Barium Studies of the Small Intestine

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1 Chin J Radiol 2004; 29: Barium Studies of the Small Intestine JEN-HUEY CHIANG RHEUN-CHUAN LEE TSIU-SHAN TSENG YI-YOU CHIOU CHENG-YEN CHANG Department of Radiology, Taipei Veterans General Hospital School of Medicine, National Yang-Ming University The small bowel follow-through examination has been applied in daily practice for a long period of time. Despite the widespread use of endoscopy, CT and MR imaging, barium meal examination remain the primary diagnostic technique for evaluation of patients suspected of having small bowel disease. To investigate the diagnostic impact barium followthrough in the assessment of small bowel disease, we prospectively compared examinations of barium follow-through and dedicated fluoroscopic examination. Barium follow-through was carried out at overhead X-ray machine room by radiological technologist. Dedicated fluoroscopic examination was performed only by radiologist in fluoroscopic room. The study showed no significant difference in diagnostic quality and examination time in either technique. Barium follow-through combined with fluoroscopic examination for the terminal ileum and suspicious bowel segments not only improved the examination quality but also result in saving much time for the radiologists. Key words: Intestines, radiography; Barium follow-through; Dedicated fluoroscopic examination; Radiological technologists; Radiologists The radiographic examination of the esophagus, stomach and colon has been changed dramatically by the introduction of upper GI endoscopy and colonoscopy, however, little has been changed in the small bowel examination. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) may be occasionally used but barium studies are still the primary imaging method for the patient with suspected small bowel disease [1]. Small bowel enema, or enteroclysis, is used in many European countries for evaluating small bowel disease; but in the United States and our country, barium follow-through or conventional overhead small bowel follow-through (overhead SBFT) remains the major radiographic examination for diagnosing small bowel disease. Current review of status of small bowel radiography suggests that the barium follow-through should be abandoned because the yield of information provided by enteroclysis has higher negative predictive value [2]. Owing to lack of enough radiologists in the country, we tried to evaluate impact of the fluoroscopy-based small bowel follow-through (SBFT) study or dedicated fluoroscopic examination on patient management. The purpose of this study was to determine the peroral small bowel single contrast barium examination in respects of clinical indications and radiographic results, diagnostic quantity and quality, transit time of barium and assessment of small bowel disease. MATERIALS AND METHODS Reprint requests to: Dr. Jen-Huey Chiang Department of Radiology, Taipei Veterans General Hospital. No 201, Sec. 2, Shih Pai Road, Taipei 112, Taiwan, R.O.C. Between January 1 and December 31, 2003, a total of 223 consecutive patients constituted the study cohort in our department. They were put into control or study groups randomly. The control group patients underwent barium follow-through or conventional overhead small bowel follow-through and the study group patients underwent dedicated fluoroscopic examination or fluoroscopic small bowel followthrough, respectively. Barium follow-through was performed for 105 patients (60 men and 45 women; age range, years; mean age 56 years) and

2 310 Barium studies of the small intestine Table 1. Clinical indications of small bowel examination Indications Number of patients Barium Dedicated follow-through fluoroscopy Abdominal pain/distension GI bleeding Suspect bowel obstruction Anemia Vomiting / Nausea 5 5 Crohn s disease 1 Suspect neoplasm 5 11 Diarrhea 3 9 Body weight loss 0 4 Total Table 2. Quality of the examinations of small bowel Barium follow-through Dedicated fluoroscopy (n = 118) (n = 105) poor fair good poor fair good Duodenum Jejunum Ileum Terminal ileum Table 3. Transit time of barium Transit time Barium follow-through Dedicated fluoroscopy (minutes) (No. of patient) (No. of patient) < > Total dedicated fluoroscopic examination for 118 patients (61 men and 47 women; age years; mean age 55 years). Barium follow-through was mainly performed by radiological technologists. Prior to the introduction of oral contrast medium, a plain radiograph of the abdomen was taken and then 500mL barium sulfate suspension (50% wt/vol E-Z paque) (E-Z-EM, Inc, Westbury, NY) was administered orally. The overhead-based X-ray films were taken at 15-, 30-, 60-, 90- and 120 minutes, respectively. The appearance of barium in the cecum and ascending colon is an indication for fluoroscopy to demonstrate the terminal ileum, crowded bowel loops and an abnormality of the small bowel loops that had been demonstrated on overhead films. The patients then were sent to the fluoroscopic room. The fluoroscopic films were taken by radiologists in the fluoroscopic examination room. Dedicated fluoroscopic examination or Fluoroscopic Small Bowel Follow-Through was performed by radiologist or supervised residents. Prior to the introduction of oral contrast medium, a preliminary plain film radiograph of the abdomen was taken. The patients were then directly sent to fluoroscopic room. The film should be seen by the radiologist before starting the examination. A cup of 500mL of 50% wt/vol E-Z paque suspension was administrated orally in the waiting area. The first small bowel fluoroscopic session was done 15 minutes after ingestion of the barium suspension. Different view spot films are taken as needed. Subsequent fluoroscopic sessions follow at 20- to 30-minute intervals, as judged by radiologist. Fluoroscopy and compression radiography should be done at least three to four times during the course of the examination until the colon is reached. Dedicated fluoroscopic examinations were carried out and controlled by radiologists or supervised residents during the whole course of procedure. Clinical indications of small bowel examination include (a) gastrointestinal bleeding with negative finding on upper GI series and colon examination, (b) anemia with unknown cause, (c) cramping abdominal pain associated with abdominal distention, nausea or vomiting, (d) abdominal pain, (e) large volume diarrhea, (f) history of small bowel disease or (g) suspected small bowel neoplasms. All studies were clinically indicated for assessment of small bowel lesions. Primary clinical indications of the study cohort were recorded prior to X-ray examination. All images were taken with digitalized X-ray unites and were stored in PACS image system. Radiographic reports were made by 4 gastrointestinal radiologists in our department. For each subject, the small bowel film quality, radiographic diagnosis from original radiological reports and clinical outcome were reviewed and collected. With good technique and good examination quality, all bowel loops must be separated from one another and should be imaged when filled with barium. Normality or pathology of the bowel segments is ascertained and demonstrated clearly. The human research committee of the institutional review board approved the study protocol. RESULTS Clinical indications for the small bowel examination were abdominal pain (60 cases), gastrointestinal bleeding (56 cases), suspected small bowel obstruction (39 cases), anemia of unknown cause (26 cases), postsurgical neoplasm evaluation or suspected abdominal tumor growth (16 cases), large volume diarrhea (12 cases), vomiting (10 cases) and body weight loss (4 cases). Clinical indications for small bowel study for

3 Barium studies of the small intestine 311 each group of patients were shown in Table 1. Radiographic film quality is shown in Table 2. Transit time of barium is shown in Table 3. There is no significant difference in film quality and examination time between the overhead small bowel follow-through and dedicated fluoroscopic examination. There is no significant difference in the accuracy of either technique, either. One hundred eighty-seven examinations were interpreted as normal radiographic findings with an overall abnormalities rate of 16% (36 of 223 patients). Peritoneal carcinomatosis with small bowel involvement was found in 14 patients who were known to have abdominal dissemination or postsurgical evaluation for malignancy. Crohn s disease was found in 5 patients with gastrointestinal bleeding or abdominal pain. Two of them had history of the disease. Four patients having gastrointestinal bleeding were found to have a small polyp in jejunum or ileum. Three patients showed smooth tumor mass in abdomen with intestinal compression. Two of them had palpable abdominal mass during physical examination. Partial intestinal obstructions with proximal bowel dilatations were present in 3 patients. Superior mesenteric artery syndrome was found in 2 patients. Acute duodenal ulcers were found in 2 patients. The normal studies were generally found in patients with anemia, watery Table 4. Positive reports of small bowel barium examination according to indications Indications Barium follow-through Dedicated fluoroscopy Abdominal pain 0% (0/35) 28% (7/25) GI bleeding 15% (4/26) 23% (7/30) Obstruction 50% (10/20) 21% (4/19) Anemia 0% (0/11) 0% (0/15) Nausea/Vomiting 20% (1/5) 20% (1/5) Suspect neoplasm 20%(1/5) 27% (3/11) Diarrhea 0% (0/3) 0% (0/9) Weight loss 0% (0/4) Total 16.2% (17/105) 18.6% (22/118) diarrhea or body weight loss. Positive radiographic reports according to clinical indications were shown in Table 4. Correlation between clinical indications and radiographic results were shown in Table 5. DISCUSSION The small bowel is a part of gastrointestinal tract that extends form duodenum to terminal ileum. The small bowel is a tube of unpredictable length with range of length 4.88 to 7.85m (average 6.5m) [1, 2]. The small bowel is attached to the posterior abdominal wall by a fan-shaped mesentery. The first part of duodenum is intraperitoneal, with the remainder of the duodenum is retroperitoneal as it runs inferiorly around the pancreatic head and to the left of aorta and then runs anteriorly to become intraperitoneal again. The jejunum normally lies in the left upper abdomen and periumbilical region, while the ileum occupied the right lower abdomen and pelvis. The caliber of the small intestine changes as the lumen fills and empties, but when full, the jejunum usually has a caliber of less than 3cm, and the ileum of less than 2.5cm [2]. Conventional radiological examinations are usually under estimated because of loop superimposition and considerable mobility within the abdomen [3]. Barium meal X-ray examination of upper gastrointestinal tract and barium enema for the colon study are being performed less frequently in current radiographic practice because of the common use of upper GI endoscopy, colonoscopy and cross-sectional abdominal imaging studies such as ultrasound, computed tomography and MR imaging [4]. However, barium meal follow-through examination of small bowel series remains widely used in the United States and many countries [5. 6] because of technical limitation of small bowel endoscopy. One of the disadvantages of the barium meal examination is that it is time consuming for the patients, the radiologist and the radiology department. Table 5. Correlation between clinical indications and radiographic results Indications Radiographic results (No. of patients) N DU SMA Adhesion Malrotation Crohn Polyp Malignancy Pain Bleeding Obstruction Anemia 26 Vomiting 10 1 Neoplasm 16 Diarrhea 12 4 Weight loss 4 Total N: normal finding. DU: duodenal ulcer with demonstrated active ulcer crater. SMA: superior mesenteric artery syndrome. Crohn: Crohn s disease.

4 312 Barium studies of the small intestine An increase in amount of the volume of meal, 900 ml of a diluted barium meal suspension, can improve examination quality of the small intestine or opacification of the ileocecal region in less than one hour [7]. However, the barium follow-through or dedicated fluoroscopic examination can be difficult to perform for the long-term bed-ridden or very ill patients. They usually can not ingest adequate amount of barium sulfate suspension in a very limited period of time, and transit time is often prolonged and therefore lowering examination quality. In such situations, the small bowel film is often nondiagnostic or inconclusive. The thoughtful selection of patients by clinicians for small bowel radiography is essential to make radiological evaluation cost effective. We compared film quality and diagnostic efficacy of barium follow-through from dedicated fluoroscopic examination. We found that there was no significant difference between two groups of examinations. Barium follow-through X-ray films, with the patient prone, were taken by X-ray technologists at intervals. Technical requirement was low and film quality was usually limited. All patients were finally undertaken to a compression view of terminal ileum with a compression paddle in supine position performed by a radiologist. This procedure provided a significant improvement in diagnostic quality of the examination. In contrast, when the whole procedure of dedicated fluoroscopic examination was performed by a radiologist, abnormality or pathology of the small bowel segment was usually ascertained. However, the dedicated fluoroscopic examination quality was more techniquedependant and the in charge residents should be very interested in searching a critical result and be paying high attention to both patients and procedures during the whole course of examination in daily practice. Examination quality was sometimes poor for ileum located in pelvic cavity even in fluoroscopic examination due to overlapping of small bowel loops. The double contrast images of the terminal ileum and pelvic ileal loops obtained with the pneumocolon might contribute to the better diagnostic quality of the examination [8]. There is not much data in the literature on the accuracy of the barium follow-through for detecting abnormalities in the intestine, probably because of the low incidence of small intestinal diseases. However, there are a few number of studies suggesting that the barium follow-through is not an accurate diagnostic technique [9-12]. The reported positive findings on small bowel examinations varied from 7-31% [13-15]. Our overall abnormal small bowel examination was 17.5%. The incidence of the disease of small intestine is low and usually associated with non-specific symptoms. The lower abnormal rate in the barium follow-through may partially be due to patient selection. Table 4 showed the relationship between clinical indications for small bowel examination and the report results. Low abnormal rate is noted in patients with anemia, body weight loss, nausea, vomiting, diarrhea or abdominal pain; in contrast, high positive rate is identified in patients with chronic intermittent gastrointestinal bleeding, a known history of small bowel disease or Crohn s disease. In our study, of 56 patients with gastrointestinal bleeding, 11 patients (19.6%) were found to have small bowel polyps, malignant tumors, acute duodenal ulcers or Crohn s disease. Out of 39 patients who were examined for suspected bowel obstruction, bowel neoplasms, obstruction or intestinal volvulus were demonstrated in 14 (35.9%) patients. Preoperative localization of gastrointestinal bleeding can be done by using endoscopy, barium follow-through, small bowel enema, 99mTc pertechnete scan, 99mTclabelled red cell scan and selective celiac and mesenteric angiography. Preoperative localization of gastrointestinal bleeding from obscure origin is usually rather difficult. Unless preoperative investigations showed the lesions in an anatomically fixed organ such as the duodenum or colon, the lesions still had to be identified at operation and therefore, intraoperative localization procedures should be used more freely [16]. Primary tumors, either benign or malignant neoplasms, of the small bowel are rare. Most of our patients found to have malignant tumor involving the small bowel or mesentery had history of malignancy. The major clinical impact of the radiological results of barium meal small bowel examination on patient management was to exclude a serious pathologic abnormality in patients with less specific symptoms, such as abdominal pain, weight loss, or miscellaneous symptoms [15]. The majority of radiology departments performed barium followthrough examinations so far. Regardless of the practice setting, these studies usually consist of a series of overhead radiographs, with routine spot images of the terminal ileum but not of the remaining small bowel. This situation may need to be reassessed and all accessible small bowel loops be visualized at fluoroscopy with representative radiographs to optimize the diagnostic yield of the examination [6]. Enteroclysis examinations (small bowel enemas) are being performed by us only for a very few particular patients. The infrequent use of enteroclysis in our department may be related to multiple factors, including, inadequate training of radiologists in the technical aspects of ente-

5 Barium studies of the small intestine 313 roclysis, reluctance of some patients to undergo this procedure and very time-consuming procedure. In conclusion, the small bowel follow-through study remains the primary diagnostic technique for the patients suspected of having small bowel disease. Barium follow-through carried out by technologists combined with fluoroscopic examination by radiologist for the terminal ileum and suspected abnormal areas can yield similar diagnostic results to the dedicated fluoroscopic examination only by radiologists. Therefore, it may save much time for the radiologists. REFERENCES 1. Underhill BML. Intestinal length in man. Br Med J 1955; 2: Backman L, Hallberg D. Small intestinal length: an intraoperative study in obesity. Acta Chir Scand 1974; 140: Herlinger H. Anatomy of the small intestine. In Herlinger H, Maglinte DDT, Birnbaum BA. Clinical imaging of the small intestine. 2nd Ed. 1999, Springer 4. Gelfand DW, Ott DJ, Chen YM. Decreaseing numbers of gastrointestinal studies: report of data from 69 radiologic practices. AJR Am J Reontgenol 1987; 148: Maglinte DDT, Kelvin FM,O Connor K, et al. Current status of small bowel radiography. Abdom Imaging 1996; 21: Ha AS, Levine MS, Rubesion SE, Laufer I, Herlinger H. Radiographic examination of the small bowel: Survey of practice patterns in the United States. Radiology 2004; 231: Bret P, Francoz JB, Gourdol Y, et al. An improved technique for radiological examination of the small intestine. J Radiol 1980; 61: Deignan RW, Malone DE, Taylor S, et al. Improving visualization of distal and terminal ileum during the small bowel meal: an evaluation of fluoroscopic manoeuvres. Clin Radiol 1996: 51: Meyers SG, Ruble PE, Ashley LB. The clinical course of regional ileitis. Am J Dig Dis 1959; 4: Goldberg HI, Caruthers SG, Nelson JA, Singleton JW. Radiographic findings of the National Cooperative Crohn s disease study. Gastroenterology 1979; 77: Rkberg O, Ekholm S. Radiography in primary tumor of the small bowel. Acta Radiol [Diagn] 1980; 21: Bessette JR, Maglinte DDT, Kelvin FM, et al. Primary malignant tumors of the small bowel: a comparison of the small bowel enema and conventional followthrough examination. AJR Am J Reontgenol 1989; 153: Fried AM, Poulos A, Hatfield DR. The effectiveness of the incidental small-bowel series. Radiology 1981; 140: Rabe FE, Becker GJ, Besozzi MJ, Miller RE. Efficacy study of the small-bowel examination. Radiology 1981; 140: Chen MYM, Ott DJ, Kelley TF, Gelfand DW. Impact of the small bowel study on patient mamagement. Gastrointest Radiol 1991; 16: Lau WY, Fan ST, Wong SH, et al. Preoperative and intraoperative localization of gastrointestinal bleeding of obscure origin. Gut 1987; 28:

6 314 Barium studies of the small intestine

Radiological examination of the small bowel

The Ulster Medical Journal, Volume 58, No. 2, pp. 124-130, October 1989. Radiological examination of the small bowel A M Gilchrist, J 0 M Mills Accepted 18 July 1989. SUMMARY A retrospective study was