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we're gonna talk today about double contrast
examinations of the gastrointestinal tract
for the non radiologic people here
in the audience.
Some of this will probably be review,
some will be new material and I hope
hopefully it's timely as virtually
everybody at one time or another does order
gastrointestinal studies on their
patients for a variety of reasons.
Obviously this is basically a radiologic
talk,
but I will orient as much as possible to
it,
to the clinicians uh when
appropriate times make themselves
available.
I have really two themes that go out
through this entire presentation and that
is um double contrast techniques
may be performed by any interested radiology
department.
They are not difficult to do.
The reason I tell that to you clinically is that if you're ever working
at other institutions and
perhaps the radiology department is not perform these
techniques,
you know,
that they can be performed with these.
There there may be reasons why they don't perform them or differences in
philosophy,
but they can technically be performed readily.
And the second theme is that uh at least
in my opinion,
in many instances,
the diagnostic capabilities
of G.
I tract radiology are extended with these
techniques.
So,
if we could have the first slide and the lights down,
like
double contrast examinations of the gastrointestinal
tract can be performed virtually the entire gastrointestinal
tract,
the esophagus,
the stomach,
the duodenum and colon colon air contrast
work has been known about for some time now,
primarily popularized in uh
europe.
However,
I think in this country it's been generally somewhat under utilized,
but now there are techniques available to study these
various sites with these techniques.
Next line
first,
we'll talk about the esophagus and we'll follow the gastrointestinal
track ab orally.
There are various techniques that may be utilized in the technique that
we have utilized here with considerable success
is using the patient upright and
having the patient hold barium in one hand and a
cup and water in the other hand,
patient has a mouthful of barium and then
swallows the barium and quickly thereafter one mouthful of
water so that you see we do not produce an heir
contrast effect but rather a double contrast
effect.
That is the water washes through the
barium that has previously been swallowed.
Leaves a coating of barium on the esophagus and
produces the double contrast effect we
use for the variant preparation
preparation that is formulated for air
contrast colon work.
It's a preparation that's a moderate moderately
viscous and has excellent coding properties and
spot films are obtained at the appropriate time.
Next slide.
This is a subject holding the barium in one hand and the
water in the other hand taking a mouthful of
barium.
Next slide
patient has the berry um in her mouth,
water is ready and she's going to swallow the barium and
follow that with a swallow of water as quickly as possible
so that the water as we said,
can wash the barium through next line.
This is an example then of a normal double contrast to
Sasha graham.
A good one obtained with this technique.
Next line.
These are the clinical and radiologic uses uh
for double contrast to soften biography.
I should point out to you when when you're ordering this in your patients,
we don't do this routinely.
We do it if there are so fragile symptoms and
or if there is a suspicious finding on a
conventional esophageal examination.
So it is not a routine examination in our department.
As several other of these techniques are.
It's obviously helpful for the detection of small esophageal
tumors.
I don't know that these small tumors are always early tumors,
but one can detect smaller
salvageable lesions with reliability.
With this technique,
it's helpful to delineate the morphological features
of lesions in the esophagus.
That is the surface characteristics.
Is it smooth?
Is it irregular?
Is it also rated?
And finally,
to distinguish between mucosal and sub
mucosal lesions?
And I'll show you some examples of these things.
And another use for this is to assess
the total vertical extent of disease that is you have a
neo plasm.
The total vertical extent of this new plasm can be
readily assessed with double contrast to soften
geography.
And this is obviously going to be helpful in treatment planning.
Next line,
this is an example of a lot dilated esophageal
carcinoma that we had some time ago
and this lesion would not be missed and was not
missed on a conventional,
say photography,
but one can see it uh very readily with a
double contrast technique and can tell the
gross vertical limits of disease very readily here,
much more readily than on the conventional technique.
Next line.
And this la belated mass in these various projections as an
example of a carcinoma sarcoma.
Now these several lesions no one is going to miss with
conventional techniques,
they're obvious.
I think there may be more elegantly displayed here and one can see a little bit more
about them.
I'm gonna show you some cases now where
the double contrast technique was of definite value in
comparison to conventional techniques.
Next slide,
This is a man that was being followed here for a gastric ulcer.
He was referred here because it was felt that the gastric ulcer might be
malignant and he did have a gastric ulcer,
had a symptomatic patient
in terms of his esophagus and on his esophagus,
RAM had this obvious uh filling
defect here.
It's difficult to characterize it,
but a definite filling defect there on multiple swallows.
As you can see next slide
and here with a double contrast techniques,
we can see this lesion in profile
and then interestingly we can see it on Fox here.
It's a little unusual to see in esophageal lesion on fox,
but this is analogous to how we see Palepoi defects in the
colon.
And this is a squamous carcinoma in this patient.
I think that we can see this uh
lesion considerably better with this technique than with a single
contrast next live
here's a very interesting patient and we'll use it to make another
point to clinicians.
This is a patient who had had a previous head neck tumor several years
before he had a carcinoma of the tonsils and
he was having difficulty swallowing and he indeed was
having difficulty swallowing.
You can see here that he's aspirated a fair amount of
contrast material.
We could not obtain very many films of his
thoracic esophagus.
But in this region once he's a little mucosal nodule
and this proved to be a squamous carcinoma of the
esophagus and a patient with a previous head and neck
legion next slide and
another more recent patient,
another patient with a head and neck lesion a few
years before.
Again asymptomatic just being studied routinely for
his head neck problem.
We see this plaque like irregularity along this wall and this has
been proven now to be a squamous carcinoma of the
esophagus.
I want to just stop here and make this point to any of
the clinicians that are here
who do see patients for head and
neck problems,
not necessarily head neck surgeons or
E.
N.
T.
People but anybody who comes in contact with these patients
at the time they are initially diagnosed and thereafter when
they're followed up one of the routine things that should be
done with them at some regular periodicity.
Maybe like every six months after the baseline examination is to
do in a sofa graham because there is a definite
increased incidents of esophageal carcinoma in
patients with any sort of squamous head and neck tumors.
And we have found a large number of them in a several year period
of time where we've been looking maybe maybe about as many as a
dozen.
Some of them quite small and others unfortunately,
very large,
bulky tumors.
So this is an association,
I think that it hasn't been entirely recognized here and then we need to look
for it and maybe just as common as these people later
developing squamous carcinomas of the lung.
Next slide,
another patient,
this patient on multiple barium swallows had this
vague area of narrowing in the esophagus.
It was definite but not hard to characterize it.
Next slide,
mucosal pattern through this area was entirely normal.
Next slide,
but on a double contrast study,
we can see some additional findings on the left here,
we can see some shouldering effect that wasn't appreciated
on the barren field study.
And we see some irregularities on the contour of the
esophagus on the opposite side.
And this is another squamous carcinoma of the esophagus.
Next live,
here's an interesting patient.
This is a brother of a physician here in this hospital
who had this vision was examined at another
hospital and had this filling defect in the
esophagus.
This filling defect identified.
He was referred here and had some studies done
here.
Next line on this double
contrast study,
we see this nice smooth interim euro lesion.
If you look very carefully here and I hope it projects There's another
thing staring at us on foss.
Next live turning the
patient into the opposite of liquidy.
We see the other lesion.
Yes,
sir.
Are to lie on my mama's in this patient's esophagus,
only the second one being recognized with double contrast
study.
Next slide,
here's another interesting patient that has this obvious
fungal irregular carcinoma with
some extension seems to be going up into the esophagus as they
commonly do.
Next slide films of the
esophagus do show some minor marginally
regularities.
And one would be suspicious that there is disease there.
But it's a little hard to define next line.
But again,
with double contrast study,
we can readily outline the total vertical extent.
This is not a good study because this patient had relative obstruction
here.
One can always obtain a beautiful study.
But even in a study here that somewhat compromised by an
obstruction,
one can still see this Neil players from crawling up the
esophagus.
This piece of tumor is up here.
So we can see that virtually the distal half the esophagus is
involved by this gastric nia plasm that's readily
identified with double contrast examination next lot.
And finally,
just in terms of inflammatory disease.
This is a patient with candid diocese and we see a nice
cobblestone pattern throughout the assad because in
this patient next line.
So in summary relating to the esophagus
double contrast of so photography is simple to perform.
We do the technique of barium and water with successive
swallows and we find that it is a useful
adjunct to the morphological examination of the
esophagus for the detection of small
esophageal tumors.
Hopefully early in some cases
defining the morphological features of the tumors
and finally the vertical extent of disease in
the esophagus.
Next slide,
we'll go on to the stomach now and talk about
air contrast or double contrast exams of the
stomach.
In this case,
the way the technique is performed on your patients.
We use 2-3 ounces of a high density berry.
Um that has certain coding properties for the stomach
to the barium is added an anti foaming agent that we'll discuss in
a moment and we use a gas preparation
effervescent powders to produce the gas in the
stomach patient ingested the gas
preparation the effervescent powders and follows this with a
barium patients turned several times to make sure the
stomach is coded and to dissipate the bubbles and then
double contrast views are obtained.
We routinely do four double contrast views
in our examination and it's readily incorporated into the
initial part of the examination.
Blue dragon and other anti spasmodic
agents may or may not be added uh to decrease
gastric peristalsis uh and decrease
gastric emptying if that's necessary.
And we use a low killer voltage on
these radiographs to obtain optimal contrast
next line these are
some of the preparations that have been available primarily
manufactured in japan effervescent
preparations and many of these had anti
foam substances in them.
However,
they are generally not available in the United States.
Uh at this time.
Next slide,
this is one of the preparations call unique Zorro.
We see here that when the cap is opened,
there are some japanese script here.
A lot of people think that this is the instructions
as to how to do the examination,
but others feel that this perhaps represents new plans
for an attack on Pearl Harbor.
Next line
we find that just plain old citric carbonate that one
can obtain from any pharmacy is just as
good as the other preparations of course here where
there is no anti foam agent and one has to
add the anti foam agent.
We use about a teaspoonful of the gas
powder next line
and we add Millikan drops.
In other words,
this is signed with a cone to the berry,
um maybe a CC or CC.
And a half of these malecon drops are added to the 2 to 3
ounces of barium.
Next line,
yes.
So the patient begins the examination
with citric carbonate powders and bury him in
hand.
Next line she ingests the powders and
drinks down the uh the barium
patients place in a recumbent position and turn from the
supine to the prone position and back three or
four times again to achieve as good
at coding as possible and to uh
make the bubbles disperse that are formed by the citric
carbonate.
Next line and then
three films in the supine and soup.
I know black positions are obtained in rapid succession.
One wants to do this fairly rapidly so that not much
gastric emptying of either barium or
uh air takes place.
Next live.
This would be an example of a nice double contrast
gastro gram in the supine position with
just a small amount of barium and not much gastric
emptying.
Haven't taking place.
Next line.
one Old Black View.
Next live the other
old black view.
Those are three routine views we obtain.
Next lied at this point we stand the patient
up and obtain an upright view of the fungus.
And at this point then the rest of the examination
is resumed as in a conventional way.
And most people would at this point do pressure,
mucosal views on the on the rest of the stomach and
there's just a small amount of barium in the stomach at this time.
And one can readily obtain these views.
Next line,
I'm just gonna digress here for a moment and talk
about one aspect of the
stomach anatomy that we've been able to appreciate with
double contrast studies of the stomach.
Should say that dr Dodd stimulated this work
in our department.
He has been interested in this for some time.
And for any of you who are further interested in this and
other aspects of stomach anatomy.
He's going to be talking at jesse jones
library building on the first floor
to the Houston Gi Forum this afternoon at three
o'clock.
The surface of the gastric mucosa,
my gastric mucosa and yours.
Everybody's is subdivided in addition to the Rue Guy that
everybody knows about into small ovoid or
political islands by a complex intersecting series
of shallow grooves.
The islands that will show you in a moment or turned the area
gas tricky and the surrounding grooves are turned the
salsa gastric next lot
this is a stomach that's been opened
up.
And if you look carefully,
you know,
there are obvious ruby.
I hear that everybody knows about in the stomach of course,
and that we use to make diagnoses with.
But there are other little
islands here.
In other words,
a fine mucosal relief pattern in and amongst the
Rue Guy and where the rug I are not in the stomach.
Next line,
this is the same stomach painted with
barium and one can appreciate this
network pattern uh in the
stomach amongst the Rue Guy and in between them and on
them,
et cetera.
Next line
here is a close up of one aspect or one portion of the
body of that stomach.
So like here's a gastric crew guy.
And there's one and then one can see on the Rue Guy and in
between them these little political islands of
tissue,
the fine mucosal relief,
the area gastric and then surrounding and
actually making up these little islands are these
intersecting grooves called the salsa
gastric E.
Those salty gastric.
Those little tunnels is where the barium goes to
make that network pattern.
Next line.
And this is a close up in vitro painted
view of that portion of the stomach showing
that appearance.
Next line.
Dr James Anderson in uh the
laboratory associated with the
diagnostic radiology department.
Uh did some scanning electron
microscopy of some stomachs.
And this is an interesting appearance of this
pattern with a scanning electron
microscopy.
One of these is an area gastric E.
These are one of these islands blown up.
And here are these tunnels.
These intersecting grooves the salsa gastric E.
And we can notice.
Then each area gastric itself has a
convoluted patterns like each area gastric has an area
gastric pattern of itself.
But we see a convoluted pattern on each area.
Gastric Next line
here's a close up of one of those.
This is one area gas tricky.
Here are these tunnels alongside the salsa gas tricky
these grooves.
Okay.
And then we see this convoluted pattern.
If you notice amongst the convoluted pattern,
our little pits,
little depressions.
Those are the gastric pits.
Those are the openings on the gastric
mucosal surface into which gastric
glands drain so that if you can see here
each area gastric E.
Each little island maybe has a dozen Of these
gastric pits into which gastric Glands one or
more drain next slide.
So this schematic drawing
summarizes what we've just said.
Then one of these islands is the area gas tricky.
And then one can see these little black dots
representing the cell site.
Excuse me representing the gastric pits.
And then we can notice here in the cross section.
One or more gastric glands drains into each one of
these gastric pits.
Thanks line Radio
graphically we can identify this pattern if we
do double contrast techniques and have
good coding variant preparations that are not too viscous so
that the the barry um
can enter the shallow sell side gastric.
And we have identified three arbitrary
patterns.
We've talked about a fine pattern,
a course pattern in a nodule or pattern.
And you will see this in your report sometime where we talk about
a course fine mucosal relief pattern
or a coarse or fine area gas tricky
pattern.
Next lot here are some
examples.
This fine little network pattern in the distal
stomach here is an example of a of an average
fine gastric find relief pattern.
This would be uh not very
spectacular.
And we see this I guess in about 50% of our cases
uh using double contrast
techniques.
Next live this would be a
coarser pattern where the islands themselves are larger and the
grooves themselves are denser appear more
coarsened.
Next line.
Another example of a course area gastric
pattern.
Next line and finally
a not very frequent appearance,
the nodule er appearance of the
fine mucosal relief pattern of the stomach.
Now,
uh anatomically
this is interesting and I think certainly one
thing it helps us with is that if we see this
with regularity,
we know,
then we have an objective criterion to say that we are
achieving excellent double contrast
examinations of the stomach.
If one can see this pattern,
one knows he's achieving ah
good double contrast work of the stomach
what their functional significance is and if they can
be used in diagnosis is
a little more questionable at this time,
we have had some cases where the pattern's been course
or Nigel er that has been diagnosis gastritis.
We've had one or two cases where it's been helpful in malignant
disease,
but at this time it would be hard to make a
definitive statement about its real diagnosable
value.
Well,
sometimes in our reports say this to the
clinicians,
you'll see a report that discusses this pattern the fund because of
relief pattern of the area gastric pattern.
And there will be a statement made that it could suggest
diagnose of gastritis and you have to correlate that
clinically with your clinical findings.
But at this time there is no definitive statement that can be
made regarding its its functional
significance as diagnostic significance.
Next line,
okay,
now,
back to double contrast gastro graffiti and some
quick examples of diagnoses that are made very
readily with double contrast uh studies
here on the post year.
While the stomach is the evidence of a healed ulcer
with multiple radiating folds right into a little gastric
pit.
Next slide
here's another lesion on the posterior wall of the
stomach,
a central ulcer crater with radiating folds.
This surprises.
Incidentally,
one can see this network pattern the area gas tricky and the more distal
stomach.
We thought that this,
you know,
in this projection at least had the appearance of a
benign ulcer with radiating foals
dr nelson and his group endoscope this
patient and took some biopsies and I understand that on this
one or two of the folds up super early there
was lymphoma patient did have known
lymphoma in his liver and this turned out to be a lymphoma.
This involvement of the stomach and this unusual presentation
of a ulcer with radiating folds.
Next line,
here's a very interesting case.
It's not something that's going to be seen very much probably at
this hospital but will be seen at other hospitals where this
technique is performed.
This is a standard right Ontario
black view of the stomach that's perfectly normal in a patient.
Next line.
This patient,
if you notice on the double contrast study has multiple
punk Tate and
linear collections of barium.
Next slide,
I think there's a close up in a different projection.
Multiple punkt eight and linear collections of barium and
many of the punk take collections are surrounded
by nuisances.
Can we go back to the other slide out and it seems from here.
It projects a little better.
Many of these little collections are surrounded by licenses and this
is a pretty classic radiologic example of
erosive gastritis with multiple fine
linear and and dot like superficial ulceration surrounded
by small halos of oedema.
And this is a diagnosis that can be made only with
this technique and with some frequency according to the
literature.
Again,
we don't see that kind of patient here.
Very often,
I should comment at this point that
these techniques were originally evolved in
Japan primarily.
Certainly they were popularized from Japan
for the earlier diagnosis of focal,
non invasive carcinomas in that country.
And judging from the literature and from our own experience here,
although it may be a little skewed by the type of institution that this
is,
we don't find many early malignancies,
certainly not add no carcinomas with this technique
that may relate to the fact that we don't see early
patients or that gastric carcinoma is not as common
a disease here as it is in japan or perhaps
to some extent the fact that we are not surveying patients in this
country for this problem as is done in many
parts of Japan.
So I think that the yield in gastric
malignant diseases not nearly going to be as high as it
is in the orient.
However,
there are diagnoses that are made in this country?
Uh that are coming here that can be made really only with this
technique and that's why I stopped here.
This is such a diagnosis.
The case of a gi bleeder bleeding from erosive
gastritis.
Uh This is going to be a high yield
diagnosis with this technique uh in the United
States and north America in general.
Next line and the next
a gastric polyp.
Next line and another
gastric pile up and we can see her again the network
pattern the area gastric pattern that you'll see discussing the
reports periodically.
Next line here's a pretty
obvious case.
Uh I don't think one is going to miss this with any technique
large sub mucosal mass and other nodule.
A rude guy representing lymphoma in this patient
but a very elegant example of the entire extent of
disease in this patient's stomach.
Next line,
another large ulcerated mass.
On the lesser curvature.
This was an adenocarcinoma.
Next slide
now we were talking about primary malignancies.
We have had a yield in about three or four patients
of one form of malignant disease in the stomach.
Not diagnosable with conventional techniques.
And here is such a case.
This is a single isolated metastatic melanoma
deposit on the greater curvature of the stomach that was only diagnosed
on this film with double contrast techniques.
Next slide and another more
recent case.
In this upright view of the fund is there is a small sub mucosal
mass in this patient with melanoma,
isolated lesion.
So we have had yield in this form of malignant
disease although not primary malignant disease.
Next line
okay that finishes discussion of the stomach and I
have a few brief words now on the duodenum.
Hi platonic doing ethnography.
That is the use of a pharmacologic agent to paralyze the
duodenum and obtain better films of the duodenal
pancreatic interface has been
uh pretty popular in this country for about
10 years or so now.
And uh air contrast portion of that
exam is is a routine portion of double
contrast of high platonic doing
ethnography.
And here is an example of a paralyzed duodenum with a nice
perry ambulatory or perry vegetarian duodenal
diverticular one can appreciate the very nice mucosal
pattern here is the longitudinal fold extending down from the
area of the ambulance.
Uh So this is certainly a very helpful technique not only
for the diagnosis of disease and the head of the pancreas,
but for primary duodenal disease as well,
it's gonna be helpful in ulcer disease and occasional
duodenal tumors as well.
Next line indications for this
exam or if a conventional upper G.
I.
Series is suspicious for primary duty or
pancreatic disease.
And if there is a strong clinical suspicion of
pancreatic disease despite an apparently normal upper
gastrointestinal uh series
technique can be done with a tube or without a tube
and uh we have done them both ways in the
department.
So this is a technique that you can order on patients
where you fit these indications.
And very often we will just incorporate it into our
examination when uh when that
is necessary to come to a more
accurate diagnosis.
Next line,
there's an interesting patient we had not long ago.
This is a patient who had a lot of nice spot films of duodenum
and had an apparent pad effect or mass along the medial
contour of that duodenum do deny
graham was performed next slide,
which is perfectly normal and shows us that this
pseudo mass appearance was formed by this
longitudinal fold extending down from this
somewhat prominent and pula.
So sometimes normal anatomical variants in
the duodenum can be mistaken for
masses and can be resolved with HIPPA tonic doing
ethnography.
Next line and this is an
example of a carcinoma of the
excuse me of the duodenum with traction
changes.
I hope you can see that.
I can't see it too well from here,
traction changes on the duodenum in this portion.
So air contrast work is a,
let's say,
a routine part of hip a tonic doing ethnography and
not infrequently the air contrast films
uh are the highest yield
among in the examination performed with a high
platonic agent of the duodenum.
Excellent.
Yeah.
Next line.
Well all that's been good.
And we've talked about the upper gastrointestinal tract.
But now we really come to the money and that's the colon at
least the money for neo plastic
disease.
This is really where I think we can most help
our patients here is a place
where when we say a small tumor,
we almost talks anonymously with an early tumor.
Unlike other anatomical parts in the gastrointestinal
track in other areas of the
body here.
A small tumor is means
early tumor.
And we want to be able to make the diagnosis of small uh
colonic tumors.
And let's talk about the colon preparation.
And let me say to you,
although you know this,
you know,
this is the most important part of the examination.
This is the whole thing.
In fact,
the exam is not very difficult and it
doesn't require particularly sophisticated equipment,
but you do have to have the colon prepared in
some ways,
colonoscopy,
which we'll talk about in a few minutes,
which has come in some centers to rival
uh,
barium studies of the colon really has done us a little
bit of help there because
clinicians now at least people are doing colonoscopy
realized that when we were talking about all the filling
defects in the colon really can be a problem making a
diagnosis.
So they colonize space,
appreciate,
appreciate now the value of a clean
colon,
the entire colon.
Um,
please please please please
please encourage your patients to take the
preparation.
Don't tell him our it's okay if you skip something,
you know,
encourage them to take the preparation and we'll discuss what
we use here.
You know,
the preparation is I'm not saying it's the most pleasant thing to get up
in the morning and go and have a very minimal,
but you know,
it has to be done,
you know,
it has to be done and we want to do it well and
help the patient.
So please encourage your patients to
take the preparation.
Okay,
that's number one.
Number two.
Um four
patients who are in patients in this hospital,
we are unable to write for routine,
very minimal preparation.
The orders have to be written out.
Well,
there is in every nurse's station at this hospital,
we've checked any number of times,
at least one copy.
If not more of our routine barium enema preparation,
follow it,
sit down with it and write it into the chart.
I don't say it's a pleasant task,
but it has to be done.
So follow it on your impatience.
If there's any question as to why a patient can't take a preparation,
You can call us,
you know,
you can call us the department and we can discuss it and we'll
modify it if necessary,
but please write for our entire preparation.
So we don't have a compromised exam.
Let me tell you that.
We will not hesitate in the radiology department to
cancel the patient's examination.
Uh If he has not taken a preparation or it
hasn't been ordered for him as an inpatient.
We do our best to,
you know,
to accomplish the examination.
We will will go so far,
we'll give multiple enemies in our own department.
But you know,
we need cooperation.
We don't feel we're going to do the patients a favor or you a
favor if we do an inadequate examination and MS
a potentially curable colon lesion.
And another point I want to make before we look at some
cases is that many times you may order a barium
enema and we'll do an air
contrast or occasionally vice versa.
Please give us adequate history on the
requisition so that we can make a reliable judgment as to
what kind of examination the patient needs.
There are certain indications that we follow that I'm going to show you in a few
moments.
And uh if we don't have reliable history
written down there or we can't communicate with the patient,
it's difficult for us to make a good decision about what
examination is best for that patient.
So uh please give us adequate history
so that we can make the judgment.
But you will find times when a conventional enemy is ordered
or just it's written barium enema and we do in air contrast and
occasionally vice versa.
But we do what we think is most indicated to
make an accurate diagnosis in that patient
after we've talked to them and seeing the history
requisition.
So this is the colon preparation that's used in this hospital.
We do our upper jeez first and we have done that for
the last several years.
And here is the rationale,
I've had a lot of phone calls on this if a
patient is going to have both exams that is an
upper gastrointestinal series and a barium
enema.
We do the upper gi first,
our scheduling people know to do that.
And the reason we do that examination first is
so that we use the berry um that they've ingested as a
marker to tell us if the colon is clean.
That is to say if a patient has an upper gastrointestinal
series on monday of a given week and
on Tuesday they begin their colon preparation
on Wednesday morning.
If there is any significant amount of barium retaining their
colon,
we have an opaque barium marker to tell us that
the colon is not clean.
That is the rationale for us doing a upper gastrointestinal
series first in most routine patents obviously if there
is a suspicion of colon obstruction,
we don't,
but in the routine patient that's being worked up for
bleeding or whatever.
Upper gastrointestinal series is done first.
It's basically an 18 hour preparation that begins
at noon the previous day and it consists of
hydration.
You got to drink a lot of water juice,
a minimal low residue diet at eight
p.m. The patient takes magnesium citrate
at 10 PM.
Doug relax pills and the morning of the examination,
a dull colak suppository.
Probably not the best thing to have to do in life but you know,
it's an important preparation and with this preparation
we can get most Coghlan's clean.
Occasionally it takes a second day in patients who are particularly not
ambulatory.
We do have uh facility and we'll have
further facility I guess in the new department dr
Dodd as uh designed for a
uh enema to be given to the patient uh
if possible and we'll give those in our
department,
I must say relating to air contrast work.
I personally don't like to do animals prior to air
contrast work because most patients don't evacuate
of the water and can affect the coating of the burial.
But others do do this routinely.
But we rely primarily on this preparation.
So please make sure as much as you
can that the Coghlan's of your patients are
prepared so that we don't do them injustice and make an inaccurate
diagnosis.
Excellent
patients done prone,
we run bury him into part of the colon,
shake the berry um into the rest of the colon,
drained the rectum and put the area.
It's a very simple technique that can be be
done can be done in any radiology department and then a number of
radiographs are obtained both spot films taken that
Flora's copy and what we call overhead
radiographs taken by the uh technical
people.
Again,
this idea of low killer voltage,
which means higher contrast on the pictures.
Next line,
these are commercial burying preparations that we are now using for a
time.
We were mixing several commercial bearing preparations.
But now there are good commercial products available for all of
these techniques to use.
This comes as a liquid and we just poured into the bag and put that into the
patient's colon.
Next this is the
enema tip.
It's a soft plastic enema tip and
piggybacked into the enema tip is a fairly
large bore needle,
like a 16 gauge needle that's tips just right in through the enema
tip into the aluminum,
aluminum,
the enemy tip and stigma nanometer bulb introduces the
air when we're ready for that.
So the barium goes through here and the air through here.
Very easy setup.
Next line,
so this is about ready to begin the bag of
barium with large bore tubing so that this moderately viscous
barium will flow through and patients began prone.
Next line we said that barium does
have to be squeezed in next line
and the Baron's run so that the colon is approximately
halfway field.
Next line and the patients turned on the
right side and shaking a little bit and usually this will advance the barium into
the right colon and we'll go ahead and drain the rectum.
Next slide after the rectums
drain will instill the air we put as much air in as
the patient can reasonably and comfortably tolerate or
until reflux into the small bowel occurs and
then we begin to take spot films at that point
we'll take spot films of the rectum.
Next line.
Let's take spot films of the fletchers.
These are done in the upright position,
many of them.
Next live
spot films of the Sikh.
Um There are certain anatomical areas in the colon that we spot in
various positions.
Next line and then large
overhead films are obtained by the technician.
Supine films.
Next line,
upright films.
Again,
these are particularly helpful these upright films and to cuBA to
films that I'm gonna show you particularly helpful because if there is a
small amount of fecal residue remaining in the colon,
if it's free,
freely moving and not attach the wall with these upright
films that fecal material will fall into the Bering land.
We can resolve whether an area is normal or
abnormal.
With these techniques.
Next line and this to cuBA's
position that is the patient laying on his side and
the x ray beam directed horizontally at the
abdomen patient in this case was laying on her patients right
side.
Next line.
Just a word about colonoscopy.
Uh There's been,
I think in the medical and surgical literature in the
last few years,
a fair amount of competition between
radiographic examinations of the colon and
colonoscopy.
Most of these have been written by uh
gastro neurologists and surgeons,
particularly one group in new york and they have kind of
condemned the barium enema examination.
Well,
I think that dr nelson agrees here I
think and probably this is the appropriate,
the appropriate ah
point to make on it is that they are complementary exams.
That's kind of almost a trite statement about so many things.
But I think in this case is true.
There are some things that we can do that colonoscopy can
do.
For example,
colonoscopies can't get to the seek them every time.
And we always can if there's an obstructing lesion of
colonoscopies can't get by it.
And we usually can to see if there are other lesions in the
colon.
And there are things that colonoscopy can do
or detect that we can't detect not
to mention the therapeutic applications
of uh colonoscopy.
So I think they are complementary techniques
and uh should be considered.
So,
certainly from a on a screening basis.
Uh you know,
the time and money involved in doing screening,
colonoscopy is,
you know,
be virtually impossible when in comparison to
uh barium study.
So,
the barium barium enema examination,
as has been said by a number of
people.
It's not a bad example,
a very fine examination.
It's just not always done well.
And part of that is our own fault perhaps is the worst
radiologic examination performed in the United States,
but we take responsibility for that.
And uh but you need to take some responsibility too and
ensuring as much as you can that your patients
do take the colon preparation and that their Coghlan's
are clean next line.
So some examples of uh of the colon here is
a classic podunk related polyp in this patient's
descending colon next line.
Yeah.
And here,
seeing this on fox is a cecil polyp.
Next line
along the right colon here,
I hope you can see them are a
number of small polyps.
We will routinely find little polyps or
Palepoi expressions is 123 millimeters in
size when we have a good clean colon.
And are studying patients very often,
they're not symptomatic in regard to
bleeding or what one would expect from
polyps.
And sometimes we don't really know what to do or say about little polyps like
this,
but we will document them and put them into the patients
record.
So that's certainly at a later time.
If the patient is re examined or become symptomatic,
one can direct his attention to that area.
But fairly routinely one will follow.
One will discover small 1 to 3
millimeter polyps in the colon.
Next line,
typical annular apple core carcinoma of
the distal sigmoid or rectal sigmoid
colon.
Next line
here are the indications that we use in this department and are
generally used by people who advocate um
Double contrast examination of the colon.
Certainly rectal bleeding is an indication of the classic
indication for air contrast colon examinations.
Also other symptoms,
ontology or findings,
constipation,
anemia,
weight loss.
Those things that might suggest a colonic
malignancy pilots having been
discovered on a practice ka pik examination or any other kind of
an examination.
Any previous history of polyps or cancer of the
colon.
Any kind of history like that leads us to do an air contrast
examination.
Any family history of polyps or cancer.
And I'm not even talking about Paula poses of the colon.
Just a family history of polyps or cancer.
And then certainly previous colon surgery
For polyps uh
cancer.
We all know about the increased incidents,
maybe 5% associated
frequency of synchronous and asynchronous carcinomas of the
colon.
So we're looking for the second lesion,
the second smaller leading to make sure that the operation
is complete.
These are the indications we use them for
many years patients that you send to us for with pelvic mass.
Uh Those don't normally get air contrast in the department unless
there are other symptoms patients who've had radiation
uh probably having symptoms from radiation practice
practice.
Sigmoid itis don't usually get uh air contrast
examinations.
And also if the patient has an unknown
primary where there is already known malignant disease to
deliver to the bone to the notes.
Very common patient in this hospital.
Those patients don't get air contrast.
We feel that we'll find the tumor if the tumor is the
unknown primary,
we'll find it on a conventional examination.
Next line,
here's an example of a carcinoma of the
recto sigmoid colon.
We have a nice feature of it in denting the wall from which it
arises or pulling in the wall from which it arises.
A small carcinoma.
Next line a
plaque like carcinoma along the posterior wall with the rectum.
Next line,
here's a lobular mass in the ascending colon that
represented a lie poma.
Next line,
here's a case that was lent to us by dr
horrible from Hermann Hospital that illustrates
this.
This was a barium study done on a patient and the sigmoid
colon in this region does look abnormal,
looks very peculiar,
but it's a little hard to define.
There is kind of a scallop defect here,
but hard to define what's going on there.
And appropriately,
air contrast study was performed the next day or several days
later.
Next slide and the question
is resolved.
There is a carcinoma of the colon,
a cecil carcinoma of the colon here and then in addition,
there is a large sentinel polyps
in this region that arises from the colon wall
adjacent to the carcinoma.
It's said that as many as 5% we said,
5% of patients have multiple invasive carcinomas of the
colon.
Another 12% of patients who have won carcinoma
will have associated polyps or carcinomas
insight to and as maybe as many as 40% of
patients that have a carcinoma will have at least one other polyps in the
colon may not always be adjacent to it in some other place
in the colon.
So it's very important to do a complete examination
prior to surgery.
Next line.
Now here makes a point that we're kind of talking about here
was a patient that was referred in for this obvious annular
apple core carcinoma of the sigmoid colon.
But as we looked around this colon,
there's all kinds of filling defects in another carcinoma.
Up here and here's a place where colonoscopy will
be very valuable but wouldn't be able to get past this
obstructed area.
So,
you know,
this is an example of where a radiology is important and
where colonoscopy uh
can't be of much use past this area.
And there are examples to the contrary,
of course.
Next slide,
this same patient also had a third carcinoma
in the Seattle area,
descending colon,
cervical area.
So this was a patient with three carcinomas and
multiple other polyps and only one
identified on an outside study the major
annular carcinoma.
Obvious one next line,
here's another interesting patient we had not long ago with this
large villas tumor right here that
has an obstruction.
But if we look over here in the ascending colon,
there's another lesion.
Next live,
here's a close up of this beautiful villas
adenocarcinoma of the colon with
these.
This is has a network pattern to caused by the very um
being trapped and interspersed among the
fronds of the villas tumor and this angular component of the
tumor indicating it's malignant nature.
Next slide and then a close up of this lesion in
the ascending Siegel region.
Another example of double primary is not
uncommon and needs to be examined.
For next slide
example of Paula poses of the colon.
This happened to be a patient with Gardner syndrome.
Next live
cone down to you to see them.
This is kind of the classic examination.
Everybody knows about air contrast colon examinations for but
it has obviously many other uses.
Next line,
another case of paul opposes the colon with a
somewhat different appearance,
more of a carpeting appearance.
Next lie,
here's a gross specimen on that patient.
Next line,
the first patient had no malignant tumors.
This particular patient,
this last one had three areas of Dominant mass
or carcinomas in his colon.
This was one of them in the rectum.
There were two others.
Next line.
I hope this project again.
I can't see it from up here but this is an entity seen in Children with
some frequency called lymphoid hyperplasia.
It's common in the terminal ilium and it's also very common in the
colon.
And these little filling defects can look like pops but
should not be mistaken for polyps.
These patients are usually asymptomatic and one doesn't want to
perform a collecting me on these patients
for benign lymphoid hyperplasia.
Next line and here's
a most unusual case given to us from texas Children's hospital
recently of a long juvenile pilot just showed it
because of its unusual nature usual appearance.
Next line
now we do uh air contrast work
occasionally for benign disease.
Uh but not not always.
Here's a patient.
An interesting problem that was resolved.
Benign diseases.
Patient had this filling defect in the cycle
tip on several outside
uh conventional studies.
Next slide and with double
contrast,
we can see this smooth filling defect and this turned out to
be an intercepted appendix patient had not
had his appendix out.
It's just that his appendix was intercepted and causing this
smooth sub mucosal defect in the
single tip next line.
And here's an example of diverticulitis with multiple
diverticular here and a sigmoid
vaginal officially diagnosed by double
contrast,
this patient had rectal bleeding and was not suspected of having
diverticulitis and that's why the patient had an air
contrast.
So one can use this technique to diagnose diseases
such as diverticulitis,
but this would not normally be an indication
for uh double contrast work next line
and inflammatory bowel disease.
Again,
we don't see too much of that at this particular institution,
but some people have advocated for the more accurate and earlier
diagnosis of inflammatory policies.
Here is one such case.
This is a spot film taken in the distal transverse colon
and one sees this cobblestone pattern.
Next slide and in the
ascending colon there were four areas in this
patient's colon.
You are seeing two of them of this.
Finally,
Nigel er cobblestone appearance in this patient with Crohn's
disease.
Of the colon.
Next line
finally,
we're gonna spend a few moments talking about the post
operative colon.
We said that one of the indications was in the postoperative patient to
find the asynchronous arm attack Cronus
carcinoma and one can do this in any
type of post op patient.
This is a patient that had a primary anastomosis
and one can visualize the nest emotions very readily with double contrast
techniques.
Next live and here is a
patient who had a right hemi collected me and one can see the
elio transverse colon anastomosis.
Not to mention looking at the rest of the colon.
So we do this in all post op patients where we can
next line and we've
also been able to evolve a technique here of examining
colostomy Coghlan's with air contrast
techniques.
We do that by asking the patient to insert a soft
rubber catheter in through their colostomy.
Similar to their irrigation practices.
We tamponade the colostomy stoma with an infant
feeding nipple.
And do the conventional examination as I showed you with running the
barium in part of the way and then introducing air.
Next slide.
These are usually these tubes are about 26-30 French and
they're about the exact same size as um
as the colostomy
irrigating tubing is given to patients in
this hospital.
Next line and this is an
in vitro picture the patient's introduce this and they always are
the one to introduce them because they are familiar with the feel of the
irrigating tube entering their colon,
introduced this into the descending colon patients holding the
nipple against the stomach to tamponade the
stomach to prevent leakage and then the barium and air
will subsequently be introduced.
Next slide.
So this is an upright air
contrast colostomy enema.
Next live and
a cubit is view.
All the same views are obtained as much as possible.
Next line an upright spot
film in the splendid lecture tubes in a little
farther next line
and this is the most dramatic case.
We've had to illustrate the value of this technique.
This was a patient who had a carcinoma,
the rectum and a colostomy performed about
four years before and then for the past two years the
patient had anemia and this patient had four
uh colon examinations in our department for
conventional animals.
I personally did one of them and called it normal.
Uh in retrospective one looks at the system.
There does appear to be a vague filling defect,
but this was a difficult seek them to palpate many times after
colostomy,
to seek them will occupy the pelvis and they're difficult to palpate and put
pressure on in that region.
Next line,
the fifth time we examine this patient with their contrast and found
this obvious lesion in the second.
Um This is the
best case.
I have to illustrate the value of this technique to this
point.
Next slide.
So in summary double contrast,
gastrointestinal examinations are simple to
perform.
Commercial tools and products are available
and any department therefore is capable of performing them.
The esophagus stomach duodenum and colon,
Both the intact and postoperative colon can be examined with these
techniques and I hope I've tried to
show you and convince you that these techniques enable
diagnostic accuracy not possible with conventional barium
studies.
I have two more slides.
I wish there were more clinicians here to see these slides.
But this is a message from our department at
least from most of the members of our department to the clinical
people.
Next line,
these are past concepts of radiologists and clinicians have
had ugly do bizarre things in the
dark,
not too bright,
couldn't really make it in clinical medicine.
That's why they're in radiology.
Need a lot of help from clinicians never can make up
his mind passive and rich.
Next line these are what present
concepts and appropriate concept.
We are all good looking,
highly intelligent.
This is the leading medical specialty.
We are indispensable to clinicians.
Many of us have never even seen a pair of red goggles,
let alone warn them were decisive,
aggressive but we are struggling financially.
Thank you.
Yeah.
Okay.
Yeah.