Roscoe E. Miller

Polypoid colonic lesions undetected by endoscopy.

Fifty-four endoscopically missed colonic polypoid lesions reveal the limitations of colonic endoscopy. Colonoscopy failed to identify 31 of the lesions, whereas 24 lesions were initially missed by proctosigmoidoscopy. One polypoid tumor of the rectosigmoid junction was missed by both. Most undetected lesions ranged from 0.5 to 1.5 cm. Endoscopic and radiologic diagnostic techniques are clearly complementary. Their combined diagnostic accuracy exceeds that of either technique alone. If results of the two methods conflict, one or both should be repeated. With a combined approach, completely missed lesions can be kept at a minimum.

Enterocylsis: the small bowel enema. How to succeed and how to fail.

Enteroclysis, the infusion of contrast medium directly into the small bowel, is a precise, rapid method for thorough small bowel examination. This technique demonstrates far more pathology than any other method when it is properly executed. However, the examination is sure to fail with poor techniques, thereby discrediting a superb method. Experience has shown that failures are usually due to inadequate technique or poor judgment or both during the examination. This article covers the proper and improper techniques of the examination and gives examples of each. The most common problems that arise during the examination are discussed in the order in which they usually develop.

Hypotonic colon examination with glucagon.

In a clinical double-blind crossover study, the effects on barium enema examinations of intramuscular injections of a placebo, glucagon, atropine sulfate, and glucagon plus atropine sulfate were compared in 12 male volunteers for a total of 48 studies. With either atropine sulfate or glucagon there were decreased colon tonicity and increased comfort during the examination. Number and intensity of side effects were less with either placebo or glucagon than with atropine sulfate alone or combined with glucagon. The subject is more comfortable, the colon and small bowel more relaxed, intracolonic pressure less, and the examination more quickly completed after glucagon than after placebo or atropine sulfate.

Detection of surgical lesions of the small bowel by enteroclysis

Enteroclysis is an examination in which barium is infused directly into the small intestine, and compression radiographs are taken on each segment. This method eliminates many of the inherent limitations of the conventional small bowel follow-through examination. This report concerns 45 patients with 48 small bowel lesions. They were missed on the conventional examination but detected within 3 months by subsequent enteroclysis and confirmed surgically. There were 15 patients with Meckels diverticula, 7 with obstructive adhesive bands, 5 with Crohns disease, 5 with blind pouch syndrome (1 with a leiomyoma inside the blind pouch), 2 with other leiomyomas, 3 with metastatic carcinoma, two with primary carcinoma 3 with radiation stricture, two with sinus tract lesions and fistulas, and 1 with another lesion. Improved intubation techniques and better barium mixtures make enteroclysis possible in most hospitals. As surgeons appreciate the value of enteroclysis, they can request this examination for appropriate patients to sooner find many surgical lesions of the small bowel which frequently go undiagnosed.

Perforated viscus in infants: a new roentgen sign.

Spontaneous nontraumatic rupture of the intestinal tract during the first few hours or days of life is an unusual, rather perplexing condition with a grave prognosis. The perforation most frequently involves the stomach wall, but occasionally occurs in the duodenum or colon. The usual entity, perforation of the stomach, is more common in boys and is often associated with prematurity or other congenital anomalies. The perforation is generally due to a congenital defect in the musculature of the stomach. Peptic ulcer, distal obstruction, trauma (especially that from the passage of tubes or the administration of oxygen), and other known causes of gastric perforation also occur in the newborn. Of 38 cases in which the site of perforation was reported, 25 were on the greater curvature, 5 on the lesser curvature, 4 on the anterior wall, 2 in the cardia, and 1 each in the fundus and posterior gastric wall. Clinically, the general picture in practically every instance is one of a baby perfectly well until four or...

Hypotonic Duodenography with Glucagon

In a double blind crossover study, the effects of 2 mg glucagon and 1 mg atropine sulfate on duodenal tonicity and motility were compared to placebo in 6 asymptomatic men. In a similar study, 2 mg glucagon and 30 mg propantheline bromide were compared to placebo. In 10 to 30 minutes after intramuscular administration of the drug there was a significant decrease in duodenal motility and tonicity with glucagon. Both tonicity and motility were near normal at 60 minutes. Responses to atropine sulfate and propantheline bromide were sometimes evident at 10, 30, and 60 minutes, but were variable and not consistently greater than with placebo. With atropine sulfate and propantheline bromide, intensity of reported side effects was greater than with placebo or glucagon.

Methods of Examination

In chapter 3, it was noted that addition of nutrients to the contrast medium was abandoned during the second world war. The problems involved in the functional examination were found to be considerably greater than those for the morphological examination. Furthermore, it was recognized that a functional examination must also be evaluated morphologically. It is therefore necessary that the morphological examination of the small intestine first attain a much higher degree of perfection. In the 1960s, only Mattsson et al. [47,153] advocated a return to this method; however, their published photographs of the ileum were very poor.

Gastrointestinal radiography with glucagon.

This report summarizes the results of nine diagnostic radiographic studies done double blind crossover comparing glucagon to placebo and to anticholinergic drugs in volunteers. In seven studies the subjects were administered drug intramuscularly and in two studies intravenously. There were five diagnostic studies of the upper gastrointestinal tract, one for esophageal varices and three of the colon. The results indicate that glucagon can be given intramuscularly and intravenously. When given intravenously it has a rapid onset and predictable length of action depending on the dose given. Reports of side effects were few consisting primarily of nausea and or vomiting. These results indicate that glucagon is the drug of choice for hypotonic diagnostic examinations.

Complete Reflux Small Bowel Examination

The Many different methods of small bowel examination recorded in the literature indicate that these are not as rapid or as exact as we would like (1–19). While the radiographic study of the colon and stomach is highly accurate when performed by competent examiners, the antegrade small bowel examination lacks this precision. For example, tumors of the small bowel are frequently not discovered until obstruction or other symptoms force an exploratory laparotomy. Most physicians hope for some improvement in this area, and we believe the complete reflux small bowel examination is a step forward. In our experience this new procedure is easier, quicker, and more fruitful than the older methods. This new method has demonstrated small ulcerations and inflammatory strictures of the small bowel as well as several other complete and incomplete obstructions: Meckels diverticula (one inverted), a radiolucent gallstone causing obstruction, adhesive bands, small bowel fistulae, and the extent of disease in regional ent...

Double-Blind Radiographic Study of Dose Response to Intravenous Glucagon for Hypotonic Duodenography

This study was undertaken to determine a dose response to glucagon during hypotonic duodenography. Fifteen male and female volunteers received placebo and 0.25 mg, 0.5 mg, 1 mg, and 2 mg of glucagon intravenously, double-blind, and crossover. Onset of drug effect occurred in approximately 45 seconds, regardless of the dose of glucagon given. There was a significant (p less than 0.01) decrease in gastrointestinal tonicity with all doses. The larger the dose, the greater the duration of drug action. Satisfactory stomach, duodenal, and small bowel hypotonicity for radiography were obtained with 0.25 to 0.5 mg of glucagon given intravenously with few side effects.