Roger K. Harned

Recognition and prevention of barium enema complications

The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, complications may result. Many of these can be prevented by proper equipment and careful attention to technique. When a complication does occur, prompt recognition and management is vital in decreasing morbidity and mortality. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02% to 0.04% of patients. Rarely the colon may burst due to excessive transmural pressure alone. However, a colon weakened by iatrogenic trauma or disease is more likely to perforate during an enema than is a normal healthy bowel. Injury to the rectal mucosa or anal canal due to the enema tip or retention balloon is probably the most common traumatic cause of barium enema perforation. Inflation of a retention balloon within a stricture, neoplasm, inflamed rectum, or colostomy stoma is particularly hazardous. Recent deep biopsy or polypectomy with electrocautery makes the bowel more vulnerable to rupture. The tensile strength of the bowel wall is impaired in elderly patients, patients receiving long-term steroid therapy, and in disease states including neoplasm, diverticulitis, inflammatory bowel disease, and ischemia. Intraperitoneal perforation leads to a severe, acute peritonitis with intravascular volume depletion. The ensuing shock may be rapidly fatal. Prompt fluid replacement and laparotomy are essential. If the patient survives the initial shock and sepsis, later complications caused by dense intraperitoneal adhesions may develop. Extraperitoneal perforation is usually less catastrophic but may result in pain, sepsis, cellulitis, abscess, rectal stricture, or fistula. Intramural extravasation often forms a persistent submucosal barium granuloma which may ulcerate or be mistaken for a neoplasm. The most dramatic complication of barium enema is venous intravasation of barium. Fortunately, this is quite rare as it may be immediately lethal. Most cases have been attributed to trauma from the enema tip or retention balloon, mucosal inflammation, or misplacement of the tip in the vagina. Bacteremia has been found in as many as 23% of patients following barium enema and, in rare cases, may cause symptomatic septicemia. Other less common complications include barium impaction, water intoxication, allergic reactions, and cardiac arrhythmias. Preparatory laxatives and cleansing enemas have been implicated in some instances of dehydration, rectal trauma, water intoxication, and perforation. Careful review of the indications for examination, previous radiographs, and clinical history will identify many of the patients at greater risk for complications so that appropriate precautions may be observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Papillary carcinoma of the thyroid and familial polyposis coli.

A 22-year-old white woman in whom multicentric papillary carcinoma of the thyroid developed two years after prophylactic colectomy for intestinal polyposis is reported. This association has been observed by others. Patients with familial polyposis coli are at risk for a variety of malignancies other than colonic, and careful life-long surveillance is necessary.

Cholelithiasis in children.

Review of 367 cases of cholelithiasis in children from the literature and our experience showed that 81% of these patients has no evidence of hemolytic anemia. Oral cholecystograms were diagnostic of cholelithiasis in approximately 70% of these cases. Plain film studies were found to be of diagnostic value as a high percentage of gallstones were visible on plain radiographs of the abdomen.

Familial polyposis coli and periampullary malignancy

Patients with polyposis coli have an increased risk of developing periampullary malignancies, particularly if duodenal polyps are present. Since periampullary neoplasms occur, on the average, 15 years following the initial diagnosis of colonic polyps, periodic follow-up radiologic studies of the upper gastrointestinal tract are necessary in the management of polyposis coli.

Gastric polyps in familial polyposis coli.

Familial polyposis coli has been considered a disease in which polyps are confined to the colon and rectum. The authors recently saw 3 cases in which either adenomatous or hyperplastic polyps were also present in the stomach and duodenum. The polyps were detected only by endoscopy or air-contrast radiographic examination. These cases and other recent studies indicate that gastric and duodenal polyps are more common in familial polyposis coli than previously recognized and should be considered an integral part of the syndrome.

Adenocarcinoma of the stomach in association with Menetrier's disease

Menetriers disease is an uncommon lesion which may have malignant potential. This report documents a case of gastric malignancy arising in a patient with long-standing Menetriers disease and emphasizes that close follow-up of patients with this condition is necessary because of the possible development of gastric malignancy.

Bile duct carcinoma associated with chronic ulcerative colitis

Patients with chronic ulcerative colitis are prone to a variety of liver disorders. This case report illustrates development of bile duct carcinoma in a patient with long-standing inactive colitis. The report emphasizes the association of chronic ulcerative colitis with bile duct carcinoma and discusses the radiologic preoperative evaluation of the ulcerative colitis patient who develops jaundice.

Psoriasis, dysphagia, and esophageal webs or rings

Esophageal webs and rings may have a congenital origin and have been associated with iron-deficiency states and esophageal mucosal inflammation. Cutaneous diseases associated with esophageal webs and rings include benign mucosal pemphigoid and epidermolysis bullosa dystrophica. We report three cases of patients with psoriasis and associated single or multiple esophageal webs. Two of the three patients experienced a significant degree of dysphagia requiring periodic esophageal dilatation. Esophageal abnormalities did not seem to correlate directly with the extent or activity of psoriasis. The cause of esophageal webs or rings in these patients with psoriasis is not known. This report suggests, but does not prove, that there may be an association between these conditions.

Preliminary abdominal films for gastrointestinal examinations: how efficacious?

A prospective study to evaluate the efficacy of preliminary abdominal films for colon and upper gastrointestinal examinations was carried out on 733 patients. The preliminary film was found to be cost effective and useful in predicting adequacy of patient preparation for colon examinations but not for upper gastrointestinal studies. Significant diagnostic information that could potentially contribute to the patients care was present in 8.4% of the cases. No contraindications to contrast examinations were found.

Abstracts Papers presented at the Eleventh Annual Session of the Society of Gastrointestinal Radiologists, October 1, 1981, Boca Raton, Florida

Papers Presented at the Eleventh Annual Session of the Society of Gastrointestinal Radiologists, October 1, 1981, Boca Raton, Florida ESOPHAGEAL NODULARITY A NORMAL VARIANT OF THE ESOPHAGEAL MUCOSA Seth N. Glick, M.D. Steven K. Teplick, M.D. Department of Diagnostic Radiology Hahnemann Medical College and Hospital 230 North Broad Street Philadelphia, PA. 19102 Small superficial round nodules (2-4 mm) are frequently observed on routine double contrast esophagrams. They may be focal or diffuse, and appear as fine granularity or sharply defined filling defects. Endoscopic~lly, they are seen as white excrescences on a normal mucosal background. However, they may not be appreciated, unless specifically sought, becaUse of inadequate lumenal distension. Biopsy reveals normal or slightly hyperplastic squamous epithelium and vacuolated epithelial cells containing abundant glycogen. This has been termed glycogenic acanthosis. Esophageal symptoms are usually absent or cannot be correlated with this morphology. We evaluated 300 consecutive esophagrams considered to demonstrate adequate mucosal detail. Nodularity was found in 30%. These were usually confirmed endoscopically when sought. In addition to true nodules, pseudo-nodules may be caused by several types of artifacts such as transverse esophageal folds. Several pathologicconditions may resemble the normal esophageal nodules, however, radiologic and clinical criteria can usually make the distinction. The Esophageal Survey in Upper Gastrointestinal Radiography Dean D. T. Maglinte, M.D., Katharine L. Krol, M.D., Lloyd D. Caudill, M.D., David L. Brown, M.D., and William Michael McCune, M.D. Gastrointestinal Radiology Section Methodist Hospital and Graduate Medical Center, 1604 North Capitol Ave., Indianapolis, IN 46206 When an upper gastrointestinal study is requested on a patient with non-specific abdominal complaints, there are no guidelines as to what should be the minimum esophageal survey. Of 200 patients referred for upper gastrointestinal series, 40 (20%) had radiographic evidence of esophageal disease. Reflux esophagitis, frequently considered difficult to diagnose radiographically, was demonstrated in 31 (16%). A non-invasive carcinoma, varices and a leiomyoma were found. It is suggested that a thorough evaluation of the esophagus consisting of double contrast, single contrast distention radiograph, fluoroscopic motility assessment and mucosal relief study be included in every upper gastrointestinal series. This minimum multiphasic routine evaluation offers the potential for improvement in diagnostic accuracy with little additional examination time. Barium Swallow After Total Laryngectomy Koehler RE, Balfe DM, Setzen M, Weyman P J, Baron RL, Ogura J Department of Radiology and Divls]on of Otolaryngology, Washington University School of Medicine, St. Louis, Mo Dysphagia is a frequent problem in patients who have undergone total laryngectomy and the barium swallow is often useful for evaluaHng the cause for the symptoms. The examination may be di f f icul t to interpret, however, because a variety of anatomic changes may be produced by radiation, infection, fistula, recurrent tumor or the operation itself. We analyzed radiographs and clinical information on 43 patients with total laryngectomy with followup periods ranging from g months to 17 years. Recurrent tumor was found in IS patients and was evident radiographically as a mass deviating the neopharynx in 14. Benign strictures in nine patients apeared either as a long symmetrical r~arrowing or as a very short, weblike narrowing. Fistulas were demonstrated in 12 patients and presaged the development of recurrent tumor in five. Cricopharyngeal muscular-dysfunctlon accounted for the dysphagia in five cases. An understanding of these patterns leads to more accurate interpretation of the postoperative barium swallow and the radiographic findings often indicate the correct diagnosis with a high degree of confidence. 0364-2356/82/0007-0087