Susan M. Williams

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)

Computed tomography and magnetic resonance imaging of cervical metastasis.

Thirteen patients with head and neck cancer underwent staging by clinical examination, computed tomography (CT), and magnetic resonance imaging (MRI) in a standardized blinded fashion. All patients subsequently underwent radical neck dissection with subsequent pathologic staging. CT and MRI each predicted 93% of staging results correctly, with clinical examination correct 67% of the time. Staging of primary tumors had an accuracy of 90% by clinical examination, 40% by CT, and 50% by MRI when compared to staging of the pathologic specimen. Understaging was seen in 50% of CT scans and 30% of MRI scans. We believe either CT or MRI should be considered for routine staging of the neck in all head and neck malignancies.

Radiographic demonstration of common bile duct varices.

Varicose veins may occur along the course of the common bile duct in patients with extrahepatic obstruction of the portal vein. These may cause partial biliary obstruction or excessive bleeding during biliary surgery. The cholangiographic appearance of choledochal varices is described.

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.

MR Imaging of a Hepatoma Associated with Alagille Syndrome

Alagille syndrome is a rare cause of chronic liver failure which may be treated by liver transplantation. When underlying hepatic tumor is present, transplantation has had poor results. Magnetic resonance imaging may be a sensitive, noninvasive method to evaluate the presence of tumor before transplantation.

Fistula following continent ileostomy

A patient who developed a fistula secondary to Marlex mesh in the nipple valve of a continent ileostomy is reported. Etiology and management of fistula following continent ileostomy are discussed. Fistula formation should be recognized as a potential hazard of the use of prosthetic material to stabilize the nipple valve of a continent ileostomy.

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.

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.

Technique for revision of continent ileostomy

A technique is described for revising an incompetent nipple valve of a continent ileostomy. The procedure involves preserving the incompetent valve and using it as a collar around the base of the new valve to improve function.