelvic lipomatosis is a rare, relatively self-limiting disease characterized by the overgrowth of unencapsulated lipomatous tissue within the pelvis. The diagnosis is suggested, but not substantiated, by the striking roentgenographic changes noted on barium enema and intravenous pyelogram. Previously, pelvic laparotomy with tissue diagnosis was essential for documenting the disease. We report three cases in which computerized tomography was utilized as a safe, noninvasive and accurate method of diagnosis. The role played by partial venous obstruction is discussed in addition to rectal bleeding as a mode of presentation.     

A study of patient acceptance of double-contrast barium enema and colonoscopy. Which procedure is preferred by patients?

To our knowledge, no previous study has addressed the question of which method of evaluation of the lower gastrointestinal tract is preferred by patients, air-contrast barium enema or colonoscopy. Over a four-month period, we asked 189 consecutive patients who had undergone colonoscopy to express their preference for either air-contrast barium enema or colonoscopy. A clear preference for colonoscopy was expressed by our patients in terms of comfort and polyp detection despite higher cost. Time lost from work and post-procedure constipation were significantly less for colonoscopy than for barium enema. These factors should be considered in the evaluation of suspected lower gastrointestinal tract disease.     

Impact of the barium enema on patient management

The medical records of 214 consecutive inpatients who had a barium enema examination were reviewed, and the clinical indications, efficacy of the barium enema, and patient outcome were correlated to determine the impact of the barium enema on patient management. The most frequent indications were rectal bleeding (33%), abdominal pain (31%), anemia (17%), weight loss (12%), and previous lesions needing reevaluation (12%). Diverticular disease (30%), colonic polyps (10%), and primary or secondary malignancies (12%) were the most common abnormalities detected radiographically. The sensitivity of the barium enema for colonic neoplasms was 89%, with only 1 small cecal polyp being undetected. The effects of barium enema on patient management were serious pathology excluded (64%), diagnosis made that changed therapy (24%), existing therapy continued (10%), and a further study ordered (2%). No serious or life-threatening lesion was missed by barium enema.     

Small-bowel enema

The results of 88 consecutive small-bowel enemas were compared retrospectively with the results of 52 routine small-bowel series and 50 barium enemas done in the same patients. Ninety-six percent of the diagnoses made by small-bowel enema were correct, as compared to only 65% made by routine small-bowel series. The incorrect studies were mostly false negatives and the abnormalities missed included regional enteritis, small-bowel obstruction, and intestinal lymphoma. The barium enema failed to achieve ileal reflux in 26% of patients and had a 23% false negative rate when reflux was achieved. Because small-bowel series as done by conventional methods was significantly less accurate, we believe small-bowel enema should be considered in patients with suspected small-bowel disease when other studies are negative.     

Screening for colorectal cancer in a high-risk population. Results of a mathematical model

A mathematical model was used to estimate the cost-effectiveness of colorectal cancer screening strategies for people who are at high risk because of a first-degree relative with colorectal cancer. The model uses indirect evidence about such factors as cancer incidence, sensitivity and specificity of different tests, and treatment effectiveness. The analysis indicates that for screening people over 40 yr old an annual fecal occult blood test may reduce colorectal cancer mortality by about one-third, either colonoscopy or barium enema may reduce mortality by approximately 85%, a 3-5-yr frequency for endoscopies or barium enemas preserves 70%-90% of the effectiveness of an annual frequency, and beginning screening at age 50 reduces effectiveness by 5%-10%. Although both barium enemas and colonoscopies appear to be effective in reducing mortality, the lower cost of the barium enema makes it a more cost-effective strategy. All of these estimates depend on the baseline estimates of each of the factors incorporated in the model; the conclusions are most sensitive to assumptions about the natural history of adenomatous polyps, the bleeding of adenomas and presymptomatic cancers, and the sensitivity of the fecal occult blood test. Recommendations about colorectal cancer screening must also consider factors such as discomfort, inconvenience, and the availability of various technologies.     

Extensively infiltrating colon adenocarcinoma similar to Crohn's disease: A case report

A 38-year-old Chinese man presenting with chronic diarrhea and secondary incomplete intestinal obstruction was hospitalized in April 2010. Electronic colonoscopy and barium enema examination initially showed longitudinal scar-like strictures and cobblestone appearance in the colon that was similar to those in Crohn's disease. After subtotal colectomy and partial intestinal resection, the pathological examination indicated colon adenocarcinoma that diffusely infiltrated along the colon longitudinal axis rather than the initial diagnosis of Crohn's disease. Pathological examination revealed colon adenocarcinoma with excessive desmoplastic reaction and infiltrating cancer cells along the colon longitudinal axis that may have accounted for the morphological similarities to Crohn's disease in this case. The findings in the present case suggest that colon carcinoma should be considered when Crohn's disease-like findings are encountered, not only in individuals with concurrent cancer in other sites, but also in patients with a long history of gastrointestinal symptoms such as chronic diarrhea or abdominal pain.