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The radiologic workup of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this complex situation have undergone considerable changes over the past two decades. The diagnosis and treatment of small bowel obstruction, a common clinical condition often associated with signs and symptoms similar to those seen in other acute abdominal disorders, continue to evolve. This article examines the changes related to the use of imaging in the diagnosis and management of patients with this potentially dangerous problem and revisits pertinent controversies.

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OBJECTIVE: Our aim was to determine which findings on abdominal radiography are relevant for distinguishing complete or high-grade partial small-bowel obstruction from low-grade partial or no small-bowel obstruction. MATERIALS AND METHODS: Admitting abdominal radiographs with the patients in the supine and upright positions were scored for 25 different findings in 81 patients with clinically suspected small-bowel obstruction. Forty-one patients had complete or high-grade partial small-bowel obstruction, and 40 had low-grade partial small-bowel obstruction or no obstruction as determined by enteroclysis examination. Abdominal radiography findings were subjected to statistical analysis for correlation with degree of obstruction. RESULTS: Of 12 radiographic findings strongly associated (p < 0.05) with the severity of obstruction, two findings were found to be the most significant (p < or = 0.0003) and predictive of a higher grade small-bowel obstruction: the presence of air-fluid levels of differential height in the same small-bowel loop and the presence of a mean air-fluid level width greater than or equal to 25 mm on upright abdominal radiographs. CONCLUSION: When both critical findings are present, the degree of small-bowel obstruction is likely high-grade or complete. When both signs are absent, small-bowel obstruction is likely low-grade or nonexistent. Upright abdominal radiographs are important in the examination of patients with suspected small-bowel obstruction and may contribute to the imaging triage of these patients.

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PURPOSE: To determine if differences in the viscosity of defecographic contrast media influence radiographic findings. MATERIALS AND METHODS: Twenty asymptomatic volunteers underwent defecography three times with a different contrast medium used for each examination. The contrast media varied in viscosity from a thin barium liquid to a commercial barium paste formulated for defecography and to an extremely thick, specially prepared barium contrast paste. RESULTS: Significant differences (P < .05) between media were demonstrated for measurements of the anorectal angle and anorectal junction during liquid medium voiding. Differences in pelvic floor descent and evacuation time were not significant (P > .05). Rectoceles occurred in 14 subjects and were demonstrated with all media. Low-grade intussusceptions were more prevalent with the liquid medium, but their occurrence was not statistically significantly more frequent (P > .05). CONCLUSION: Altering the viscosity of the barium contrast medium used for defecography does not substantially affect the subsequent radiographic findings.

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BACKGROUND: In the past, small bowel examinations were usually ordered for the sake of "completeness." As a result, small bowel radiography was performed casually and without attention to detail. This review examines pertinent clinical issues and the recent contribution of small bowel radiography to the evaluation and management of the patient with suspected small bowel disease. Recommendations for the clinical utilization of small bowel radiography are discussed. METHODS: Analysis of pertinent citations addressing valid indications for, and technique of, small bowel radiography from 1980 to July 1995 through a computerized bibliographic search (Medline and Current Contents). RESULTS: Accepted clinical indications for small bowel radiography include (1) unexplained gastrointestinal bleeding, (2) possible small bowel tumor, (3) small bowel obstruction, (4) Crohn disease, and (5) malabsorption. The current literature reflects the limitations of the conventional small bowel follow-through, various modifications to improve its clinical yield, the important contribution of enteroclysis in the workup, and subsequent management of patients with possible small bowel disease. A controversy in the radiology literature exists as to whether to use the small bowel follow-through or enteroclysis as the primary method of examining the small bowel. CONCLUSION: The thoughtful selection of patients by clinicians for small bowel radiography is essential to make radiologic evaluation cost effective. The incidence of disease of the small intestine is low and is associated with nonspecific symptoms. Because of the inherent difficulty of visualizing numerous loops of an actively peristalsing bowel, a reliable imaging method is needed that not only detects small or early structural abnormality but also accurately documents normalcy. The yield of information provided by enteroclysis and its high negative predictive value suggests that it should be the primary method for small bowel examination. The "overhead"-based conventional small bowel follow-through should be abandoned. The "fluoroscopy"-based small bowel follow-through augmented when necessary by the peroral pneumocolon or the gas-enhanced double-contrast follow-through method is an acceptable alternative when enteroclysis is not possible.

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The type of colonic imaging (radiological vs colonoscopic) for evaluating symptomatic patients without evidence of bleeding in both an efficacious and cost-conserving manner has become a very debated issue. In a randomized, controlled clinical trial, the authors hoped to examine the prevalence of neoplasm and the effectiveness and cost-effectiveness of initial diagnostic strategies of colonoscopy versus flexible sigmoidoscopy and air contrast barium enema in patients without evidence of intestinal bleeding. One hundred forty-nine patients over the age of 40 with symptoms suggestive a colonic disease without evidence of bleeding (no hematechezia, negative test for fecal occult blood, and normal serum hemoglobin) were randomized to undergo either initial colonoscopy or flexible sigmoidoscopy plus barium enema. Patients with incomplete lower GI tests were referred for the corresponding alternative imaging modality. Cost analyses using sensitivity analysis were performed. Baseline information with respect to age, race, sex, inpatient status, reason for referral, mean weight loss, hemoglobin, blood urea nitrogen, and albumin were similar in both groups. Eighteen patients (24%) who initially received air contrast barium enema and flexible sigmoidoscopy then required colonoscopy, whereas only five patients (6%) who initially underwent colonoscopy first required air contrast barium enema plus flexible sigmoidoscopy. The study found that: a) The prevalence of cancer in the study was low (one of 149 patients); b) initial colonoscopy detected more persons with adenomas than that of air contrast barium enema plus flexible sigmoidoscopy (23 of 75 patients vs 13 of 74 patients, odds radio, 2.07, CI,0.90-4.92; this approached significance); and c) air contrast barium enema plus flexible sigmoidoscopy detected more diverticulosis (46 of 74 patients vs 31 of 75 patients, odds ratio, 0.41, 95% CI, 0.21-0.87). The significant conclusions were that patients undergoing flexible sigmoidoscopy plus air contrast barium enema were more likely to undergo alternative procedures and that sensitivity analysis suggested that, for most areas in the United States, initial colonoscopy would be more cost-effective for the outcome of detection of adenomas (1).

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PURPOSE: To evaluate the effectiveness of glucagon and diazepam as compared with placebo in decreasing abdominal discomfort in patients during double-contrast barium enema examination. MATERIALS AND METHODS: Thirty-six men (n = 9) and women (n = 27) aged 21-62 years with "a lot or terrible discomfort" during double-contrast barium enema examination were randomized into double-blind groups of 12 patients each at the onset of examination. Each group received a placebo, glucagon (1 mg), or diazepam (5 mg) intravenously. Discomfort was scored on a four-point scale by the patients. RESULTS: Repeated measures analysis of variance findings indicated that those who received an active drug reported significantly (P = .001) greater relief of discomfort. Discomfort scores improved, on average, 2.2 in the glucagon, 2.0 in the diazepam, and 1.2 in the placebo groups. Colonic spasm did not correlate with abdominal discomfort. CONCLUSION: Discomfort during double-contrast barium enema examination can be statistically significantly diminished with a hypotonic agent or a sedative.

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One hundred forty-nine patients aged 40 years or more with symptoms suggestive of colonic disease but without evidence of gastrointestinal bleeding (absence of hematochezia, normal serum levels of hemoglobin, and at least one test negative for fecal occult blood) were randomized to undergo either initial colonoscopy or initial flexible sigmoidoscopy plus air-contrast barium enema. Patients with incomplete initial colonoscopy and certain patients with polyps seen on flexible sigmoidoscopy plus barium enema underwent the alternative procedure (barium enema or colonoscopy). The main results were as follows: First, the overall prevalence of cancer in the study was very low (0.67%). Second, initial flexible sigmoidoscopy plus barium enema detected more patients with diverticulosis than did initial colonoscopy (46% versus 31%; p = .01). Initial colonoscopy detected more persons with adenomas (p = .06) than did initial flexible sigmoidoscopy plus barium enema. Patients undergoing initial flexible sigmoidoscopy plus barium enema require the alternative procedure (24%) than were patients undergoing initial colonoscopy (6%; p = .002). Third, sensitivity analyses suggested that for most areas in the United States, initial colonoscopy would be more cost-effective for the outcomes of detection of adenomas and detection of large adenomas, although very few patients in the study had large adenomas. We conclude that the prevalence of colorectal cancer in persons with colonic symptoms but no evidence of bleeding is low and is comparable with the prevalence in an asymptomatic population. Cost-effective selection of imaging strategies in this population can be based on demographic factors such as age and sex, which are better predictors of the presence of adenomas than are symptoms.

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The initial clinical experience with the use of a triple lumen long tube designed for gastrointestinal decompression and enteroclysis is reported in 150 patients. Based on clinical observations, this tube is effective in suctioning retained gastric and intestinal fluid but requires frequent irrigation of the sump port for effective decompression of distended small bowel. In all patients with a preexisting nasogastric tube, the replacement by the decompression/enteroclysis tube was considered more comfortable by the patients. Successful placement of the tube in the jejunum was achieved in 147 of 150 consecutive patients on the initial attempt. The use of this tube obviates dual intubations for decompression and enteroclysis, the attendant discomfort on the patient, and it expedites subsequent performance of enteroclysis if needed. The complications reported with other long intestinal tubes were not observed with this device.

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Fifty consecutive patients presenting with fecal incontinence were evaluated prospectively with anorectal manometry, defecography, and other tests of anorectal function to assess the clinical utility of defecography in fecal incontinence. Leakage of contrast at rest and failure to narrow the anorectal angle with pelvic squeezing were specific but not sensitive predictors of decreased sphincter pressures as determined by manometry. Thus, after manometry, defecography provided no additional information regarding sphincter strength. Retention of contrast in large rectoceles or incomplete rectal evacuation at defecography had excellent correlation with the presence of clinical symptoms of outlet obstruction constipation (present concurrently with incontinence) and indicated an etiology of outlet obstruction symptoms. Defecography may provide useful information in incontinent patients with outlet obstruction constipation symptoms but has little additive value to anorectal manometry in incontinent patients without such symptoms.

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The quality of 17 air contrast barium enemas performed the same day as incomplete colonoscopies using air insufflation was compared with 21 air contrast barium enemas performed on a different day from incomplete colonoscopies. A gastrointestinal radiologist blinded to the timing of the procedures reviewed the barium studies scoring them as 1 (unsatisfactory) to 4 (excellent) in four areas. The mean overall quality score for the air contrast barium enemas done the same day as incomplete colonoscopy was 3.29 vs. 2.97 for those done on a different day (p = 0.24). There were no significant differences in quality scores between same-day versus different-day air contrast barium enemas for the specific parameters of quality of distention, barium coating, and amount of spasm. We conclude that when colonoscopy using air insufflation is incomplete because of looping or angulation, air contrast barium enema can be done the same day without impairing the quality of the barium study.

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We evaluated 224 consecutive patients referred for severe constipation prospectively by strict criteria to determine their candidacy for subtotal colectomy. Eighteen patients had insufficient symptoms to warrant evaluation. Two hundred six patients had anorectal manometry and defecography, and 182 had colonic transit measurement. Forty-nine patients had normal or minimally abnormal studies. One-hundred twenty-nine patients had abnormalities such as outlet obstruction, mild colonic inertia, diffuse gut dysfunction, or combinations of factors not favoring subtotal colectomy. Twenty-eight patients had colonic inertia without outlet obstruction and with disabling symptoms; 19 of these patients underwent subtotal colectomy. Follow-up > or = 12 months was available in 14 patients from this group. Of these patients, 12 (86%) were clinically improved. Preoperative evaluation accurately predicted postoperative fecal incontinence and likely reduced postoperative constipation. Small-bowel obstruction occurred postoperatively in 4 patients (29%), and remains a major risk of subtotal colectomy even in carefully selected candidates.

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Radiologic imaging continues to play an integral role in the diagnosis and management of diseases of the small bowel. The mesenteric small intestine remains the only gastrointestinal tract segment for which diagnostic study is not principally dependent on endoscopic viewing. Because radiologists assume primary responsibility in the diagnostic evaluation of the small bowel, it is essential that methods capable of accurately demonstrating small bowel morphology are appropriately applied. Barium contrast studies and enteroclysis, in particular, remain the primary diagnostic methods in the small bowel for most clinical indications. Cross-sectional imaging modalities often provide unique diagnostic information, but their role remains either complementary to the demonstration of surface details by barium contrast studies or directed to specific clinical circumstances that require discrete evaluation of the small bowel wall and adjacent tissues and organs.

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Radiologic imaging continues to play an integral role in the diagnosis and management of diseases of the small bowel. Except for the most proximal jejunal loop, which may occasionally be reached during upper gastrointestinal tract panendoscopy, and the terminal ileum, which can frequently be examined by the colonoscope, the mesenteric small intestine is the only gastrointestinal tract segment for which diagnostic study is not principally dependent upon endoscopic viewing. To the extent that radiologists assume primary responsibility in the diagnostic evaluation of the small bowel, it is essential that methods capable of accurately demonstrating small bowel morphology are appropriately applied (Maglinte et al., Radiology 1987, 163:297-305). Barium contrast studies and enteroclysis in particular remain the primary diagnostic methods in the small bowel for most clinical indications. Cross-sectional imaging modalities often provide unique diagnostic information, but their role remains either complementary to the demonstration of surface details by barium contrast studies or directed toward specific clinical circumstances that require discrete evaluation of the small-bowel wall and the adjacent tissues and organs.

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All 118 hospital-based radiology departments in Indiana responded to a survey of barium enema (BE) use. The percentage of community hospitals in Indiana using barium enema, both single contrast (SCBE) and double contrast (DCBE) for various indications, was similar to that reported for major medical centers around the world. The use of SCBE and DCBE did not differ between small and large hospitals or between hospitals in small versus large communities. There was, however, wide variation among community hospitals in their overall use of either contrast technique. Barium enema usually was performed without antecedent sigmoidoscopy. However, 60% of Indiana hospitals perform BE on the same day as flexible sigmoidoscopy. The results indicate that the use of BE in community hospitals in Indiana is similar to that reported for major medical centers. Like major medical centers, there is no consensus regarding many issues in the performance of BE.

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Plain abdominal radiographs and enteroclysis studies were reviewed blindly in 117 consecutive patients undergoing enteroclysis for suspected small bowel obstruction. Plain radiographs were unreliably predictive of the presence of obstruction as determined by enteroclysis and surgery. Among patients with normal or abnormal nonspecific plain radiographs, varying degrees of small bowel obstruction were demonstrated by enteroclysis in 22%. Conversely, of patients with obstruction on plain radiographs, 42% had either normal enteroclysis studies or only minor adhesions. Enteroclysis correctly predicted the presence of obstruction in 100%, the absence of obstruction in 88%, the level (proximal vs distal) of obstruction in 89%, and the etiology of obstruction in 86% of operated patients. Enteroclysis is advocated as the definitive study in patients with clinical uncertainty about the diagnosis of small bowel obstruction.

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The incidence of pathology in the small bowel is substantially lower than in the upper gastrointestinal tract or colon. This is fortunate since the small bowel, with its unique anatomy and remote location is the most difficult section of the gastrointestinal tract to study. Instillation of contrast into the small bowel lumen can be achieved by the oral route or by the more recently refined technique of small bowel intubation/infusion called enteroclysis. This brief review will focus on the clinical infusion indications for and efficacy of enteroclysis and the relative advantages of enteroclysis over oral methods of small bowel radiography.

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A 25-year-old nulliparous woman with adult onset constipation and slight anterior displacement of the anus underwent pelvic magnetic resonance imaging and was diagnosed with congenital hemiabsence of the levator ani sling. Impaired defecation was confirmed by anorectal function studies and defecography demonstrated an anterior rectocele, perineal descent at the upper limit of normal, and partial obstruction of defecation, which appeared related to the levator sling abnormality. To our knowledge, this combination of findings has not been previously described as a cause of adult onset constipation.

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