John C. Lappas

Wireless Capsule Endoscopy Detects Small Bowel Ulcers in Patients With Normal Results From State of the Art Enteroclysis

BACKGROUND:Wireless capsule endoscopy (WCE) is a new technology for small bowel imaging.AIM:To report our initial experience with sensitivity of high quality enteroclysis in patients with small bowel ulcers detected by WCE.METHODS:Medical records of all patients referred for WCE from December, 2001 to April, 2002 at our institution were reviewed. All patients had negative upper and lower endoscopies and small bowel barium studies before WCE.RESULTS:There were 40 patients (19 female, mean age 57.3 yr) during this study period. Three patients had multiple small bowel ulcers detected by WCE. One with ileal ulcers and abdominal pain had an enteroclysis at another hospital before WCE. Review of the study at our institution showed that it was of excellent quality and was normal. Two patients with chronic iron deficiency anemia had multiple small bowel ulcers and were referred after WCE for a repeat small bowel barium study by biphasic enteroclysis performed by experienced GI radiologists. The radiologists were told in advance of the WCE findings. Both studies were considered technically to be of perfect quality. Despite this, both studies were negative. All 3 patients improved after therapy for Crohns disease.CONCLUSIONS:Our data indicates that WCE may be more sensitive for small bowel ulcers than the best enteroclysis available.

Multidetector-row helical CT enteroclysis.

Currently, CT-E is not recommended as the first-line examination in patients when mucosal detail is required. Double-contrast barium air enteroclysis has advantages in demonstrating small mucosal abnormalities. The authors find CT-E of value in the work-up of patients with symptoms of intermittent small bowel obstruction, particularly those with a history of prior abdominal surgery; in the further work-up of selected patients with high-grade obstruction in whom general surgeons prefer initial conservative management (immediate postoperative small bowel obstruction, patients with history of prior abdominal surgery for malignant tumor, history of radiation treatment, and possible internal extraintestinal fistulae); in looking for complications of small bowel Crohns disease; and in the patient with unexplained anemia or gastrointestinal bleeding. In a series of patients who had both abdominal CT and barium enteroclysis done, each examination provided unique and complimentary diagnostic information. Because CT-E combines the advantages of both methods of examination, is it the optimum imaging work-up in the investigation of small bowel disease? Further research and clinical experience will define the precise role of CT-E in the investigation of small bowel disease. Experience with this method of examination is limited to a few institutions, performed by investigators with interest in small bowel diseases. The addition of cross-sectional display and multiplanar reformatting made possible by multidetector-row helical CT to enteral volume change and the use of multifunctional nasointestinal catheters make CT-E an important tool in the investigation of small bowel disease. Experience has shown the increased reliability of any method of examining the small bowel that challenges intestinal wall distensibility by fluid enteral volume infusion.

Reliability of indications for cervical spine films in trauma patients

Common emergency room practice mandates cervical spine (C-spine) films in all trauma patients with potential injuries. With the increasing costs of medical care, such liberal criteria may not be justified. This 1-year prospective study of 860 patients who presented to a Level I Trauma Center was undertaken to determine the signs and symptoms that would select the patients at risk of C-spine injury. The clinical presentation of each patient was correlated with the presence of C-spine fracture. Twenty-four patients (2.8%) had injuries demonstrated by plain film radiography. The incidence of fracture in 536 symptomatic patients was 4%. A significant likelihood of C-spine fracture was seen in patients with respiratory compromise (100%), motor dysfunction (54.5%), and altered sensorium (8.9%) (p less than 0.001). No fractures were seen in asymptomatic patients (p less than 0.001). Cervical spine radiography should be performed in patients with abnormal neurologic findings or symptoms referable to the neck. In alert asymptomatic patients, cervical spine radiography may be omitted.

Current concepts in imaging of small bowel obstruction

The diagnosis and treatment of small bowel obstruction continue to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the current concepts related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.

Enteroclysis in the evaluation of suspected small intestinal bleeding

One hundred twenty-five consecutive enteroclysis studies performed for the indication of gastrointestinal bleeding were reviewed. The overall yield of positive studies was low (10%) but important lesions were found. Patients with unequivocally normal evaluations of the upper gastrointestinal tract and colon had the highest yield of positive enteroclysis studies (20%). Neither the specific type of bleeding, the presence or absence of abdominal symptoms or physical examination findings, nor the results of laboratory tests were associated with a positive or negative enteroclysis study.

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.

Radiology of small bowel obstruction: contemporary approach and controversies

The radiologic workup of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this complex situation have undergone considerable changes over the past two decades. The diagnosis and treatment of small bowel obstruction, a common clinical condition often associated with signs and symptoms similar to those seen in other acute abdominal disorders, continue to evolve. This article examines the changes related to the use of imaging in the diagnosis and management of patients with this potentially dangerous problem and revisits pertinent controversies.

Radiologic Investigations Complement and Add Diagnostic Information to Capsule Endoscopy of Small-Bowel Diseases

OBJECTIVE The purpose of our study was to review how commonly performed radiologic examinations compare with capsule endoscopy in the investigation of small-bowel diseases, to analyze the limitations of capsule imaging, and to propose an algorithm for use of specific radiologic examinations to complement wireless capsule endoscopy. CONCLUSION The diagnostic yield of capsule endoscopy is superior to that of radiologic examinations except air double-contrast enteroclysis for mucosal details. Radiologic investigations find new applications in clinical practice by complementing capsule endoscopy to overcome its limitations.

Technical refinements in enteroclysis

As the primary method of investigating the small bowel, enteroclysis remains a technique in evolution. Technical refinements have made the examination faster to perform, better tolerated by patients, and easier to interpret. More recently, its essential principle of volume challenge has been combined with the tremendous advantage of CT cross-sectional imaging with multiplanar reformatting to give rise to the exciting new techniques of CT enteroclysis and MR enteroclysis (see separate reviews in this issue). Through improvements in methodology and advancements in technology, the future of enteroclysis looks bright indeed.

Peritoneal and Retroperitoneal Anatomy and Its Relevance for Cross-Sectional Imaging

It is difficult to identify normal peritoneal folds and ligaments at imaging. However, infectious, inflammatory, neoplastic, and traumatic processes frequently involve the peritoneal cavity and its reflections; thus, it is important to identify the affected peritoneal ligaments and spaces. Knowledge of these structures is important for accurate reporting and helps elucidate the sites of involvement to the surgeon. The potential peritoneal spaces; the peritoneal reflections that form the peritoneal ligaments, mesenteries, and omenta; and the natural flow of peritoneal fluid determine the route of spread of intraperitoneal fluid and disease processes within the abdominal cavity. The peritoneal ligaments, mesenteries, and omenta also serve as boundaries for disease processes and as conduits for the spread of disease.