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Aim: To determine retrospectively the sensitivity and specificity of the double contrast barium enema (DCBE) as performed in one institution for the detection of colorectal carcinoma., Subjects and Methods: Eight hundred and eighty barium enema reports were reviewed of consecutive adult patients who underwent DCBE and also had hospital case notes with a minimum follow up of two years, a later diagnostic colonoscopy, or operative and histological findings., Results: Seventy-four true positive cases of colorectal carcinoma diagnosed at DCBE were confirmed at surgery and histological examination. There were four false positive diagnoses of carcinoma at DCBE. Eight false negative cases at DCBE were demonstrated within a two-year follow-up period. The sensitivity of the DCBE for detecting colorectal carcinoma was therefore 90.2% and the specificity was 99.5%., Conclusion: DCBE is a sensitive and highly specific investigation for the detection of colorectal carcinoma., (Copyright 2002 The Royal College of Radiologists.)

Nolan, D. J. (2000). Clinical Radiology55, 809. Copyright 2000 The Royal College of Radiologists.

We report two patients in whom the primary presentation of an appendix abscess was atypical, and who later developed obstructive symptoms due to extrinsic intestinal stricturing from chronic inflammation. In one case a short ileal stricture was revealed on enteroclysis, in the other double contrast barium enema showed sigmoid stricturing.

Sodium picosulphate (Picolax) is widely used for bowel preparation prior to colonic investigation or surgery. The most troublesome side effect reported is headache, which has been thought to be due to dehydration. In a prospective randomized study we investigated the incidence of adverse effects in patients given Picolax prior to barium enema examination, and assessed the incidence of adverse effects with different oral fluid regimens. A total of 197 outpatients were allocated to one of five fluid regimens on the day prior to the enema: (a) 4 pints of Dioralyte (glucose and electrolyte solution); (b) 4 pints of half-strength Dioralyte; (c) 4 pints of water; (d) 6 pints of water; and (e) free fluids. In a questionnaire, 36% of patients had no headache (graded 0/5), while 38% had a significant headache (graded 3/5 or greater). Sixteen per cent had significant abdominal pain, 42% had dry mouths, 43% thirst and 34% tiredness or irritability. There was no correlation between headache and fluid regimen. Furthermore, we have found no evidence of dehydration. None of the five fluid regimens was shown to offer any advantage, and we therefore recommend that patients be allowed to drink according to thirst when taking Picolax.

In a retrospective study the radiological reports of small bowel enema (enteroclysis) examinations of 1465 patients were reviewed and compared with the subsequent clinical outcome, and where possible with findings at laparotomy. A sensitivity of 93.1% and a specificity of 96.9% was found, based on whether the small intestine was reported as normal or an abnormality was diagnosed to account for the patient's clinical presentation. The correct specific diagnosis was made in 67.5% of the examinations that were considered abnormal. We believe that these figures support the use of small bowel enema as the routine barium examination for suspected disorders of the small intestine.

A search of the literature suggests that the conventional 20 mg dose of intravenous hyoscine-N-butylbromide (HBB) for smooth muscle relaxation in double-contrast barium meal (DCBM) studies is largely empirical. This study analysed the merits of three different doses (5 mg, 10 mg, 20 mg) in the performance of routine DCBMs. One hundred and twenty DCBM examinations were prospectively and randomly allocated to receive one of three doses. Three parameters were measured for each examination: gastroduodenal distension, delay in gastric emptying and gastric antrum overlapping with barium-filled duodenal loops. Almost half the examinations using 5 mg produced undesirable duodenal-gastric overlay. Unacceptable early flooding of the duodenal bulb with barium was seen mostly with doses of 5 mg and 10 mg. Overall, the best results were obtained with 20 mg. The continued use of 20 mg HBB in routine DCBMs is recommended.

Colonic carcinomas may be missed on the barium enema examination for a variety of perceptive, technical, and interpretive reasons. We report an uncommon source of error-persistent bowel spasm resulting in concealment of an underlying carcinoma. Awareness of this association is necessary in the effort to minimize diagnostic pitfalls of the barium enema examination.

The radiographs of 60 patients having double-contrast barium meal examinations were analysed by a linear analogue technique to assess variation in the quality of mucosal coating between morning and afternoon studies. No significant difference (P greater than 0.5) was found between morning and afternoon gastric mucosal coating. Factors that could in theory contribute to a diurnal variation are discussed. We conclude that afternoon DCBMs can be confidently booked and performed, in the knowledge that their diagnostic quality is not impaired.

Fifty-nine patients with an ileostomy were studied who were examined by small bowel enema over a 10-year period. Twenty-two subsequently underwent surgery, nine for recurrent Crohn's disease, seven for obstruction due to adhesions or internal hernia and one for ovarian carcinoma. The remaining five patients with colonic Crohn's disease had panproctocolectomy or closure of the ileostomy. The small bowel enema is a reliable method for investigating the small intestine of patients with an ileostomy.

A size 12 French radiopaque catheter, 135 cm long, suitable for rapid duodenal and jejunal intubation, is described. Its size and flexibility enable it to be passed with ease through the nose, stomach and duodenum. A guide wire is used to act as a stiffener as the catheter is passed through the stomach. The catheter is suitable for infusing barium directly into the small intestine and for performing hypotonic duodenography. The technique for duodenal and jejunal intubation is discussed.

The radiological features of five cases of primary adenocarcinoma of the jejunum are described and the differential diagnosis is discussed. Barium examination is the best method for detecting adenocarcinoma in the small intestine and angiography is useful for pre-operative assessment.

A retrospective analysis was made of 114 new patients attending a gastroenterology clinic, in whom the initial clinical diagnosis was irritable bowel syndrome. Barium enemas were performed in 84 patients (74%), 15 of whom were found to have significant other disease. In each case this would have been suspected from the routine haematological and biochemical screening tests. It is suggested that, in the investigation of patients under 50 years of age presenting to a gastroenterology clinic with a typical history of irritable bowel syndrome, a barium enema should only be performed if the clinical examination, sigmoidoscopy, rectal biopsy or routine blood tests are abnormal. This policy would reduce substantially the number of normal barium enemas performed.

Primary carcinoid tumours are rarely detected in the small intestine by conventional radiological methods. The radiological features are presented of 11 patients with primary small-intestinal carcinoids, in whom the tumour was demonstrated by the barium infusion technique. In four of these patients the site of the primary tumour was also demonstrated angiographically. We have found these methods valuable in identifying primary carcinoid tumours and consider them to be the investigations of choice in evaluating patients with suspected or established carcinoid syndrome.

The radiological features of Crohn's disease of the small intestine are described in a report on 100 patients examined by a barium infusion method. The examination is performed by introducing a large volume of barium suspension through a tube directly into the small intestine. A multiplicity of radiological signs were seen in the majority of the examinations. Discrete and fissure ulcers were present in many cases; longitudinal ulcers, sinuses and fistulae were seen less frequently. Other signs commonly seen were strictures, in many cases with proximal dilatation, thickening and distortion of the mucosal folds, cobblestoning, asymmetrical involvement, thickening of the wall of diseased intestine and good demarcation of normal from abnormal small intestine. Adhesions, skip lesions, gross distortion, a featureless outline of the diseased intestine and pseudo polyps were less commonly seen. The disease was more extensive in patients who previously had resections for small intestinal Crohn's disease.

Clinical compliance with the Royal College of Radiologists' guidelines on the use of pre-operative chest radiology was examined in a random sample of patients in four hospitals in England and Wales. Pre-operative clinical data were abstracted from medical reports and, in one hospital, from special chest radiograph request forms completed by clinicians. Seventy-five per cent of patients had clinical indications warranting a pre-operative chest radiograph. This level of compliance is compatible with that found with other guidelines and would suggest that the pre-operative chest radiograph guidelines are suitable for wider implementation in the National Health Service.

The radiological features of small intestinal lymphoma are described in 11 patients examined using the small bowel enema technique. The signs include luminal narrowing with mucosal destruction and occasionally shouldering of the margins and stricture formation, broad based ulceration, cavitation, non-specific thickening of the valvulae conniventes, discrete intraluminal filling defects, and a mass. In one patient, small nodules were scattered throughout the small intestine. Aneurysmal dilatation of a segment of intestine was seen in one case and an extraluminal mesenteric mass in another. A combination of different signs was a frequent finding and multiple intestinal lesions were present in four cases. Predisposing factors were present in five cases including coeliac disease, chronic lymphatic leukaemia, immunoproliferative small intestinal (alpha-chain) disease and previous extraintestinal lymphoma. In another patient there was evidence of extraintestinal lymphoma at the time of presentation.

A prospective study was carried out to compare the radiological and pathological appearances of Crohn's disease of the small intestine. The X-ray examinations were carried out by infusing barium directly into the small intestine. Thirty-six patients who were operated on for Crohn's disease of the small intestine are included. There was excellent correlation between the radiological appearances and the findings at morbid anatomy.

The small bowel enema (barium infusion, enteroclysis) is a valuable radiological procedure that is easy to use and gives consistently good results. The technique is described and important aspects of the examination are discussed.

The information obtained at percutaneous transhepatic cholangiography in patients with obstructive jaundice is not always conclusive about the nature of the obstructing lesion. Hypotonic duodenography performed immediately after transhepatic cholangiography may assist in such cases by demonstrating the presence or absence of duodenal involvement. This ensures that the appropriate surgical procedure can be planned before operation. Our experience using the combined techniques in nine patients is reported.

Chondroblastoma is a rare benign neoplasm of cartilaginous origin. It appears as a round or oval translucent area with a thin sclerotic rim situated most often in the epiphysis of a long bone, and occurs mainly in the 12-20 age group. It has an excellent prognosis and the radiological features should suggest the correct diagnosis. Ten cases have been reviewed in this paper. The clinical, pathological as well as the radiological features and the differential diagnosis of this entity are discussed. It is hoped that this will help in its earlier diagnosis.

The radiological findings, using a single-contrast barium infusion technique, are described in a series of 13 patients with chronic radiation enteritis. The signs include evidence of submucosal thickening, single or multiple stenoses, adhesions and sinus or fistula formation. A combination of these signs characterises the condition. This technique is particularly suited to the investigation of radiation enteritis because of its ability to distend maximally the small intestine. A cause, stenosis and/or adhesions, was demonstrated in the eight of the 13 patients presenting with intermittent small-intestinal obstruction. Three patients had diarrhoea as their predominant complaint and a fistula was demonstrated in two.

The radiological appearances are described of acquired ileal diverticula, seen in four patients as an incidental finding. All the diverticula were small and sited on the mesenteric border of the terminal ileum. Solitary diverticula were seen in three patients and in the fourth case there were three diverticula.

During a 10 year period 49 patients were operated upon in Oxford for Meckel's diverticulum. Radiological imaging of the small intestine with radionuclide scintigraphy, small bowel barium enema or angiography was performed in 11 patients. Radionuclide scintigraphy was positive in one out of six patients investigated. The small bowel barium enema detected an abnormality in seven out of eight patients examined and identified the diverticulum in six. Angiography was performed in three patients and active bleeding was demonstrated in two. Our experience would indicate that the small bowel enema is the method of choice for the investigation of suspected Meckel's diverticulum. Patients with acute bleeding should, however, be investigated with angiography.

During a two-year period 26 patients with suspected small bowel obstruction were examined by infusing barium into the small intestine. Mechanical obstruction was confirmed in 25 patients and the level of obstruction was shown in all except one who had carcinoma of the caecum. Surgery was avoided in nine patients-six of whom had Crohn's disease, two had adhesions and the investigation showed no abnormality in one patient. There were no complications associated with the examination or with the subsequent operation.

Two cases of abdominal aortic aneurysm presenting with duodenal obstruction following truncal vagotomy and pyloroplasty are described. Barium examination revealed the site and cause of obstruction in both. In one case the aneurysm was successfully resected.