WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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we're gonna talk today about double contrast

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examinations of the gastrointestinal tract

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for the non radiologic people here

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in the audience.

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Some of this will probably be review,

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some will be new material and I hope

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hopefully it's timely as virtually

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everybody at one time or another does order

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gastrointestinal studies on their

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patients for a variety of reasons.

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Obviously this is basically a radiologic

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talk,

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but I will orient as much as possible to

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it,

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to the clinicians uh when

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appropriate times make themselves

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available.

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I have really two themes that go out

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through this entire presentation and that

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is um double contrast techniques

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may be performed by any interested radiology

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department.

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They are not difficult to do.

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The reason I tell that to you clinically is that if you're ever working

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at other institutions and

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perhaps the radiology department is not perform these

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techniques,

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you know,

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that they can be performed with these.

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There there may be reasons why they don't perform them or differences in

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philosophy,

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but they can technically be performed readily.

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And the second theme is that uh at least

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in my opinion,

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in many instances,

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the diagnostic capabilities

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of G.

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I tract radiology are extended with these

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techniques.

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So,

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if we could have the first slide and the lights down,

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like

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double contrast examinations of the gastrointestinal

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tract can be performed virtually the entire gastrointestinal

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tract,

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the esophagus,

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the stomach,

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the duodenum and colon colon air contrast

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work has been known about for some time now,

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primarily popularized in uh

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europe.

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However,

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I think in this country it's been generally somewhat under utilized,

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but now there are techniques available to study these

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various sites with these techniques.

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Next line

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first,

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we'll talk about the esophagus and we'll follow the gastrointestinal

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track ab orally.

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There are various techniques that may be utilized in the technique that

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we have utilized here with considerable success

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is using the patient upright and

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having the patient hold barium in one hand and a

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cup and water in the other hand,

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patient has a mouthful of barium and then

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swallows the barium and quickly thereafter one mouthful of

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water so that you see we do not produce an heir

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contrast effect but rather a double contrast

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effect.

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That is the water washes through the

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barium that has previously been swallowed.

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Leaves a coating of barium on the esophagus and

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produces the double contrast effect we

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use for the variant preparation

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preparation that is formulated for air

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contrast colon work.

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It's a preparation that's a moderate moderately

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viscous and has excellent coding properties and

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spot films are obtained at the appropriate time.

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Next slide.

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This is a subject holding the barium in one hand and the

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water in the other hand taking a mouthful of

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barium.

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Next slide

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patient has the berry um in her mouth,

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water is ready and she's going to swallow the barium and

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follow that with a swallow of water as quickly as possible

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so that the water as we said,

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can wash the barium through next line.

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This is an example then of a normal double contrast to

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Sasha graham.

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A good one obtained with this technique.

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Next line.

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These are the clinical and radiologic uses uh

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for double contrast to soften biography.

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I should point out to you when when you're ordering this in your patients,

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we don't do this routinely.

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We do it if there are so fragile symptoms and

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or if there is a suspicious finding on a

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conventional esophageal examination.

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So it is not a routine examination in our department.

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As several other of these techniques are.

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It's obviously helpful for the detection of small esophageal

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tumors.

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I don't know that these small tumors are always early tumors,

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but one can detect smaller

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salvageable lesions with reliability.

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With this technique,

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it's helpful to delineate the morphological features

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of lesions in the esophagus.

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That is the surface characteristics.

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Is it smooth?

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Is it irregular?

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Is it also rated?

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And finally,

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to distinguish between mucosal and sub

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mucosal lesions?

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And I'll show you some examples of these things.

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And another use for this is to assess

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the total vertical extent of disease that is you have a

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neo plasm.

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The total vertical extent of this new plasm can be

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readily assessed with double contrast to soften

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geography.

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And this is obviously going to be helpful in treatment planning.

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Next line,

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this is an example of a lot dilated esophageal

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carcinoma that we had some time ago

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and this lesion would not be missed and was not

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missed on a conventional,

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say photography,

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but one can see it uh very readily with a

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double contrast technique and can tell the

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gross vertical limits of disease very readily here,

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much more readily than on the conventional technique.

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Next line.

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And this la belated mass in these various projections as an

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example of a carcinoma sarcoma.

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Now these several lesions no one is going to miss with

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conventional techniques,

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they're obvious.

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I think there may be more elegantly displayed here and one can see a little bit more

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about them.

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I'm gonna show you some cases now where

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the double contrast technique was of definite value in

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comparison to conventional techniques.

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Next slide,

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This is a man that was being followed here for a gastric ulcer.

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He was referred here because it was felt that the gastric ulcer might be

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malignant and he did have a gastric ulcer,

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had a symptomatic patient

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in terms of his esophagus and on his esophagus,

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RAM had this obvious uh filling

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defect here.

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It's difficult to characterize it,

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but a definite filling defect there on multiple swallows.

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As you can see next slide

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and here with a double contrast techniques,

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we can see this lesion in profile

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and then interestingly we can see it on Fox here.

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It's a little unusual to see in esophageal lesion on fox,

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but this is analogous to how we see Palepoi defects in the

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colon.

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And this is a squamous carcinoma in this patient.

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I think that we can see this uh

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lesion considerably better with this technique than with a single

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contrast next live

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here's a very interesting patient and we'll use it to make another

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point to clinicians.

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This is a patient who had had a previous head neck tumor several years

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before he had a carcinoma of the tonsils and

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he was having difficulty swallowing and he indeed was

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having difficulty swallowing.

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You can see here that he's aspirated a fair amount of

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contrast material.

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We could not obtain very many films of his

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thoracic esophagus.

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But in this region once he's a little mucosal nodule

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and this proved to be a squamous carcinoma of the

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esophagus and a patient with a previous head and neck

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legion next slide and

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another more recent patient,

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another patient with a head and neck lesion a few

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years before.

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Again asymptomatic just being studied routinely for

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his head neck problem.

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We see this plaque like irregularity along this wall and this has

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been proven now to be a squamous carcinoma of the

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esophagus.

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I want to just stop here and make this point to any of

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the clinicians that are here

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who do see patients for head and

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neck problems,

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not necessarily head neck surgeons or

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E.

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N.

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T.

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People but anybody who comes in contact with these patients

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at the time they are initially diagnosed and thereafter when

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they're followed up one of the routine things that should be

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done with them at some regular periodicity.

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Maybe like every six months after the baseline examination is to

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do in a sofa graham because there is a definite

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increased incidents of esophageal carcinoma in

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patients with any sort of squamous head and neck tumors.

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And we have found a large number of them in a several year period

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of time where we've been looking maybe maybe about as many as a

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dozen.

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Some of them quite small and others unfortunately,

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very large,

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bulky tumors.

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So this is an association,

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I think that it hasn't been entirely recognized here and then we need to look

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for it and maybe just as common as these people later

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developing squamous carcinomas of the lung.

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Next slide,

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another patient,

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this patient on multiple barium swallows had this

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vague area of narrowing in the esophagus.

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It was definite but not hard to characterize it.

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Next slide,

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mucosal pattern through this area was entirely normal.

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Next slide,

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but on a double contrast study,

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we can see some additional findings on the left here,

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we can see some shouldering effect that wasn't appreciated

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on the barren field study.

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And we see some irregularities on the contour of the

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esophagus on the opposite side.

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And this is another squamous carcinoma of the esophagus.

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Next live,

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here's an interesting patient.

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This is a brother of a physician here in this hospital

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who had this vision was examined at another

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hospital and had this filling defect in the

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esophagus.

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This filling defect identified.

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He was referred here and had some studies done

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here.

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Next line on this double

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contrast study,

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we see this nice smooth interim euro lesion.

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If you look very carefully here and I hope it projects There's another

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thing staring at us on foss.

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Next live turning the

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patient into the opposite of liquidy.

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We see the other lesion.

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Yes,

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sir.

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Are to lie on my mama's in this patient's esophagus,

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only the second one being recognized with double contrast

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study.

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Next slide,

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here's another interesting patient that has this obvious

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fungal irregular carcinoma with

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some extension seems to be going up into the esophagus as they

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commonly do.

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Next slide films of the

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esophagus do show some minor marginally

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regularities.

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And one would be suspicious that there is disease there.

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But it's a little hard to define next line.

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But again,

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with double contrast study,

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we can readily outline the total vertical extent.

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This is not a good study because this patient had relative obstruction

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here.

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One can always obtain a beautiful study.

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But even in a study here that somewhat compromised by an

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obstruction,

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one can still see this Neil players from crawling up the

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esophagus.

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This piece of tumor is up here.

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So we can see that virtually the distal half the esophagus is

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involved by this gastric nia plasm that's readily

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identified with double contrast examination next lot.

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And finally,

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just in terms of inflammatory disease.

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This is a patient with candid diocese and we see a nice

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cobblestone pattern throughout the assad because in

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this patient next line.

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So in summary relating to the esophagus

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double contrast of so photography is simple to perform.

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We do the technique of barium and water with successive

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swallows and we find that it is a useful

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adjunct to the morphological examination of the

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esophagus for the detection of small

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esophageal tumors.

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Hopefully early in some cases

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defining the morphological features of the tumors

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and finally the vertical extent of disease in

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the esophagus.

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Next slide,

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we'll go on to the stomach now and talk about

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air contrast or double contrast exams of the

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stomach.

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In this case,

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the way the technique is performed on your patients.

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We use 2-3 ounces of a high density berry.

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Um that has certain coding properties for the stomach

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to the barium is added an anti foaming agent that we'll discuss in

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a moment and we use a gas preparation

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effervescent powders to produce the gas in the

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stomach patient ingested the gas

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preparation the effervescent powders and follows this with a

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barium patients turned several times to make sure the

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stomach is coded and to dissipate the bubbles and then

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double contrast views are obtained.

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We routinely do four double contrast views

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in our examination and it's readily incorporated into the

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initial part of the examination.

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Blue dragon and other anti spasmodic

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agents may or may not be added uh to decrease

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gastric peristalsis uh and decrease

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gastric emptying if that's necessary.

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And we use a low killer voltage on

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these radiographs to obtain optimal contrast

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next line these are

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some of the preparations that have been available primarily

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manufactured in japan effervescent

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preparations and many of these had anti

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foam substances in them.

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However,

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they are generally not available in the United States.

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Uh at this time.

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Next slide,

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this is one of the preparations call unique Zorro.

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We see here that when the cap is opened,

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there are some japanese script here.

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A lot of people think that this is the instructions

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as to how to do the examination,

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but others feel that this perhaps represents new plans

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for an attack on Pearl Harbor.

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Next line

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we find that just plain old citric carbonate that one

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can obtain from any pharmacy is just as

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good as the other preparations of course here where

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there is no anti foam agent and one has to

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add the anti foam agent.

13:27.090 --> 13:30.000
We use about a teaspoonful of the gas

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powder next line

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and we add Millikan drops.

13:34.800 --> 13:35.150
In other words,

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this is signed with a cone to the berry,

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um maybe a CC or CC.

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And a half of these malecon drops are added to the 2 to 3

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ounces of barium.

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Next line,

13:45.040 --> 13:45.250
yes.

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So the patient begins the examination

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with citric carbonate powders and bury him in

13:51.380 --> 13:52.050
hand.

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Next line she ingests the powders and

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drinks down the uh the barium

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patients place in a recumbent position and turn from the

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supine to the prone position and back three or

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four times again to achieve as good

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at coding as possible and to uh

14:09.440 --> 14:12.060
make the bubbles disperse that are formed by the citric

14:12.060 --> 14:12.560
carbonate.

14:13.040 --> 14:15.510
Next line and then

14:15.550 --> 14:18.180
three films in the supine and soup.

14:18.180 --> 14:21.040
I know black positions are obtained in rapid succession.

14:21.040 --> 14:23.470
One wants to do this fairly rapidly so that not much

14:23.470 --> 14:26.270
gastric emptying of either barium or

14:26.280 --> 14:28.260
uh air takes place.

14:28.270 --> 14:28.950
Next live.

14:30.640 --> 14:33.400
This would be an example of a nice double contrast

14:33.410 --> 14:36.210
gastro gram in the supine position with

14:36.210 --> 14:39.050
just a small amount of barium and not much gastric

14:39.050 --> 14:39.350
emptying.

14:39.350 --> 14:40.380
Haven't taking place.

14:40.500 --> 14:41.150
Next line.

14:43.340 --> 14:44.450
one Old Black View.

14:45.440 --> 14:48.390
Next live the other

14:48.390 --> 14:49.160
old black view.

14:50.840 --> 14:52.700
Those are three routine views we obtain.

14:52.700 --> 14:55.590
Next lied at this point we stand the patient

14:55.590 --> 14:57.750
up and obtain an upright view of the fungus.

14:58.240 --> 15:00.810
And at this point then the rest of the examination

15:01.070 --> 15:03.470
is resumed as in a conventional way.

15:03.470 --> 15:06.210
And most people would at this point do pressure,

15:06.210 --> 15:09.150
mucosal views on the on the rest of the stomach and

15:09.150 --> 15:11.420
there's just a small amount of barium in the stomach at this time.

15:11.420 --> 15:14.300
And one can readily obtain these views.

15:14.300 --> 15:14.760
Next line,

15:17.340 --> 15:20.010
I'm just gonna digress here for a moment and talk

15:20.010 --> 15:23.000
about one aspect of the

15:23.010 --> 15:25.730
stomach anatomy that we've been able to appreciate with

15:25.730 --> 15:27.740
double contrast studies of the stomach.

15:27.750 --> 15:30.710
Should say that dr Dodd stimulated this work

15:30.710 --> 15:31.430
in our department.

15:31.430 --> 15:33.060
He has been interested in this for some time.

15:33.060 --> 15:35.850
And for any of you who are further interested in this and

15:35.850 --> 15:37.410
other aspects of stomach anatomy.

15:37.410 --> 15:39.510
He's going to be talking at jesse jones

15:39.940 --> 15:42.160
library building on the first floor

15:42.660 --> 15:45.480
to the Houston Gi Forum this afternoon at three

15:45.480 --> 15:45.960
o'clock.

15:47.940 --> 15:49.620
The surface of the gastric mucosa,

15:49.620 --> 15:51.270
my gastric mucosa and yours.

15:51.270 --> 15:54.210
Everybody's is subdivided in addition to the Rue Guy that

15:54.210 --> 15:57.050
everybody knows about into small ovoid or

15:57.050 --> 15:59.970
political islands by a complex intersecting series

15:59.970 --> 16:01.160
of shallow grooves.

16:01.840 --> 16:04.680
The islands that will show you in a moment or turned the area

16:04.680 --> 16:07.500
gas tricky and the surrounding grooves are turned the

16:07.500 --> 16:09.860
salsa gastric next lot

16:11.840 --> 16:14.740
this is a stomach that's been opened

16:14.740 --> 16:14.970
up.

16:14.970 --> 16:16.030
And if you look carefully,

16:16.030 --> 16:16.220
you know,

16:16.220 --> 16:17.030
there are obvious ruby.

16:17.030 --> 16:20.000
I hear that everybody knows about in the stomach of course,

16:20.000 --> 16:22.480
and that we use to make diagnoses with.

16:22.490 --> 16:24.780
But there are other little

16:25.340 --> 16:26.280
islands here.

16:26.290 --> 16:26.740
In other words,

16:26.740 --> 16:29.640
a fine mucosal relief pattern in and amongst the

16:29.640 --> 16:32.060
Rue Guy and where the rug I are not in the stomach.

16:32.440 --> 16:33.060
Next line,

16:35.040 --> 16:37.480
this is the same stomach painted with

16:37.480 --> 16:39.920
barium and one can appreciate this

16:39.920 --> 16:42.540
network pattern uh in the

16:42.540 --> 16:45.430
stomach amongst the Rue Guy and in between them and on

16:45.430 --> 16:45.630
them,

16:45.630 --> 16:46.150
et cetera.

16:46.160 --> 16:46.770
Next line

16:48.940 --> 16:51.760
here is a close up of one aspect or one portion of the

16:51.760 --> 16:52.690
body of that stomach.

16:52.690 --> 16:54.350
So like here's a gastric crew guy.

16:54.350 --> 16:57.310
And there's one and then one can see on the Rue Guy and in

16:57.310 --> 17:00.160
between them these little political islands of

17:00.160 --> 17:00.490
tissue,

17:00.490 --> 17:01.840
the fine mucosal relief,

17:01.840 --> 17:04.610
the area gastric and then surrounding and

17:04.620 --> 17:07.300
actually making up these little islands are these

17:07.310 --> 17:10.060
intersecting grooves called the salsa

17:10.060 --> 17:10.770
gastric E.

17:11.240 --> 17:12.770
Those salty gastric.

17:12.770 --> 17:15.610
Those little tunnels is where the barium goes to

17:15.610 --> 17:16.960
make that network pattern.

17:17.340 --> 17:17.960
Next line.

17:19.540 --> 17:22.290
And this is a close up in vitro painted

17:22.290 --> 17:25.040
view of that portion of the stomach showing

17:25.040 --> 17:26.100
that appearance.

17:26.840 --> 17:27.460
Next line.

17:29.540 --> 17:32.480
Dr James Anderson in uh the

17:32.480 --> 17:35.040
laboratory associated with the

17:35.050 --> 17:36.810
diagnostic radiology department.

17:36.820 --> 17:39.220
Uh did some scanning electron

17:39.230 --> 17:41.910
microscopy of some stomachs.

17:42.140 --> 17:44.960
And this is an interesting appearance of this

17:44.970 --> 17:47.260
pattern with a scanning electron

17:47.260 --> 17:48.110
microscopy.

17:48.640 --> 17:51.040
One of these is an area gastric E.

17:51.040 --> 17:53.050
These are one of these islands blown up.

17:54.140 --> 17:55.670
And here are these tunnels.

17:56.520 --> 17:59.150
These intersecting grooves the salsa gastric E.

17:59.150 --> 17:59.940
And we can notice.

17:59.940 --> 18:02.870
Then each area gastric itself has a

18:02.870 --> 18:05.490
convoluted patterns like each area gastric has an area

18:05.490 --> 18:06.950
gastric pattern of itself.

18:07.340 --> 18:09.700
But we see a convoluted pattern on each area.

18:09.700 --> 18:11.360
Gastric Next line

18:13.040 --> 18:14.610
here's a close up of one of those.

18:14.610 --> 18:16.060
This is one area gas tricky.

18:17.940 --> 18:20.860
Here are these tunnels alongside the salsa gas tricky

18:20.860 --> 18:21.690
these grooves.

18:22.240 --> 18:22.580
Okay.

18:22.580 --> 18:24.450
And then we see this convoluted pattern.

18:24.650 --> 18:26.960
If you notice amongst the convoluted pattern,

18:26.960 --> 18:27.730
our little pits,

18:27.730 --> 18:28.590
little depressions.

18:28.590 --> 18:30.120
Those are the gastric pits.

18:30.460 --> 18:33.130
Those are the openings on the gastric

18:33.130 --> 18:36.030
mucosal surface into which gastric

18:36.030 --> 18:38.620
glands drain so that if you can see here

18:38.630 --> 18:40.410
each area gastric E.

18:40.410 --> 18:43.380
Each little island maybe has a dozen Of these

18:43.380 --> 18:46.370
gastric pits into which gastric Glands one or

18:46.370 --> 18:48.360
more drain next slide.

18:49.840 --> 18:52.180
So this schematic drawing

18:52.180 --> 18:54.340
summarizes what we've just said.

18:54.340 --> 18:57.300
Then one of these islands is the area gas tricky.

18:57.580 --> 19:00.560
And then one can see these little black dots

19:00.560 --> 19:01.960
representing the cell site.

19:01.970 --> 19:04.780
Excuse me representing the gastric pits.

19:04.780 --> 19:06.890
And then we can notice here in the cross section.

19:07.340 --> 19:10.190
One or more gastric glands drains into each one of

19:10.190 --> 19:11.410
these gastric pits.

19:12.240 --> 19:15.150
Thanks line Radio

19:15.150 --> 19:17.890
graphically we can identify this pattern if we

19:17.890 --> 19:20.850
do double contrast techniques and have

19:20.850 --> 19:23.690
good coding variant preparations that are not too viscous so

19:23.690 --> 19:26.660
that the the barry um

19:26.660 --> 19:29.070
can enter the shallow sell side gastric.

19:29.070 --> 19:31.810
And we have identified three arbitrary

19:31.810 --> 19:32.370
patterns.

19:32.370 --> 19:34.790
We've talked about a fine pattern,

19:34.790 --> 19:36.790
a course pattern in a nodule or pattern.

19:36.790 --> 19:39.790
And you will see this in your report sometime where we talk about

19:39.790 --> 19:42.560
a course fine mucosal relief pattern

19:42.570 --> 19:45.200
or a coarse or fine area gas tricky

19:45.200 --> 19:45.670
pattern.

19:47.640 --> 19:49.920
Next lot here are some

19:49.920 --> 19:51.000
examples.

19:51.140 --> 19:53.890
This fine little network pattern in the distal

19:53.890 --> 19:56.820
stomach here is an example of a of an average

19:56.820 --> 19:59.460
fine gastric find relief pattern.

19:59.840 --> 20:02.590
This would be uh not very

20:02.600 --> 20:03.340
spectacular.

20:03.340 --> 20:06.130
And we see this I guess in about 50% of our cases

20:06.140 --> 20:08.750
uh using double contrast

20:08.750 --> 20:09.390
techniques.

20:09.430 --> 20:12.160
Next live this would be a

20:12.160 --> 20:15.110
coarser pattern where the islands themselves are larger and the

20:15.110 --> 20:18.050
grooves themselves are denser appear more

20:18.050 --> 20:18.600
coarsened.

20:19.640 --> 20:20.360
Next line.

20:22.240 --> 20:24.810
Another example of a course area gastric

20:24.820 --> 20:25.360
pattern.

20:27.740 --> 20:30.690
Next line and finally

20:30.690 --> 20:32.770
a not very frequent appearance,

20:32.770 --> 20:35.480
the nodule er appearance of the

20:35.490 --> 20:37.960
fine mucosal relief pattern of the stomach.

20:39.340 --> 20:40.540
Now,

20:40.570 --> 20:42.690
uh anatomically

20:42.960 --> 20:45.870
this is interesting and I think certainly one

20:45.870 --> 20:48.740
thing it helps us with is that if we see this

20:48.740 --> 20:49.630
with regularity,

20:49.780 --> 20:50.530
we know,

20:50.530 --> 20:53.300
then we have an objective criterion to say that we are

20:53.300 --> 20:55.800
achieving excellent double contrast

20:55.800 --> 20:57.080
examinations of the stomach.

20:57.080 --> 20:58.350
If one can see this pattern,

20:58.350 --> 21:00.770
one knows he's achieving ah

21:01.140 --> 21:03.660
good double contrast work of the stomach

21:04.240 --> 21:07.120
what their functional significance is and if they can

21:07.120 --> 21:10.060
be used in diagnosis is

21:10.060 --> 21:11.950
a little more questionable at this time,

21:11.950 --> 21:14.920
we have had some cases where the pattern's been course

21:14.920 --> 21:17.250
or Nigel er that has been diagnosis gastritis.

21:17.510 --> 21:20.140
We've had one or two cases where it's been helpful in malignant

21:20.140 --> 21:20.770
disease,

21:21.140 --> 21:23.740
but at this time it would be hard to make a

21:23.740 --> 21:26.490
definitive statement about its real diagnosable

21:26.490 --> 21:26.900
value.

21:26.900 --> 21:27.130
Well,

21:27.130 --> 21:29.940
sometimes in our reports say this to the

21:29.940 --> 21:30.500
clinicians,

21:30.600 --> 21:33.600
you'll see a report that discusses this pattern the fund because of

21:33.600 --> 21:35.450
relief pattern of the area gastric pattern.

21:35.840 --> 21:38.730
And there will be a statement made that it could suggest

21:39.050 --> 21:41.740
diagnose of gastritis and you have to correlate that

21:41.740 --> 21:43.900
clinically with your clinical findings.

21:44.050 --> 21:46.900
But at this time there is no definitive statement that can be

21:46.900 --> 21:49.410
made regarding its its functional

21:49.420 --> 21:51.550
significance as diagnostic significance.

21:51.550 --> 21:52.060
Next line,

21:54.340 --> 21:54.740
okay,

21:54.740 --> 21:54.920
now,

21:54.920 --> 21:57.750
back to double contrast gastro graffiti and some

21:57.760 --> 22:00.650
quick examples of diagnoses that are made very

22:00.650 --> 22:03.420
readily with double contrast uh studies

22:03.430 --> 22:04.600
here on the post year.

22:04.600 --> 22:07.480
While the stomach is the evidence of a healed ulcer

22:07.890 --> 22:10.690
with multiple radiating folds right into a little gastric

22:10.700 --> 22:11.050
pit.

22:12.740 --> 22:13.460
Next slide

22:15.940 --> 22:18.660
here's another lesion on the posterior wall of the

22:18.660 --> 22:19.120
stomach,

22:19.120 --> 22:21.910
a central ulcer crater with radiating folds.

22:22.530 --> 22:23.980
This surprises.

22:23.980 --> 22:24.430
Incidentally,

22:24.430 --> 22:27.360
one can see this network pattern the area gas tricky and the more distal

22:27.360 --> 22:27.770
stomach.

22:28.140 --> 22:29.750
We thought that this,

22:29.760 --> 22:30.320
you know,

22:30.320 --> 22:33.020
in this projection at least had the appearance of a

22:33.030 --> 22:35.010
benign ulcer with radiating foals

22:35.300 --> 22:38.160
dr nelson and his group endoscope this

22:38.160 --> 22:40.960
patient and took some biopsies and I understand that on this

22:40.970 --> 22:43.800
one or two of the folds up super early there

22:43.800 --> 22:46.790
was lymphoma patient did have known

22:46.790 --> 22:49.790
lymphoma in his liver and this turned out to be a lymphoma.

22:49.790 --> 22:52.670
This involvement of the stomach and this unusual presentation

22:53.040 --> 22:55.360
of a ulcer with radiating folds.

22:55.370 --> 22:56.060
Next line,

22:58.240 --> 22:59.620
here's a very interesting case.

22:59.620 --> 23:02.540
It's not something that's going to be seen very much probably at

23:02.550 --> 23:05.260
this hospital but will be seen at other hospitals where this

23:05.260 --> 23:06.400
technique is performed.

23:06.630 --> 23:09.550
This is a standard right Ontario

23:09.550 --> 23:11.910
black view of the stomach that's perfectly normal in a patient.

23:11.910 --> 23:12.560
Next line.

23:14.540 --> 23:15.180
This patient,

23:15.180 --> 23:17.990
if you notice on the double contrast study has multiple

23:18.310 --> 23:21.200
punk Tate and

23:21.200 --> 23:23.230
linear collections of barium.

23:23.270 --> 23:23.800
Next slide,

23:23.800 --> 23:25.860
I think there's a close up in a different projection.

23:27.040 --> 23:30.040
Multiple punkt eight and linear collections of barium and

23:30.040 --> 23:32.600
many of the punk take collections are surrounded

23:32.600 --> 23:33.910
by nuisances.

23:33.910 --> 23:36.660
Can we go back to the other slide out and it seems from here.

23:36.660 --> 23:37.770
It projects a little better.

23:38.090 --> 23:41.010
Many of these little collections are surrounded by licenses and this

23:41.010 --> 23:43.850
is a pretty classic radiologic example of

23:43.850 --> 23:46.730
erosive gastritis with multiple fine

23:46.730 --> 23:49.700
linear and and dot like superficial ulceration surrounded

23:49.700 --> 23:51.170
by small halos of oedema.

23:51.730 --> 23:54.670
And this is a diagnosis that can be made only with

23:54.670 --> 23:57.320
this technique and with some frequency according to the

23:57.320 --> 23:57.710
literature.

23:57.710 --> 23:57.960
Again,

23:57.960 --> 24:00.840
we don't see that kind of patient here.

24:00.840 --> 24:01.560
Very often,

24:01.940 --> 24:04.670
I should comment at this point that

24:05.040 --> 24:07.600
these techniques were originally evolved in

24:07.600 --> 24:08.960
Japan primarily.

24:09.340 --> 24:11.950
Certainly they were popularized from Japan

24:11.960 --> 24:14.850
for the earlier diagnosis of focal,

24:14.860 --> 24:17.170
non invasive carcinomas in that country.

24:17.540 --> 24:20.470
And judging from the literature and from our own experience here,

24:20.470 --> 24:23.190
although it may be a little skewed by the type of institution that this

24:23.190 --> 24:23.660
is,

24:24.040 --> 24:26.590
we don't find many early malignancies,

24:26.900 --> 24:29.460
certainly not add no carcinomas with this technique

24:29.590 --> 24:32.010
that may relate to the fact that we don't see early

24:32.010 --> 24:35.010
patients or that gastric carcinoma is not as common

24:35.010 --> 24:37.520
a disease here as it is in japan or perhaps

24:37.890 --> 24:40.800
to some extent the fact that we are not surveying patients in this

24:40.800 --> 24:43.460
country for this problem as is done in many

24:43.460 --> 24:45.060
parts of Japan.

24:45.440 --> 24:48.050
So I think that the yield in gastric

24:48.050 --> 24:50.590
malignant diseases not nearly going to be as high as it

24:50.590 --> 24:53.450
is in the orient.

24:53.840 --> 24:54.410
However,

24:54.410 --> 24:57.180
there are diagnoses that are made in this country?

24:57.190 --> 24:59.950
Uh that are coming here that can be made really only with this

24:59.950 --> 25:01.500
technique and that's why I stopped here.

25:01.500 --> 25:02.720
This is such a diagnosis.

25:02.720 --> 25:05.470
The case of a gi bleeder bleeding from erosive

25:05.470 --> 25:06.300
gastritis.

25:06.670 --> 25:09.110
Uh This is going to be a high yield

25:09.110 --> 25:11.730
diagnosis with this technique uh in the United

25:11.730 --> 25:13.460
States and north America in general.

25:13.540 --> 25:16.060
Next line and the next

25:18.040 --> 25:19.170
a gastric polyp.

25:20.640 --> 25:23.640
Next line and another

25:23.640 --> 25:26.340
gastric pile up and we can see her again the network

25:26.340 --> 25:29.050
pattern the area gastric pattern that you'll see discussing the

25:29.050 --> 25:30.170
reports periodically.

25:31.940 --> 25:34.830
Next line here's a pretty

25:34.830 --> 25:35.720
obvious case.

25:35.730 --> 25:38.510
Uh I don't think one is going to miss this with any technique

25:38.630 --> 25:40.880
large sub mucosal mass and other nodule.

25:40.880 --> 25:43.740
A rude guy representing lymphoma in this patient

25:43.740 --> 25:46.560
but a very elegant example of the entire extent of

25:46.560 --> 25:48.060
disease in this patient's stomach.

25:48.740 --> 25:49.670
Next line,

25:51.340 --> 25:53.080
another large ulcerated mass.

25:53.080 --> 25:53.950
On the lesser curvature.

25:53.950 --> 25:55.450
This was an adenocarcinoma.

25:56.040 --> 25:56.760
Next slide

25:58.940 --> 26:01.160
now we were talking about primary malignancies.

26:01.160 --> 26:03.430
We have had a yield in about three or four patients

26:03.650 --> 26:06.150
of one form of malignant disease in the stomach.

26:06.150 --> 26:08.030
Not diagnosable with conventional techniques.

26:08.030 --> 26:09.120
And here is such a case.

26:09.440 --> 26:12.390
This is a single isolated metastatic melanoma

26:12.390 --> 26:15.360
deposit on the greater curvature of the stomach that was only diagnosed

26:15.360 --> 26:18.070
on this film with double contrast techniques.

26:18.380 --> 26:21.080
Next slide and another more

26:21.080 --> 26:21.670
recent case.

26:21.670 --> 26:24.410
In this upright view of the fund is there is a small sub mucosal

26:24.410 --> 26:27.350
mass in this patient with melanoma,

26:28.440 --> 26:30.290
isolated lesion.

26:30.300 --> 26:32.990
So we have had yield in this form of malignant

26:32.990 --> 26:35.290
disease although not primary malignant disease.

26:35.290 --> 26:35.850
Next line

26:38.240 --> 26:41.240
okay that finishes discussion of the stomach and I

26:41.250 --> 26:43.550
have a few brief words now on the duodenum.

26:43.940 --> 26:45.670
Hi platonic doing ethnography.

26:45.670 --> 26:48.400
That is the use of a pharmacologic agent to paralyze the

26:48.400 --> 26:51.160
duodenum and obtain better films of the duodenal

26:51.160 --> 26:53.300
pancreatic interface has been

26:53.310 --> 26:56.240
uh pretty popular in this country for about

26:56.250 --> 26:57.840
10 years or so now.

26:58.020 --> 27:00.990
And uh air contrast portion of that

27:00.990 --> 27:03.530
exam is is a routine portion of double

27:03.530 --> 27:06.510
contrast of high platonic doing

27:06.510 --> 27:06.990
ethnography.

27:06.990 --> 27:09.900
And here is an example of a paralyzed duodenum with a nice

27:10.340 --> 27:12.740
perry ambulatory or perry vegetarian duodenal

27:12.740 --> 27:15.550
diverticular one can appreciate the very nice mucosal

27:15.550 --> 27:18.420
pattern here is the longitudinal fold extending down from the

27:18.420 --> 27:19.460
area of the ambulance.

27:19.940 --> 27:22.800
Uh So this is certainly a very helpful technique not only

27:22.800 --> 27:25.080
for the diagnosis of disease and the head of the pancreas,

27:25.080 --> 27:27.150
but for primary duodenal disease as well,

27:27.150 --> 27:30.030
it's gonna be helpful in ulcer disease and occasional

27:30.030 --> 27:31.270
duodenal tumors as well.

27:31.740 --> 27:34.640
Next line indications for this

27:34.640 --> 27:36.650
exam or if a conventional upper G.

27:36.650 --> 27:36.780
I.

27:36.780 --> 27:39.480
Series is suspicious for primary duty or

27:39.480 --> 27:40.620
pancreatic disease.

27:40.900 --> 27:43.510
And if there is a strong clinical suspicion of

27:43.510 --> 27:46.210
pancreatic disease despite an apparently normal upper

27:46.210 --> 27:49.020
gastrointestinal uh series

27:49.590 --> 27:52.300
technique can be done with a tube or without a tube

27:52.300 --> 27:55.230
and uh we have done them both ways in the

27:55.240 --> 27:55.770
department.

27:55.770 --> 27:58.600
So this is a technique that you can order on patients

27:58.600 --> 28:00.880
where you fit these indications.

28:01.150 --> 28:03.570
And very often we will just incorporate it into our

28:03.570 --> 28:06.570
examination when uh when that

28:06.570 --> 28:08.850
is necessary to come to a more

28:08.850 --> 28:11.390
accurate diagnosis.

28:11.670 --> 28:12.270
Next line,

28:14.440 --> 28:16.710
there's an interesting patient we had not long ago.

28:16.710 --> 28:19.640
This is a patient who had a lot of nice spot films of duodenum

28:19.760 --> 28:22.760
and had an apparent pad effect or mass along the medial

28:22.760 --> 28:25.670
contour of that duodenum do deny

28:25.670 --> 28:27.350
graham was performed next slide,

28:29.140 --> 28:31.850
which is perfectly normal and shows us that this

28:31.870 --> 28:34.460
pseudo mass appearance was formed by this

28:34.460 --> 28:37.390
longitudinal fold extending down from this

28:37.390 --> 28:38.830
somewhat prominent and pula.

28:38.890 --> 28:41.870
So sometimes normal anatomical variants in

28:41.870 --> 28:44.600
the duodenum can be mistaken for

28:44.600 --> 28:47.500
masses and can be resolved with HIPPA tonic doing

28:47.500 --> 28:48.180
ethnography.

28:48.320 --> 28:51.320
Next line and this is an

28:51.320 --> 28:53.820
example of a carcinoma of the

28:53.830 --> 28:56.460
excuse me of the duodenum with traction

28:56.460 --> 28:56.840
changes.

28:56.840 --> 28:57.660
I hope you can see that.

28:57.660 --> 28:58.810
I can't see it too well from here,

28:58.810 --> 29:01.030
traction changes on the duodenum in this portion.

29:01.030 --> 29:03.550
So air contrast work is a,

29:03.550 --> 29:03.880
let's say,

29:03.880 --> 29:06.490
a routine part of hip a tonic doing ethnography and

29:06.670 --> 29:09.000
not infrequently the air contrast films

29:09.010 --> 29:11.540
uh are the highest yield

29:11.540 --> 29:14.350
among in the examination performed with a high

29:14.350 --> 29:16.260
platonic agent of the duodenum.

29:16.640 --> 29:17.170
Excellent.

29:17.640 --> 29:17.840
Yeah.

29:18.440 --> 29:18.950
Next line.

29:20.440 --> 29:21.960
Well all that's been good.

29:21.960 --> 29:23.800
And we've talked about the upper gastrointestinal tract.

29:23.800 --> 29:26.630
But now we really come to the money and that's the colon at

29:26.630 --> 29:29.170
least the money for neo plastic

29:29.540 --> 29:30.350
disease.

29:31.750 --> 29:34.270
This is really where I think we can most help

29:34.640 --> 29:37.520
our patients here is a place

29:37.520 --> 29:39.470
where when we say a small tumor,

29:39.630 --> 29:42.380
we almost talks anonymously with an early tumor.

29:42.530 --> 29:45.170
Unlike other anatomical parts in the gastrointestinal

29:45.170 --> 29:47.700
track in other areas of the

29:47.720 --> 29:48.900
body here.

29:48.900 --> 29:51.240
A small tumor is means

29:51.250 --> 29:52.380
early tumor.

29:52.380 --> 29:55.260
And we want to be able to make the diagnosis of small uh

29:55.440 --> 29:56.920
colonic tumors.

29:56.920 --> 29:59.900
And let's talk about the colon preparation.

29:59.900 --> 30:00.890
And let me say to you,

30:00.890 --> 30:02.810
although you know this,

30:02.810 --> 30:03.360
you know,

30:03.740 --> 30:06.260
this is the most important part of the examination.

30:06.260 --> 30:07.160
This is the whole thing.

30:07.160 --> 30:07.770
In fact,

30:07.780 --> 30:10.690
the exam is not very difficult and it

30:10.690 --> 30:12.800
doesn't require particularly sophisticated equipment,

30:12.810 --> 30:15.600
but you do have to have the colon prepared in

30:15.600 --> 30:16.110
some ways,

30:16.110 --> 30:16.980
colonoscopy,

30:16.980 --> 30:18.440
which we'll talk about in a few minutes,

30:18.450 --> 30:21.420
which has come in some centers to rival

30:21.430 --> 30:22.510
uh,

30:22.520 --> 30:25.480
barium studies of the colon really has done us a little

30:25.480 --> 30:27.960
bit of help there because

30:27.970 --> 30:30.490
clinicians now at least people are doing colonoscopy

30:30.490 --> 30:33.380
realized that when we were talking about all the filling

30:33.380 --> 30:35.950
defects in the colon really can be a problem making a

30:35.950 --> 30:36.610
diagnosis.

30:36.610 --> 30:38.030
So they colonize space,

30:38.030 --> 30:38.600
appreciate,

30:38.610 --> 30:41.170
appreciate now the value of a clean

30:41.180 --> 30:41.620
colon,

30:41.620 --> 30:42.600
the entire colon.

30:43.240 --> 30:43.940
Um,

30:43.950 --> 30:46.590
please please please please

30:46.590 --> 30:49.140
please encourage your patients to take the

30:49.140 --> 30:49.770
preparation.

30:50.340 --> 30:52.460
Don't tell him our it's okay if you skip something,

30:52.940 --> 30:53.300
you know,

30:53.300 --> 30:56.110
encourage them to take the preparation and we'll discuss what

30:56.110 --> 30:57.030
we use here.

30:57.030 --> 30:57.180
You know,

30:57.180 --> 31:00.010
the preparation is I'm not saying it's the most pleasant thing to get up

31:00.010 --> 31:01.900
in the morning and go and have a very minimal,

31:01.900 --> 31:02.520
but you know,

31:02.530 --> 31:03.450
it has to be done,

31:03.450 --> 31:03.670
you know,

31:03.670 --> 31:06.260
it has to be done and we want to do it well and

31:06.270 --> 31:07.340
help the patient.

31:07.350 --> 31:10.240
So please encourage your patients to

31:10.240 --> 31:11.310
take the preparation.

31:11.740 --> 31:12.370
Okay,

31:12.380 --> 31:13.270
that's number one.

31:13.840 --> 31:14.770
Number two.

31:15.140 --> 31:18.050
Um four

31:18.440 --> 31:20.940
patients who are in patients in this hospital,

31:20.960 --> 31:23.760
we are unable to write for routine,

31:23.760 --> 31:25.020
very minimal preparation.

31:25.140 --> 31:26.950
The orders have to be written out.

31:27.240 --> 31:27.430
Well,

31:27.430 --> 31:30.120
there is in every nurse's station at this hospital,

31:30.120 --> 31:31.690
we've checked any number of times,

31:32.230 --> 31:33.330
at least one copy.

31:33.330 --> 31:36.270
If not more of our routine barium enema preparation,

31:36.640 --> 31:37.450
follow it,

31:37.940 --> 31:40.110
sit down with it and write it into the chart.

31:40.120 --> 31:41.510
I don't say it's a pleasant task,

31:41.520 --> 31:42.650
but it has to be done.

31:42.790 --> 31:44.720
So follow it on your impatience.

31:44.980 --> 31:47.840
If there's any question as to why a patient can't take a preparation,

31:48.040 --> 31:48.870
You can call us,

31:48.870 --> 31:49.130
you know,

31:49.130 --> 31:51.680
you can call us the department and we can discuss it and we'll

31:51.680 --> 31:53.010
modify it if necessary,

31:53.010 --> 31:55.800
but please write for our entire preparation.

31:55.800 --> 31:57.670
So we don't have a compromised exam.

31:58.240 --> 31:59.120
Let me tell you that.

31:59.120 --> 32:01.820
We will not hesitate in the radiology department to

32:01.820 --> 32:03.670
cancel the patient's examination.

32:04.040 --> 32:06.890
Uh If he has not taken a preparation or it

32:06.890 --> 32:08.960
hasn't been ordered for him as an inpatient.

32:08.960 --> 32:10.140
We do our best to,

32:10.250 --> 32:10.580
you know,

32:10.580 --> 32:12.070
to accomplish the examination.

32:12.070 --> 32:13.280
We will will go so far,

32:13.280 --> 32:15.470
we'll give multiple enemies in our own department.

32:15.560 --> 32:16.260
But you know,

32:16.260 --> 32:17.540
we need cooperation.

32:17.540 --> 32:20.360
We don't feel we're going to do the patients a favor or you a

32:20.360 --> 32:23.150
favor if we do an inadequate examination and MS

32:23.150 --> 32:25.790
a potentially curable colon lesion.

32:26.240 --> 32:28.960
And another point I want to make before we look at some

32:28.970 --> 32:31.970
cases is that many times you may order a barium

32:31.970 --> 32:34.390
enema and we'll do an air

32:34.390 --> 32:36.960
contrast or occasionally vice versa.

32:37.320 --> 32:39.810
Please give us adequate history on the

32:39.810 --> 32:42.720
requisition so that we can make a reliable judgment as to

32:42.720 --> 32:45.210
what kind of examination the patient needs.

32:45.210 --> 32:47.900
There are certain indications that we follow that I'm going to show you in a few

32:47.900 --> 32:48.350
moments.

32:48.740 --> 32:51.180
And uh if we don't have reliable history

32:51.350 --> 32:53.930
written down there or we can't communicate with the patient,

32:53.930 --> 32:56.850
it's difficult for us to make a good decision about what

32:56.850 --> 32:58.780
examination is best for that patient.

32:58.890 --> 33:01.720
So uh please give us adequate history

33:01.720 --> 33:03.110
so that we can make the judgment.

33:03.280 --> 33:06.230
But you will find times when a conventional enemy is ordered

33:06.230 --> 33:09.170
or just it's written barium enema and we do in air contrast and

33:09.170 --> 33:10.310
occasionally vice versa.

33:10.310 --> 33:12.550
But we do what we think is most indicated to

33:12.940 --> 33:15.540
make an accurate diagnosis in that patient

33:15.560 --> 33:18.500
after we've talked to them and seeing the history

33:18.500 --> 33:19.060
requisition.

33:19.060 --> 33:22.060
So this is the colon preparation that's used in this hospital.

33:22.640 --> 33:25.610
We do our upper jeez first and we have done that for

33:25.610 --> 33:27.080
the last several years.

33:27.080 --> 33:28.250
And here is the rationale,

33:28.250 --> 33:30.790
I've had a lot of phone calls on this if a

33:30.790 --> 33:33.490
patient is going to have both exams that is an

33:33.500 --> 33:36.010
upper gastrointestinal series and a barium

33:36.010 --> 33:36.580
enema.

33:36.690 --> 33:38.420
We do the upper gi first,

33:38.420 --> 33:40.290
our scheduling people know to do that.

33:40.300 --> 33:42.960
And the reason we do that examination first is

33:43.340 --> 33:46.100
so that we use the berry um that they've ingested as a

33:46.100 --> 33:48.560
marker to tell us if the colon is clean.

33:48.940 --> 33:51.930
That is to say if a patient has an upper gastrointestinal

33:51.930 --> 33:54.800
series on monday of a given week and

33:54.800 --> 33:57.450
on Tuesday they begin their colon preparation

33:57.460 --> 33:58.870
on Wednesday morning.

33:58.870 --> 34:01.660
If there is any significant amount of barium retaining their

34:01.660 --> 34:02.170
colon,

34:02.290 --> 34:05.240
we have an opaque barium marker to tell us that

34:05.240 --> 34:06.560
the colon is not clean.

34:06.940 --> 34:09.930
That is the rationale for us doing a upper gastrointestinal

34:09.930 --> 34:12.790
series first in most routine patents obviously if there

34:12.790 --> 34:14.430
is a suspicion of colon obstruction,

34:14.430 --> 34:14.980
we don't,

34:15.310 --> 34:18.060
but in the routine patient that's being worked up for

34:18.060 --> 34:19.260
bleeding or whatever.

34:19.510 --> 34:21.760
Upper gastrointestinal series is done first.

34:22.540 --> 34:25.490
It's basically an 18 hour preparation that begins

34:25.750 --> 34:28.500
at noon the previous day and it consists of

34:28.500 --> 34:29.210
hydration.

34:29.230 --> 34:31.080
You got to drink a lot of water juice,

34:31.540 --> 34:34.340
a minimal low residue diet at eight

34:34.340 --> 34:36.850
p.m. The patient takes magnesium citrate

34:37.540 --> 34:38.380
at 10 PM.

34:38.380 --> 34:41.220
Doug relax pills and the morning of the examination,

34:41.290 --> 34:42.850
a dull colak suppository.

34:42.930 --> 34:45.740
Probably not the best thing to have to do in life but you know,

34:45.740 --> 34:48.060
it's an important preparation and with this preparation

34:48.540 --> 34:50.030
we can get most Coghlan's clean.

34:50.030 --> 34:52.600
Occasionally it takes a second day in patients who are particularly not

34:52.600 --> 34:53.360
ambulatory.

34:53.740 --> 34:56.540
We do have uh facility and we'll have

34:56.540 --> 34:59.270
further facility I guess in the new department dr

34:59.280 --> 35:02.080
Dodd as uh designed for a

35:02.090 --> 35:04.990
uh enema to be given to the patient uh

35:05.000 --> 35:07.470
if possible and we'll give those in our

35:07.470 --> 35:08.020
department,

35:08.020 --> 35:10.190
I must say relating to air contrast work.

35:10.190 --> 35:13.010
I personally don't like to do animals prior to air

35:13.010 --> 35:15.600
contrast work because most patients don't evacuate

35:15.940 --> 35:18.520
of the water and can affect the coating of the burial.

35:18.520 --> 35:20.070
But others do do this routinely.

35:20.070 --> 35:22.250
But we rely primarily on this preparation.

35:22.250 --> 35:24.810
So please make sure as much as you

35:24.810 --> 35:27.800
can that the Coghlan's of your patients are

35:27.800 --> 35:30.750
prepared so that we don't do them injustice and make an inaccurate

35:30.750 --> 35:31.510
diagnosis.

35:31.630 --> 35:32.160
Excellent

35:34.640 --> 35:35.960
patients done prone,

35:36.340 --> 35:38.350
we run bury him into part of the colon,

35:39.040 --> 35:41.120
shake the berry um into the rest of the colon,

35:41.130 --> 35:42.660
drained the rectum and put the area.

35:42.660 --> 35:45.600
It's a very simple technique that can be be

35:45.600 --> 35:48.240
done can be done in any radiology department and then a number of

35:48.240 --> 35:50.670
radiographs are obtained both spot films taken that

35:51.040 --> 35:53.670
Flora's copy and what we call overhead

35:53.670 --> 35:56.120
radiographs taken by the uh technical

35:56.130 --> 35:56.710
people.

35:56.720 --> 35:57.250
Again,

35:57.250 --> 35:58.860
this idea of low killer voltage,

35:58.870 --> 36:01.540
which means higher contrast on the pictures.

36:01.930 --> 36:02.550
Next line,

36:04.730 --> 36:07.670
these are commercial burying preparations that we are now using for a

36:07.670 --> 36:07.990
time.

36:07.990 --> 36:09.940
We were mixing several commercial bearing preparations.

36:09.940 --> 36:12.890
But now there are good commercial products available for all of

36:12.890 --> 36:14.020
these techniques to use.

36:14.300 --> 36:17.300
This comes as a liquid and we just poured into the bag and put that into the

36:17.300 --> 36:18.050
patient's colon.

36:18.140 --> 36:20.910
Next this is the

36:20.910 --> 36:21.430
enema tip.

36:21.430 --> 36:23.820
It's a soft plastic enema tip and

36:23.820 --> 36:26.450
piggybacked into the enema tip is a fairly

36:26.450 --> 36:27.350
large bore needle,

36:27.350 --> 36:30.310
like a 16 gauge needle that's tips just right in through the enema

36:30.310 --> 36:31.320
tip into the aluminum,

36:31.650 --> 36:31.990
aluminum,

36:31.990 --> 36:34.860
the enemy tip and stigma nanometer bulb introduces the

36:34.860 --> 36:35.890
air when we're ready for that.

36:35.890 --> 36:38.590
So the barium goes through here and the air through here.

36:38.600 --> 36:39.750
Very easy setup.

36:39.760 --> 36:40.350
Next line,

36:42.330 --> 36:44.990
so this is about ready to begin the bag of

36:44.990 --> 36:47.910
barium with large bore tubing so that this moderately viscous

36:47.910 --> 36:50.800
barium will flow through and patients began prone.

36:50.800 --> 36:53.740
Next line we said that barium does

36:53.740 --> 36:55.960
have to be squeezed in next line

36:57.810 --> 37:00.620
and the Baron's run so that the colon is approximately

37:00.620 --> 37:01.540
halfway field.

37:01.930 --> 37:04.770
Next line and the patients turned on the

37:04.770 --> 37:07.680
right side and shaking a little bit and usually this will advance the barium into

37:07.680 --> 37:10.400
the right colon and we'll go ahead and drain the rectum.

37:10.400 --> 37:13.140
Next slide after the rectums

37:13.140 --> 37:16.070
drain will instill the air we put as much air in as

37:16.070 --> 37:18.810
the patient can reasonably and comfortably tolerate or

37:18.810 --> 37:21.680
until reflux into the small bowel occurs and

37:21.680 --> 37:24.530
then we begin to take spot films at that point

37:24.530 --> 37:26.450
we'll take spot films of the rectum.

37:26.650 --> 37:27.250
Next line.

37:28.830 --> 37:30.750
Let's take spot films of the fletchers.

37:31.290 --> 37:32.680
These are done in the upright position,

37:32.680 --> 37:33.290
many of them.

37:33.700 --> 37:34.350
Next live

37:36.630 --> 37:37.640
spot films of the Sikh.

37:37.640 --> 37:40.600
Um There are certain anatomical areas in the colon that we spot in

37:40.600 --> 37:42.450
various positions.

37:42.830 --> 37:45.570
Next line and then large

37:45.580 --> 37:48.240
overhead films are obtained by the technician.

37:48.240 --> 37:49.280
Supine films.

37:49.280 --> 37:49.850
Next line,

37:52.630 --> 37:53.450
upright films.

37:53.450 --> 37:53.950
Again,

37:55.330 --> 37:58.090
these are particularly helpful these upright films and to cuBA to

37:58.090 --> 38:01.080
films that I'm gonna show you particularly helpful because if there is a

38:01.080 --> 38:03.980
small amount of fecal residue remaining in the colon,

38:04.240 --> 38:04.940
if it's free,

38:04.950 --> 38:07.940
freely moving and not attach the wall with these upright

38:07.940 --> 38:10.830
films that fecal material will fall into the Bering land.

38:10.830 --> 38:13.370
We can resolve whether an area is normal or

38:13.370 --> 38:13.850
abnormal.

38:13.850 --> 38:15.490
With these techniques.

38:15.500 --> 38:18.140
Next line and this to cuBA's

38:18.140 --> 38:20.960
position that is the patient laying on his side and

38:20.960 --> 38:23.750
the x ray beam directed horizontally at the

38:23.750 --> 38:26.710
abdomen patient in this case was laying on her patients right

38:26.710 --> 38:27.240
side.

38:27.820 --> 38:28.450
Next line.

38:31.620 --> 38:33.840
Just a word about colonoscopy.

38:34.420 --> 38:35.790
Uh There's been,

38:35.790 --> 38:38.270
I think in the medical and surgical literature in the

38:38.270 --> 38:39.570
last few years,

38:39.570 --> 38:42.480
a fair amount of competition between

38:42.490 --> 38:45.480
radiographic examinations of the colon and

38:45.490 --> 38:46.450
colonoscopy.

38:47.020 --> 38:49.840
Most of these have been written by uh

38:49.850 --> 38:51.360
gastro neurologists and surgeons,

38:51.360 --> 38:54.240
particularly one group in new york and they have kind of

38:54.240 --> 38:56.250
condemned the barium enema examination.

38:57.520 --> 38:57.910
Well,

38:57.910 --> 39:00.910
I think that dr nelson agrees here I

39:00.910 --> 39:03.430
think and probably this is the appropriate,

39:03.970 --> 39:06.950
the appropriate ah

39:07.720 --> 39:10.210
point to make on it is that they are complementary exams.

39:10.210 --> 39:12.830
That's kind of almost a trite statement about so many things.

39:12.830 --> 39:14.100
But I think in this case is true.

39:14.100 --> 39:16.960
There are some things that we can do that colonoscopy can

39:16.960 --> 39:17.400
do.

39:17.410 --> 39:18.180
For example,

39:18.180 --> 39:20.510
colonoscopies can't get to the seek them every time.

39:20.510 --> 39:23.460
And we always can if there's an obstructing lesion of

39:23.460 --> 39:24.880
colonoscopies can't get by it.

39:24.880 --> 39:27.620
And we usually can to see if there are other lesions in the

39:27.620 --> 39:28.040
colon.

39:28.120 --> 39:30.750
And there are things that colonoscopy can do

39:30.760 --> 39:33.700
or detect that we can't detect not

39:33.700 --> 39:36.340
to mention the therapeutic applications

39:36.340 --> 39:38.070
of uh colonoscopy.

39:38.070 --> 39:40.840
So I think they are complementary techniques

39:41.220 --> 39:43.280
and uh should be considered.

39:43.290 --> 39:43.960
So,

39:44.120 --> 39:46.200
certainly from a on a screening basis.

39:46.210 --> 39:47.040
Uh you know,

39:47.050 --> 39:49.770
the time and money involved in doing screening,

39:49.770 --> 39:50.600
colonoscopy is,

39:50.610 --> 39:51.010
you know,

39:51.020 --> 39:53.470
be virtually impossible when in comparison to

39:53.480 --> 39:54.730
uh barium study.

39:54.730 --> 39:54.880
So,

39:54.880 --> 39:57.380
the barium barium enema examination,

39:57.380 --> 40:00.140
as has been said by a number of

40:00.140 --> 40:00.420
people.

40:00.430 --> 40:01.390
It's not a bad example,

40:01.390 --> 40:02.840
a very fine examination.

40:02.840 --> 40:04.250
It's just not always done well.

40:04.250 --> 40:07.150
And part of that is our own fault perhaps is the worst

40:07.150 --> 40:09.690
radiologic examination performed in the United States,

40:10.110 --> 40:12.490
but we take responsibility for that.

40:12.490 --> 40:15.060
And uh but you need to take some responsibility too and

40:15.060 --> 40:17.460
ensuring as much as you can that your patients

40:17.800 --> 40:20.440
do take the colon preparation and that their Coghlan's

40:20.440 --> 40:23.330
are clean next line.

40:25.010 --> 40:27.920
So some examples of uh of the colon here is

40:27.920 --> 40:30.920
a classic podunk related polyp in this patient's

40:30.920 --> 40:33.630
descending colon next line.

40:38.110 --> 40:38.310
Yeah.

40:41.910 --> 40:42.650
And here,

40:42.970 --> 40:45.330
seeing this on fox is a cecil polyp.

40:47.710 --> 40:48.430
Next line

40:50.810 --> 40:52.160
along the right colon here,

40:52.160 --> 40:54.950
I hope you can see them are a

40:54.950 --> 40:56.530
number of small polyps.

40:59.110 --> 41:01.820
We will routinely find little polyps or

41:01.820 --> 41:04.590
Palepoi expressions is 123 millimeters in

41:04.590 --> 41:07.520
size when we have a good clean colon.

41:07.520 --> 41:09.350
And are studying patients very often,

41:09.350 --> 41:12.020
they're not symptomatic in regard to

41:12.710 --> 41:15.410
bleeding or what one would expect from

41:15.410 --> 41:15.830
polyps.

41:15.830 --> 41:18.710
And sometimes we don't really know what to do or say about little polyps like

41:18.710 --> 41:18.900
this,

41:18.900 --> 41:21.520
but we will document them and put them into the patients

41:22.210 --> 41:22.900
record.

41:22.900 --> 41:24.390
So that's certainly at a later time.

41:24.390 --> 41:26.810
If the patient is re examined or become symptomatic,

41:26.840 --> 41:29.700
one can direct his attention to that area.

41:29.730 --> 41:31.780
But fairly routinely one will follow.

41:31.790 --> 41:34.730
One will discover small 1 to 3

41:34.730 --> 41:36.530
millimeter polyps in the colon.

41:36.710 --> 41:37.330
Next line,

41:39.310 --> 41:42.140
typical annular apple core carcinoma of

41:42.140 --> 41:44.880
the distal sigmoid or rectal sigmoid

41:44.880 --> 41:45.350
colon.

41:45.410 --> 41:46.030
Next line

41:48.710 --> 41:51.650
here are the indications that we use in this department and are

41:51.650 --> 41:54.530
generally used by people who advocate um

41:55.110 --> 41:56.860
Double contrast examination of the colon.

41:56.860 --> 41:59.650
Certainly rectal bleeding is an indication of the classic

41:59.650 --> 42:01.920
indication for air contrast colon examinations.

42:02.300 --> 42:03.320
Also other symptoms,

42:03.320 --> 42:04.440
ontology or findings,

42:04.440 --> 42:05.360
constipation,

42:05.370 --> 42:05.910
anemia,

42:05.910 --> 42:06.460
weight loss.

42:06.460 --> 42:08.980
Those things that might suggest a colonic

42:08.980 --> 42:11.920
malignancy pilots having been

42:11.920 --> 42:14.920
discovered on a practice ka pik examination or any other kind of

42:14.920 --> 42:15.710
an examination.

42:16.070 --> 42:18.900
Any previous history of polyps or cancer of the

42:18.900 --> 42:19.250
colon.

42:19.250 --> 42:21.750
Any kind of history like that leads us to do an air contrast

42:21.750 --> 42:22.460
examination.

42:22.760 --> 42:24.860
Any family history of polyps or cancer.

42:24.860 --> 42:27.010
And I'm not even talking about Paula poses of the colon.

42:27.010 --> 42:29.670
Just a family history of polyps or cancer.

42:30.000 --> 42:32.520
And then certainly previous colon surgery

42:32.800 --> 42:35.390
For polyps uh

42:35.400 --> 42:36.120
cancer.

42:36.120 --> 42:37.980
We all know about the increased incidents,

42:37.980 --> 42:40.510
maybe 5% associated

42:40.510 --> 42:43.240
frequency of synchronous and asynchronous carcinomas of the

42:43.240 --> 42:43.600
colon.

42:43.600 --> 42:45.260
So we're looking for the second lesion,

42:45.550 --> 42:48.440
the second smaller leading to make sure that the operation

42:48.440 --> 42:50.180
is complete.

42:50.190 --> 42:52.840
These are the indications we use them for

42:52.990 --> 42:55.880
many years patients that you send to us for with pelvic mass.

42:56.300 --> 42:59.260
Uh Those don't normally get air contrast in the department unless

42:59.260 --> 43:02.190
there are other symptoms patients who've had radiation

43:02.190 --> 43:05.170
uh probably having symptoms from radiation practice

43:05.450 --> 43:06.200
practice.

43:06.200 --> 43:09.120
Sigmoid itis don't usually get uh air contrast

43:09.120 --> 43:09.820
examinations.

43:09.820 --> 43:12.390
And also if the patient has an unknown

43:12.390 --> 43:15.190
primary where there is already known malignant disease to

43:15.190 --> 43:17.060
deliver to the bone to the notes.

43:17.400 --> 43:19.290
Very common patient in this hospital.

43:19.440 --> 43:21.260
Those patients don't get air contrast.

43:21.260 --> 43:23.940
We feel that we'll find the tumor if the tumor is the

43:23.940 --> 43:24.610
unknown primary,

43:24.610 --> 43:26.430
we'll find it on a conventional examination.

43:27.200 --> 43:27.730
Next line,

43:29.200 --> 43:32.120
here's an example of a carcinoma of the

43:32.120 --> 43:33.430
recto sigmoid colon.

43:33.430 --> 43:36.230
We have a nice feature of it in denting the wall from which it

43:36.230 --> 43:38.440
arises or pulling in the wall from which it arises.

43:38.440 --> 43:39.370
A small carcinoma.

43:39.370 --> 43:42.090
Next line a

43:42.090 --> 43:45.020
plaque like carcinoma along the posterior wall with the rectum.

43:46.900 --> 43:47.620
Next line,

43:49.800 --> 43:52.360
here's a lobular mass in the ascending colon that

43:52.370 --> 43:53.730
represented a lie poma.

43:54.400 --> 43:55.120
Next line,

43:56.900 --> 43:59.310
here's a case that was lent to us by dr

43:59.320 --> 44:02.270
horrible from Hermann Hospital that illustrates

44:02.270 --> 44:02.730
this.

44:03.110 --> 44:06.010
This was a barium study done on a patient and the sigmoid

44:06.010 --> 44:08.660
colon in this region does look abnormal,

44:08.660 --> 44:09.400
looks very peculiar,

44:09.400 --> 44:10.850
but it's a little hard to define.

44:11.090 --> 44:12.810
There is kind of a scallop defect here,

44:12.810 --> 44:14.570
but hard to define what's going on there.

44:14.570 --> 44:15.750
And appropriately,

44:15.760 --> 44:18.460
air contrast study was performed the next day or several days

44:18.460 --> 44:18.800
later.

44:19.090 --> 44:22.030
Next slide and the question

44:22.030 --> 44:22.790
is resolved.

44:22.790 --> 44:24.430
There is a carcinoma of the colon,

44:24.430 --> 44:27.430
a cecil carcinoma of the colon here and then in addition,

44:27.430 --> 44:29.300
there is a large sentinel polyps

44:31.190 --> 44:33.720
in this region that arises from the colon wall

44:33.720 --> 44:35.210
adjacent to the carcinoma.

44:36.490 --> 44:39.350
It's said that as many as 5% we said,

44:39.350 --> 44:42.210
5% of patients have multiple invasive carcinomas of the

44:42.210 --> 44:42.650
colon.

44:43.290 --> 44:46.210
Another 12% of patients who have won carcinoma

44:46.210 --> 44:48.840
will have associated polyps or carcinomas

44:48.840 --> 44:51.680
insight to and as maybe as many as 40% of

44:51.680 --> 44:54.430
patients that have a carcinoma will have at least one other polyps in the

44:54.430 --> 44:57.350
colon may not always be adjacent to it in some other place

44:57.350 --> 44:57.870
in the colon.

44:57.870 --> 45:00.420
So it's very important to do a complete examination

45:00.790 --> 45:01.800
prior to surgery.

45:01.810 --> 45:02.410
Next line.

45:04.490 --> 45:07.440
Now here makes a point that we're kind of talking about here

45:07.440 --> 45:10.220
was a patient that was referred in for this obvious annular

45:10.230 --> 45:12.460
apple core carcinoma of the sigmoid colon.

45:12.470 --> 45:14.110
But as we looked around this colon,

45:15.990 --> 45:18.600
there's all kinds of filling defects in another carcinoma.

45:18.600 --> 45:21.570
Up here and here's a place where colonoscopy will

45:21.570 --> 45:24.280
be very valuable but wouldn't be able to get past this

45:24.280 --> 45:25.210
obstructed area.

45:25.220 --> 45:25.780
So,

45:25.780 --> 45:26.190
you know,

45:26.200 --> 45:29.040
this is an example of where a radiology is important and

45:29.040 --> 45:31.610
where colonoscopy uh

45:32.390 --> 45:34.830
can't be of much use past this area.

45:34.830 --> 45:36.580
And there are examples to the contrary,

45:36.580 --> 45:36.990
of course.

45:36.990 --> 45:37.610
Next slide,

45:38.890 --> 45:41.610
this same patient also had a third carcinoma

45:42.650 --> 45:43.730
in the Seattle area,

45:43.740 --> 45:44.420
descending colon,

45:44.420 --> 45:44.970
cervical area.

45:44.970 --> 45:47.710
So this was a patient with three carcinomas and

45:47.710 --> 45:50.180
multiple other polyps and only one

45:50.180 --> 45:53.090
identified on an outside study the major

45:53.090 --> 45:54.080
annular carcinoma.

45:54.110 --> 45:55.420
Obvious one next line,

45:57.890 --> 46:00.250
here's another interesting patient we had not long ago with this

46:00.250 --> 46:03.210
large villas tumor right here that

46:03.210 --> 46:04.070
has an obstruction.

46:04.280 --> 46:06.170
But if we look over here in the ascending colon,

46:06.170 --> 46:07.080
there's another lesion.

46:07.230 --> 46:07.790
Next live,

46:09.480 --> 46:11.380
here's a close up of this beautiful villas

46:11.380 --> 46:13.800
adenocarcinoma of the colon with

46:14.180 --> 46:14.530
these.

46:14.540 --> 46:17.450
This is has a network pattern to caused by the very um

46:17.450 --> 46:20.350
being trapped and interspersed among the

46:20.350 --> 46:23.230
fronds of the villas tumor and this angular component of the

46:23.230 --> 46:25.040
tumor indicating it's malignant nature.

46:25.370 --> 46:28.320
Next slide and then a close up of this lesion in

46:28.320 --> 46:30.290
the ascending Siegel region.

46:30.780 --> 46:33.260
Another example of double primary is not

46:33.260 --> 46:35.070
uncommon and needs to be examined.

46:35.070 --> 46:36.000
For next slide

46:38.380 --> 46:40.390
example of Paula poses of the colon.

46:40.390 --> 46:42.400
This happened to be a patient with Gardner syndrome.

46:42.980 --> 46:43.600
Next live

46:46.180 --> 46:47.250
cone down to you to see them.

46:47.250 --> 46:48.860
This is kind of the classic examination.

46:48.860 --> 46:51.820
Everybody knows about air contrast colon examinations for but

46:51.820 --> 46:53.520
it has obviously many other uses.

46:54.080 --> 46:54.710
Next line,

46:56.080 --> 46:58.980
another case of paul opposes the colon with a

46:58.980 --> 47:00.070
somewhat different appearance,

47:00.070 --> 47:01.430
more of a carpeting appearance.

47:01.590 --> 47:02.200
Next lie,

47:03.880 --> 47:05.710
here's a gross specimen on that patient.

47:06.680 --> 47:07.430
Next line,

47:07.470 --> 47:09.110
the first patient had no malignant tumors.

47:09.110 --> 47:10.000
This particular patient,

47:10.000 --> 47:12.990
this last one had three areas of Dominant mass

47:12.990 --> 47:14.860
or carcinomas in his colon.

47:14.860 --> 47:16.180
This was one of them in the rectum.

47:16.180 --> 47:17.090
There were two others.

47:18.080 --> 47:18.590
Next line.

47:20.930 --> 47:22.530
I hope this project again.

47:22.530 --> 47:25.350
I can't see it from up here but this is an entity seen in Children with

47:25.350 --> 47:28.010
some frequency called lymphoid hyperplasia.

47:28.060 --> 47:30.720
It's common in the terminal ilium and it's also very common in the

47:30.720 --> 47:31.240
colon.

47:31.490 --> 47:34.380
And these little filling defects can look like pops but

47:34.380 --> 47:36.240
should not be mistaken for polyps.

47:36.550 --> 47:39.350
These patients are usually asymptomatic and one doesn't want to

47:39.350 --> 47:42.030
perform a collecting me on these patients

47:42.030 --> 47:44.100
for benign lymphoid hyperplasia.

47:44.480 --> 47:47.440
Next line and here's

47:47.440 --> 47:50.360
a most unusual case given to us from texas Children's hospital

47:50.360 --> 47:53.340
recently of a long juvenile pilot just showed it

47:53.340 --> 47:56.300
because of its unusual nature usual appearance.

47:57.580 --> 47:58.210
Next line

48:00.470 --> 48:03.210
now we do uh air contrast work

48:03.210 --> 48:04.720
occasionally for benign disease.

48:04.730 --> 48:07.110
Uh but not not always.

48:07.110 --> 48:07.770
Here's a patient.

48:07.770 --> 48:09.300
An interesting problem that was resolved.

48:09.300 --> 48:10.020
Benign diseases.

48:10.020 --> 48:12.940
Patient had this filling defect in the cycle

48:12.950 --> 48:15.740
tip on several outside

48:15.750 --> 48:17.120
uh conventional studies.

48:17.120 --> 48:19.900
Next slide and with double

48:19.900 --> 48:20.400
contrast,

48:20.400 --> 48:23.320
we can see this smooth filling defect and this turned out to

48:23.320 --> 48:26.270
be an intercepted appendix patient had not

48:26.270 --> 48:27.100
had his appendix out.

48:27.100 --> 48:29.850
It's just that his appendix was intercepted and causing this

48:31.550 --> 48:34.360
smooth sub mucosal defect in the

48:34.370 --> 48:35.790
single tip next line.

48:37.470 --> 48:40.460
And here's an example of diverticulitis with multiple

48:40.460 --> 48:42.900
diverticular here and a sigmoid

48:43.570 --> 48:46.240
vaginal officially diagnosed by double

48:46.240 --> 48:46.990
contrast,

48:47.000 --> 48:49.320
this patient had rectal bleeding and was not suspected of having

48:49.320 --> 48:51.710
diverticulitis and that's why the patient had an air

48:51.710 --> 48:52.360
contrast.

48:52.370 --> 48:55.320
So one can use this technique to diagnose diseases

48:55.320 --> 48:56.220
such as diverticulitis,

48:56.220 --> 48:58.580
but this would not normally be an indication

48:58.580 --> 49:01.500
for uh double contrast work next line

49:03.770 --> 49:05.470
and inflammatory bowel disease.

49:05.470 --> 49:05.730
Again,

49:05.730 --> 49:07.810
we don't see too much of that at this particular institution,

49:07.810 --> 49:10.520
but some people have advocated for the more accurate and earlier

49:10.520 --> 49:13.020
diagnosis of inflammatory policies.

49:13.020 --> 49:14.280
Here is one such case.

49:14.490 --> 49:17.490
This is a spot film taken in the distal transverse colon

49:17.490 --> 49:19.900
and one sees this cobblestone pattern.

49:19.900 --> 49:22.630
Next slide and in the

49:22.640 --> 49:25.440
ascending colon there were four areas in this

49:25.440 --> 49:26.160
patient's colon.

49:26.160 --> 49:27.440
You are seeing two of them of this.

49:27.440 --> 49:28.000
Finally,

49:28.000 --> 49:30.810
Nigel er cobblestone appearance in this patient with Crohn's

49:30.810 --> 49:31.200
disease.

49:31.200 --> 49:31.790
Of the colon.

49:33.170 --> 49:33.790
Next line

49:35.870 --> 49:36.580
finally,

49:36.580 --> 49:39.300
we're gonna spend a few moments talking about the post

49:39.310 --> 49:40.280
operative colon.

49:40.280 --> 49:43.210
We said that one of the indications was in the postoperative patient to

49:43.210 --> 49:45.390
find the asynchronous arm attack Cronus

49:45.840 --> 49:48.740
carcinoma and one can do this in any

49:48.740 --> 49:49.890
type of post op patient.

49:49.900 --> 49:52.300
This is a patient that had a primary anastomosis

49:53.770 --> 49:56.750
and one can visualize the nest emotions very readily with double contrast

49:56.750 --> 49:57.190
techniques.

49:57.190 --> 49:59.880
Next live and here is a

49:59.880 --> 50:02.460
patient who had a right hemi collected me and one can see the

50:02.470 --> 50:05.200
elio transverse colon anastomosis.

50:05.200 --> 50:07.680
Not to mention looking at the rest of the colon.

50:07.680 --> 50:10.270
So we do this in all post op patients where we can

50:10.860 --> 50:13.650
next line and we've

50:13.650 --> 50:16.390
also been able to evolve a technique here of examining

50:16.390 --> 50:19.170
colostomy Coghlan's with air contrast

50:19.170 --> 50:19.690
techniques.

50:19.690 --> 50:22.510
We do that by asking the patient to insert a soft

50:22.510 --> 50:24.490
rubber catheter in through their colostomy.

50:24.490 --> 50:26.440
Similar to their irrigation practices.

50:26.960 --> 50:29.870
We tamponade the colostomy stoma with an infant

50:29.870 --> 50:30.650
feeding nipple.

50:30.880 --> 50:33.840
And do the conventional examination as I showed you with running the

50:33.840 --> 50:36.080
barium in part of the way and then introducing air.

50:36.460 --> 50:37.180
Next slide.

50:38.260 --> 50:41.210
These are usually these tubes are about 26-30 French and

50:41.210 --> 50:43.570
they're about the exact same size as um

50:43.960 --> 50:46.050
as the colostomy

50:46.050 --> 50:48.980
irrigating tubing is given to patients in

50:48.980 --> 50:49.660
this hospital.

50:49.670 --> 50:52.660
Next line and this is an

50:52.660 --> 50:55.570
in vitro picture the patient's introduce this and they always are

50:55.570 --> 50:58.180
the one to introduce them because they are familiar with the feel of the

50:58.560 --> 51:00.480
irrigating tube entering their colon,

51:00.480 --> 51:03.470
introduced this into the descending colon patients holding the

51:03.470 --> 51:06.220
nipple against the stomach to tamponade the

51:06.230 --> 51:09.180
stomach to prevent leakage and then the barium and air

51:09.180 --> 51:10.380
will subsequently be introduced.

51:10.380 --> 51:10.990
Next slide.

51:13.260 --> 51:15.750
So this is an upright air

51:15.750 --> 51:17.490
contrast colostomy enema.

51:18.060 --> 51:21.050
Next live and

51:21.050 --> 51:21.910
a cubit is view.

51:21.910 --> 51:24.270
All the same views are obtained as much as possible.

51:25.260 --> 51:28.220
Next line an upright spot

51:28.220 --> 51:30.880
film in the splendid lecture tubes in a little

51:30.880 --> 51:32.780
farther next line

51:34.560 --> 51:36.530
and this is the most dramatic case.

51:36.530 --> 51:39.010
We've had to illustrate the value of this technique.

51:39.070 --> 51:40.800
This was a patient who had a carcinoma,

51:40.800 --> 51:43.630
the rectum and a colostomy performed about

51:43.630 --> 51:46.380
four years before and then for the past two years the

51:46.380 --> 51:49.380
patient had anemia and this patient had four

51:49.420 --> 51:52.210
uh colon examinations in our department for

51:52.210 --> 51:52.980
conventional animals.

51:52.980 --> 51:55.780
I personally did one of them and called it normal.

51:56.260 --> 51:58.990
Uh in retrospective one looks at the system.

51:59.360 --> 52:01.620
There does appear to be a vague filling defect,

52:01.630 --> 52:04.250
but this was a difficult seek them to palpate many times after

52:04.250 --> 52:04.680
colostomy,

52:04.680 --> 52:07.680
to seek them will occupy the pelvis and they're difficult to palpate and put

52:07.680 --> 52:08.770
pressure on in that region.

52:09.350 --> 52:09.980
Next line,

52:10.850 --> 52:13.730
the fifth time we examine this patient with their contrast and found

52:13.730 --> 52:15.970
this obvious lesion in the second.

52:16.750 --> 52:19.070
Um This is the

52:19.650 --> 52:20.230
best case.

52:20.230 --> 52:23.090
I have to illustrate the value of this technique to this

52:23.090 --> 52:23.480
point.

52:24.050 --> 52:24.680
Next slide.

52:26.050 --> 52:28.650
So in summary double contrast,

52:28.660 --> 52:31.150
gastrointestinal examinations are simple to

52:31.150 --> 52:31.770
perform.

52:32.550 --> 52:34.880
Commercial tools and products are available

52:35.350 --> 52:38.070
and any department therefore is capable of performing them.

52:38.740 --> 52:41.140
The esophagus stomach duodenum and colon,

52:41.140 --> 52:44.130
Both the intact and postoperative colon can be examined with these

52:44.130 --> 52:46.380
techniques and I hope I've tried to

52:46.750 --> 52:49.610
show you and convince you that these techniques enable

52:49.610 --> 52:52.550
diagnostic accuracy not possible with conventional barium

52:52.550 --> 52:53.030
studies.

52:53.650 --> 52:54.610
I have two more slides.

52:54.610 --> 52:56.610
I wish there were more clinicians here to see these slides.

52:56.610 --> 52:59.580
But this is a message from our department at

52:59.580 --> 53:02.350
least from most of the members of our department to the clinical

53:02.350 --> 53:02.820
people.

53:03.170 --> 53:03.770
Next line,

53:04.850 --> 53:07.700
these are past concepts of radiologists and clinicians have

53:07.700 --> 53:10.530
had ugly do bizarre things in the

53:10.530 --> 53:10.970
dark,

53:11.650 --> 53:12.570
not too bright,

53:13.450 --> 53:15.210
couldn't really make it in clinical medicine.

53:15.210 --> 53:16.490
That's why they're in radiology.

53:17.020 --> 53:19.890
Need a lot of help from clinicians never can make up

53:19.890 --> 53:22.470
his mind passive and rich.

53:22.950 --> 53:25.770
Next line these are what present

53:25.770 --> 53:27.190
concepts and appropriate concept.

53:27.190 --> 53:28.370
We are all good looking,

53:28.750 --> 53:29.920
highly intelligent.

53:30.290 --> 53:32.070
This is the leading medical specialty.

53:32.550 --> 53:34.260
We are indispensable to clinicians.

53:34.650 --> 53:36.800
Many of us have never even seen a pair of red goggles,

53:36.800 --> 53:38.950
let alone warn them were decisive,

53:38.950 --> 53:40.920
aggressive but we are struggling financially.

53:40.930 --> 53:42.060
Thank you.

53:42.850 --> 53:43.170
Yeah.

53:44.250 --> 53:44.590
Okay.

53:47.550 --> 53:47.870
Yeah.