Traumatic rectal hematoma following anal rape

We describe the case of a 28-year-old male prisoner with a traumatic rectal hematoma caused by anal rape. Barium enema showed a large rectal mass confirmed to be a hematoma by proctoscopic examination. Surgery was performed due to a falling hemoglobin level, and an 800-mL hematoma was evacuated. The patient became febrile following surgery, and computed tomography revealed a pelvic mass consistent with recurrent hematoma or abscess. Repeat surgery showed recurrent hematoma. The patient recovered uneventfully.

Single-contrast vs double-contrast barium enema in the detection of colonic polyps

Radiographic and colonoscopic correlation in 139 patients with 234 colonic polyps compared the sensitivity of single- and double-contrast barium enema. Single-contrast barium enema detected 68 (80%) of polyps, with 72% of polyps under 1 cm and 94% of those 1 cm or over detected. Double-contrast barium enema detected 135 (91%) of 149 polyps, with 88% of polyps under 1 cm and 96% of larger polyps detected. Thus, the double-contrast barium enema was more effective than the single-contrast examination only for detection of polyps under 1 cm. The single-contrast barium enema was more likely performed on patients in poor physical condition and in those over 70 years old. The results suggest that for elderly patients, who may have difficulty in cooperating for a double-contrast enema, a properly performed single-contrast examination is an acceptable option.

Pseudocalculus sign. A pitfall of static cholangiography

The pseudocalculus formation was first noted by Caroli in 1960, and was first called a sign by Beneventano and Schein in 1968. It is a cholangiographic illusion that appears as a filling defect in the distal common bile duct when static or "spot" films are exposed during the contractile phase of choledochal sphincter activity. Although first noted and most frequently seen in T-tube cholangiography, it is seen also during intravenous and intraoperative cholangiography. Because it mimics radiographically an impacted stone in the distal common bile duct, its delineation is critical to avoid unnecessary instrumentation of the common bile duct or even reoperation. In this review the authors discuss briefly the anatomy and physiology of the distal common bile duct and the etiology, differential diagnosis, and recognition of the pseudocalculus sign.

Retrograde examination of the small bowel in patients with an ileostomy

The retrograde small-bowel examination is a convenient method for studying the small bowel in patients with an ileostomy. Adhesions, recurrent Crohn's disease, ileostomy dysfunction due to prestomal narrowing, and obstruction due to neoplasm are demonstrable. The technique described is faster than the peroral examination or enteroclysis, does not cause patient discomfort, and produces a rapid examination of the entire small bowel in any patient with an ileostomy.

Analysis of a multiphasic radiographic examination for detecting reflux esophagitis

Radiographic and endoscopic findings were correlated in 46 normal patients and in 49 with reflux esophagitis to assess the efficacy of a multiphasic examination employing mucosal relief full-column, and double-contrast techniques. Esophagitis was graded endoscopically as mild, moderate, or severe, and the quality and sensitivity of each technique and of the examination as a whole were determined. The radiographic specificity in the normal patients was 98%. The overall sensitivity was 65% for all grades of esophagitis, and 90% for the moderate and severe grades. Sensitivities of the individual techniques were: mucosal relief: 43%; full-column: 53%; double-contrast: 45%. These differences were not statistically significant. We conclude that a combination of radiographic techniques is needed to detect reflux esophagitis optimally.

Positive predictive value and examiner variability in diagnosing duodenal ulcer

The positive predictive value of a diagnosis of duodenal ulcer was studied in 255 patients with 274 ulcers diagnosed radiographically. Retrospective analysis of the radiographic examinations and correlation with endoscopy assessed examiner variability, ulcer size, duodenal bulb deformity, and the confidence level of the ulcer diagnoses. For all diagnoses, the overall positive predictive value was 57% with individual predictive values of 47%, 54%, and 70% among three examiners. The individual predictive values correlated directly with the average level of confidence of the diagnoses for each examiner. The sensitivity of the individual examiner for ulcer detection had an inverse relation to the examiner's positive predictive value, confirming that higher sensitivities are achieved at the expense of an increased false-positive rate.

Duodenitis: endoscopic-radiologic correlation in 272 patients

Potential radiologic findings of duodenitis were investigated in 272 patients, 157 with endoscopically diagnosed duodenitis and 115 endoscopically normal controls. The study assessed the value of four signs: folds more than 4 mm thick, mucosal nodules, bulbar deformity, and erosions. The most sensitive signs were thickened folds (72.0%) and nodularity (48.4%), while demonstration of erosions was the least sensitive (10.8%). Overall sensitivity (77.7%) approximated that for the radiologic diagnosis of peptic ulcer or esophagitis. Radiologic specificity (76.5%) was in the same range.

Upper gastrointestinal series: patient management and a study of 199 cases

Records of 199 patients were analyzed retrospectively after upper gastrointestinal (UGI) series to assess its impact on patient management. Symptoms most predictive of an abnormal UGI series were dysphagia, UGI hemorrhage, abdominal pain, and chest pain. However, 23% of inpatients with seemingly trivial symptoms had shown abnormal results of the study. Overall sensitivity of the UGI series was 65%, which rose to 82% if esophagitis, gastritis, and abnormalities of the postoperative stomach were excluded. Effects on patient management included: serious pathologic change ruled out (53%), further studies ordered (21%), change of therapy (17%), existing therapy continued (16%), surgery performed (7%), and radiologic abnormality ignored (5%). In no case did the combination of initial screening by UGI series followed by endoscopy as indicated lead to subsequently reported morbidity or mortality due to a failure of diagnosis.

Multiphasic examination of the esophagogastric region for strictures, rings, and hiatal hernia: evaluation of the individual techniques

Three hundred multiphasic examinations of the lower esophagus and esophagogastric region were assessed to determine the individual sensitivities of the full-column, mucosal relief, and double-contrast techniques in the detection of common structural abnormalities, such as hiatal hernia, lower esophageal rings, and peptic strictures. In 159 patients, there were 211 structural abnormalities including 153 hiatal hernias, 35 mucosal rings, 20 peptic strictures, and 3 esophageal diverticula. The overall sensitivity of the full-column technique in detecting these abnormalities was 100% compared to 52% and 34% for the mucosal relief and double-contrast techniques, respectively. We conclude that the prone full-column technique must be incorporated into any examination of the esophagogastric region if these common abnormalities are to be demonstrated reliably.

Predictive relationship of hiatal hernia to reflux esophagitis

The relationship between hiatal hernia and reflux esophagitis was compared in 93 patients who underwent both radiographic and endoscopic examination of the esophagus. In 46 patients with a normal esophagus shown endoscopically, hiatal hernia was present in 59%, while 94% of 47 patients with reflux esophagitis had hiatal hernia. The positive and negative predictive values for hiatal hernia in diagnosing or excluding esophagitis were 62% and 86%, respectively. Extrapolation of these data and review of the literature suggest that much of the confusion concerning the relationship between hiatal hernia and reflux esophagitis is based on reports of populations with considerable variation in the prevalence of esophagitis and in which the radiographic criteria for diagnosing hiatal hernia have not been uniformly applied.

The radiologic detection of duodenal ulcers: effects of examiner variability, ulcer size and location, and technique

Study of 91 endoscopically verified duodenal ulcers compared the effects of examiner variability, ulcer size and location, and radiographic technique on ulcer detection. Radiologic sensitivity of 61.5% was found for the entire group of 91 ulcers. Examiner variability was the strongest determinant of success; sensitivities for individual examiners ranged from 44.4% to 80%. Ulcer size was a second factor in radiologic detectability; ulcers 5 mm or larger were detected at a higher rate (80.0%) than those less than 5 mm (64.5%). Sensitivities of 65.9% and 57.4% were recorded for single- and double-contrast examinations, respectively, a statistically insignificant difference.

Colonoscopy and the barium enema: a radiologic viewpoint

Adherents of colonoscopy are recommending that it replace the radiologic examination as the initial diagnostic study of the colon. We present the radiologic view, supporting the barium enema as a more practical approach to initial diagnostic evaluation. The radiologic examination is an equally reliable, less costly, and much safer method for detecting colonic disease.

Barrett esophagus as an extension of severe esophagitis: analysis of radiologic signs in 29 cases

Twenty-nine cases of Barrett esophagus verified by endoscopy and 16 cases confirmed by histology were reviewed for pertinent radiologic signs. All patients had barium-filled and mucosal relief films, and all but five cases had double-contrast films. Common radiologic signs in descending order were thickened and irregular mucosal folds (28/29), hiatal hernia (26/29), esophageal stricture (25/29), esophageal ulcer (20/29), distal esophageal widening (19/29), granular mucosal pattern (16/24), reticular mucosal pattern (9/24), and intramural pseudodiverticula (6/29), all of which are also recognized signs of reflux esophagitis. Midesophageal stricture, esophageal ulcer, and distal esophageal widening were particularly indicative of Barrett esophagus. Since there appears to be no specific sign of Barrett esophagus, a multifaceted approach is suggested concentrating on the association of Barrett esophagus with the radiographic signs of severe reflux esophagitis.

Methodologic considerations in comparing imaging methods

Current methods for evaluating and comparing imaging methods may be inadequate in several important aspects. Prospective investigations often fail to provide uniform conditions for data collection due to variable physician skills in performing the studies being evaluated. The double-blind format, although seemingly objective, is inherently unable to prevent the effects of examiner or observer prejudice when imaging methods are being compared. Commonly used statistical terms are limited in their ability to characterize the clinical efficacy of imaging methods, and are easily misused. Reference examinations, or "gold standards," may be used in a manner preordaining an inferior result for the diagnostic method under evaluation. These problems are discussed and examples of their effects are presented. Suggestions are presented for minimizing existing methodologic limitations.

Infectious jejunitis with stricture after gastrojejunostomy

Although bacterial overgrowth has often been reported in postgastrectomy patients, inflammatory stricture near the surgical anastomosis is rare. We describe a 36-year-old woman with infectious jejunitis and subsequent jejunal stenosis after gastrojejunostomy.

Detailed per-oral small bowel examination vs. enteroclysis. Part I: Expenditures and radiation exposure

Time involved, patient reaction, and radiation exposure were compared for 25 patients undergoing a per-oral small bowel series and 18 having enteroclysis. For the per-oral study, mean room time was 17 minutes and fluoroscopy time was 4 minutes; for enteroclysis, mean room time was 44 minutes and fluoroscopy time was 22 minutes. Side effects were categorized as mild to moderate in two thirds of patients having enteroclysis, whereas they were minimal in 20% of those having the per-oral examination. Radiation exposure was five times greater for enteroclysis. These factors should be considered along with the age of the patient, indications for the examination, and the accuracy of the technique when planning a study of the small bowel.

Detailed per-oral small bowel examination vs. enteroclysis. Part II: Radiographic accuracy

Accuracy of the detailed per-oral small bowel series and enteroclysis was compared in 134 patients known to have (or not have) disease of the small bowel. Overall sensitivity of the per-oral examination was 92% and specificity 94%, compared to 94% and 89%, respectively, for enteroclysis. There was no difference between the two in Crohn disease, adhesions, and metastatic disease; however, enteroclysis was thought to be more effective in delineating peritoneal adhesions in patients with obstruction. The authors conclude that while the per-oral study and enteroclysis are equally valid methods of examining the small bowel, the per-oral study is preferable as a screening examination because it requires less time, has fewer side effects, and involves a lower radiation exposure.

Endoscopic sensitivity in the detection of esophageal strictures

Endoscopy was compared in 90 patients with a radiographic diagnosis of peptic esophageal stricture. Retrospectively, 78 strictures were classified as valid diagnoses giving a positive radiographic predictive value of 87%. Endoscopy diagnosed 74 (95%) of the 78 peptic strictures, detecting all 45 strictures under 10 mm in caliber, but failing to detect four (12%) of 33 broader strictures. Nine (75%) of the 12 radiographic false-positive errors involved misinterpretation of muscular or mucosal rings of the lower esophagus. We conclude that endoscopy and radiology are equally effective and complementary methods for evaluating patients with suspected peptic stricture.

Anaphylactic and allergic reactions during double-contrast studies: is glucagon or barium suspension the allergen?

The authors report three anaphylactic reactions and one allergic reaction during double-contrast studies using glucagon. Symptoms included hives, periorbital edema, and breathing difficulties. Studies performed were three double-contrast barium enemas and one double-contrast upper gastrointestinal series. Glucagon injection and/or an additive in barium suspension are suspected as the likely causes. The allergic potential of glucagon injection, which is not generally appreciated, is reviewed.

Radiographic evaluation of the achalasic esophagus immediately following pneumatic dilatation

Sixteen patients with achalasia of the esophagus were treated by fluoroscopically guided pneumatic dilatation. All patients were examined radiographically immediately following dilatation. The caliber of the esophagogastric region increased from a pretreatment mean of 5.3 mm to 9.6 mm following dilatation. The margins of the dilated area remained smooth in 6 patients (38%) and became irregular in 10 (62%). Initial symptomatic improvement was found in 14 patients (88%) with a mean follow-up of 1.7 months. One (6%) perforation occurred, necessitating surgery. The radiographic appearance of the esophagogastric region following pneumatic dilatation, however, poorly predicted patient response.

The extent of successful colonoscopy: a second assessment using modern equipment

Records of 200 consecutive and unselected colonoscopies were reviewed to determine both the success in viewing the entire colon and the average extent of colon visualized, using the most modern equipment. Colonoscopy was completed to the cecum or ileum in 82.5% of studies, and an average of 93.8% of the colon was viewed. These data show considerable improvement compared to those previously reported by us. However, the significant number of incomplete colonoscopies still suggests that colonoscopy and barium enema examination must remain complementary for maximum detection of colonic lesions.

Cold barium suspensions in the clinical evaluation of the esophagus

Cold barium suspensions have been shown to reduce primary esophageal peristalsis and improve distention of the lower esophagus and esophagogastric region. Cold barium is a useful adjunct to the standard radiographic examination when adequate distention of the esophagus has not initially been achieved. It is particularly applicable to evaluation of reflux esophagitis and esophageal strictures and rings.

The location and size of gastric ulcers: radiologic and endoscopic evaluation

The location and size of 132 gastric ulcers were evaluated radiologically and endoscopically. Results suggest that the classically noted concentration of ulcers along the lesser curvature and in the distal stomach remains valid despite changes in diagnostic methods. It was also found that proximally located ulcers tend to be larger than those elsewhere, whereas those in the distal stomach are smaller. Concentration of ulcers in the proximal stomach in elderly patients, as suggested by previous authors, could not be confirmed.

Predictive value of a diagnosis of colonic polyp on the double-contrast barium enema

The positive predictive value of a diagnosis of colonic polyp on the double-contrast barium enema was determined by analyzing 160 polypoid lesions reported in 105 patients. Of the 160 polyps, 139 were confirmed by endoscopy, surgery, or repeat barium enema for a positive predictive value of 87%. Twenty-one lesions were not confirmed despite repeat endoscopy, repeat barium enema, review of the original study, or surgery, giving a false positive rate of 13%. The individual false positive error rates of 5 radiologists ranged from 8% to 26%. False positive errors were due to stool, diverticula, air bubbles, misinterpretation of the ileocecal valve, and haustration. Many of the false positive errors appeared to have been avoidable if the original examination had been more meticulously interpreted.

Sensitivity of single-contrast radiology in esophageal disease: a study of 240 patients with endoscopically verified abnormality

Single-contrast radiology of the esophagus was correlated with endoscopy in 240 patients with the following endoscopically verified abnormalities: esophagitis 170, rings 28, malignancies 19, varices 9, miscellaneous 14. For all the abnormalities except mild esophagitis, the overall sensitivity of the radiology in these 240 patients was 92%. All 19 cancers were diagnosed radiologically, whereas 90% of moderate and severe esophagitis was detected. The single-contrast examination thus reliably identified clinically significant disease of the esophagus. Comparison of these results to recent reports employing double-contrast technique suggests that claims of superiority for the double-contrast esophagram over the single-contrast study are not supported.

Colon polyp morphology on double-contrast barium enema: its pathologic predictive value

The morphologic appearance of 96 polyps seen on double-contrast barium enema was reviewed to assess the predictive value of various signs described to diagnose malignancy. Size, surface contour, basal indentation, and pedunculation were studied. Sessile polyps had an appreciable incidence of malignancy, with size being the best indicator of that risk. Pedunculation was found to be a reliable sign of benignity in predicting the absence of malignant invasion into the adjacent colonic wall. Polyps under 1 cm and having a smooth contour were invariably benign. Conversely, polyps larger than 1 cm with a lobulated contour and basal indentation had a significant incidence of malignancy.

Declining volume of gastrointestinal fluoroscopies: a survey of 18 hospitals

A survey of the volume of gastrointestinal fluoroscopies at 18 hospitals suggests a decline in the number of these examinations performed over the past 5 years. Data were acquired on 4 types of examinations: upper gastrointestinal series, small bowel studies, barium enemas (all types), and oral cholecystograms. Modest decreases of 8.4%, 10.3%, and 2.0% were noted in the numbers of upper gastrointestinal examinations, small bowel examinations, and barium enemas, respectively. A considerable decline of 45.9% was found in performance of oral cholecystograms. An overall decline of 14.4% was noted for all 4 examinations.

The sensitivity of radiography of the postoperative stomach

The results of radiology and endoscopy were compared in 140 patients who had undergone gastric surgery for ulcer disease. Of 74 patients who were examined with single-contrast radiography, 37 had abnormalities that were demonstrated endoscopically. The radiographic sensitivities in these patients were: gastritis 2/22 (9%); ulcer 3/5 (60%); obstruction 8/8 (100%); and miscellaneous abnormalities 2/2 (100%). The predictive accuracy of a diagnosis of ulcer was 38%. Of the 66 patients who were examined with double-contrast radiography, 33 abnormalities were found with endoscopy. The radiographic sensitivities were: gastritis 3/13 (23%); ulcer 7/10 (70%); obstruction 4/4 (100%); and miscellaneous abnormalities 6/6 (100%). The predictive accuracy of a diagnosis of ulcer was 44%. Radiology appears to be unreliable in diagnosing gastritis and recurrent ulceration in the postoperative stomach. The double-contrast technique does not offer significant improvement over the single-contrast method in evaluating these postoperative problems.

Extent of colonic visualization with the fiberoptic sigmoidoscope

Forty-two patients underwent flexible sigmoidoscopy in the radiology department. After maximal insertion of the sigmoidoscope, a supine abdominal film documented the position of the tip of the instrument. Correlation with barium enema in all patients determined the extent of visualization of the colon relative to the length of insertion of the sigmoidoscope. Insertion to 60 cm was achieved in 31 (74%), 40-59 cm in six (14%), 25-39 cm in three (7%), and under 25 cm in two (5%), with a mean depth of insertion of 54 cm. Full insertion examined the entire sigmoid colon in 14 (45%) of 31 patients. Insertion between 40-59 cm achieved complete sigmoid evaluation in only one (17%) of six patients. Thus, flexible sigmoidoscopy does not necessarily guarantee evaluation of the entire sigmoid colon.

Detection of gastric ulcer: comparison of single- and double-contrast examination

The radiographic sensitivities of single- and double-contrast examinations for detecting gastric ulcer were compared. Single-contrast radiography detected 30 (75%) of 40 endoscopically verified gastric ulcers. Only 56% of ulcers under 5 mm were detected with the single-contrast method, while 88% of those larger were identified. Double-contrast radiography detected 58 (62%) of 93 endoscopically verified gastric ulcers. Only 45% of ulcers under 5 mm were detected with the double-contrast method, while 78% of those larger were identified. Statistically, the probability of ulcer detection was found to be primarily dependent on ulcer size, regardless of the technique used, and no significant difference could be demonstrated between the sensitivities of single- and double-contrast radiography.

Barium sulfate suspensions: an evaluation of available products

Commercially available barium sulfate suspensions were evaluated for suspension stability and coating characteristics important to the most commonly performed gastrointestinal examinations. Products tested included powders supplied in bulk, unit dose powders, and factory-prepared liquids. Results indicated considerable differences in suspension stability and coating properties among the products tested. Results also suggest that no single barium suspension currently available is likely to provide optimum performance during all of the more frequently performed studies.

Sensitivity of single- vs. double-contrast radiology in erosive gastritis

Radiologic sensitivity was determined in 54 patients with endoscopically diagnosed erosive gastritis. Four (24%) of 17 cases examined by single-contrast radiography and 16 (43%) of 37 cases examined by double-contrast radiography were detected. Double-contrast views and compression filming were both equally effective in diagnosing erosive gastritis during examinations where both were used. Although double-contrast examinations were more effective than single-contrast studies, both radiologic methods demonstrated poor sensitivity in detecting erosive gastritis.

Radiologic detection and spectrum of appearances of peptic esophageal strictures

We compared radiology and endoscopy in 80 patients with peptic esophageal stricture, with special attention to radiographic sensitivity for stricture caliber. Each stricture was classified by length into three types: 1) short (6-25 mm in length); 2) annular (under 6 mm in length); and 3) long (over 25 mm in length). Overall, radiology detected 95% of all strictures, including 90% of those over 1 cm in caliber. Morphologically, 75% of all strictures were short; 14% annular, and 11% long. Radiographically, smooth-stricture margins reliably excluded active esophagitis, while irregularity correlated well with its presence. Properly performed, barium esophagram can accurately detect esophageal strictures with a sensitivity approximating that of endoscopy.

Efficacy of radiology of the esophagus for evaluation of dysphagia

The efficacy of radiology in evaluating dysphagia was studied in 86 patients by comparison to endoscopic findings. In the 66 patients with endoscopic abnormalities radiology was correct in 54, for a sensitivity of 82%. Sensitivity of radiology improved to 95% if mild esophagitis was excluded. In the 20 patients with normal endoscopy, radiology was normal in 18 (90%). Thus radiology proved to be a reliable means of evaluating the esophagus in patients with dysphagia.