Detailed evaluation of the small bowel is difficult because of its inaccessibility. The small bowel  follow-through examination using barium, has low diagnostic sensitivity. Enteroclysis, the injection of contrast material through a duodenal or jejunal tube, offers a newer and highly sensitive method of radiological evaluation. Our paper describes the technique, clinical indications, and side effects of enteroclysis

Feczko, Peter J.

Halpert, Robert D.

Iorio, Judith

Keller, Cathrine E.

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 33 Number 2 Medical Imaging 1985 Article 17 6-1985 Enteroclysis for the Examination of the Small Bowel Robert D. Halpert Peter J. Feczko Cathrine E. Keller Judith Iorio Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Halpert, Robert D.; Feczko, Peter J.; Keller, Cathrine E.; and Iorio, Judith (1985) "Enteroclysis for the Examination of the Small Bowel," Henry Ford Hospital Medical Journal : Vol. 33 : No. 2 , 116-121. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol33/iss2/17 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med J Vol 33, Nos 2 and 3, 1985 Enteroclysis for the Examination of the Small Bowel Robert D. Halpert, MD,* Peter J. Feczko, MD,* Cathrine E. Keller, MD,+ and Judith lorio, RT* Detailed evaluation ofthe small bowel is difficult because of its inaccessibility. The small bowel follow-through ex-aminadon using barium, has low diagnoshc sensidvity. Enteroclysis, the injection of contrast material through a Traditionally, diagnostic evaluation ofthe small bowel has depended on the small bowel follow-through (SBFT) exami-nation using barium. However, the effectiveness of this method has been limited by its low diagnostic sensitivity (1) and by the inaccessibility ofthe small bowel itself. Despite considerable advances in fiberoptic endoscopy of the gas-trointestinal tract, development of better techniques to evaluate the small bowel is much needed. Tubal installation of barium, or enteroclysis, has long been known (2), but its use has been quite limited until recently because it has been associated with considerable patient discomfort. Now, as a resultof technical improvements, enteroclysis is being used more widely (3). Comparison of Small Bowel Follow-through with Enteroclysis In 1982, 854 SBFT studies were performed at our institution. Diagnostic evaluation was based on the interpretation of intermittent radiographs of the small bowel (Fig 1) obtained after the patient had ingested a large amount of barium; the procedure was continued until barium reached the colon. If the loop of bowel where a lesion occurred was not filled or if adjacent barium-filled loops covered the loop in ques-tion, lesions of considerable size might be missed (4). By contrast, the enteroclysis examination can provide de-tailed evaluation ofthe entire small bowel from the ligament of Treitz to the ileocecal valve (Fig 2). The radiologist per-forms intermittent fluoroscopy during the entire examination and, using a compression technique, examines each loop of bowel as it becomes distended with contrast medium. Diagnostic evaluation by enteroclysis can be made with some confidence, whereas the SBFT examination is at best a good survey technique. While the SBFT examination is suitable for evaluation of diseases that diffusely involve all or major portions ofthe small bowel, it is particularly weak in the iden-tification of focal lesions (5). Technique Before the examination, 10 mg of metaclopramide is adminis-tered intravenously. This is usually withheld if there is clinical duodenal or jejunal tube, offers a newer and highly sen^ tive method of radiological evaluation. Our paper describes the technique, clinical indications, and side effects of e^. teroclysis. and radiologic evidence of significant small bowel ob-struction. After a topical anesthetic has been applied tothe posterior pharynx, a 12-polyvinyl enterostomy tube is passed through the patient's mouth and into the stomach. A guidewire is then introduced through the tube to control the direction of the tube tip so that it can be maneuvered through' the stomach and pyloric channel into the duodenum. Ifthe tip extends beyond the ligament of Treitz, the final position of the tube is considered to be optimal (Fig 3). An electric I pumping device is used to instill a dilute barium sulfate sus-[ pension at a constant flow rate. Fluoroscopic evaluationol each loop of bowel is undertaken by means of compression technique and 100-mm camera spot radiographs. Both the metaclopramide and the installation of contrast medium in-to the small bowel stimulate peristaltic activity and move the barium column along. Behind the head ofthe column where maximal distention occurs, detailed mucosal evaluation is possible because of physiological hypotonia resulting from bowel distention. The examination is complete when barium reaches the cecum, usually within 10 to 15 minutes. Fac-tors that may delay the passage of barium include dWated, fluid-filled loops of bowel (secondary to obstruction or ileus) or inadequate patient bowel preparation. Patient Preparation Adequacy ofthe bowel preparation before the examination wil l determine the rate of passage of barium to the cecum. In our experience, a full colonic preparation like that per-formed before a double-contrast barium enema examination is necessary. An empty collapsed cecum and right colon fa-cilitate movement ofthe barium column through the ileum whereas residual fluid or fecal material wil l decelerate the Submitted for publication: February 27. 1985 Accepted for publication: April 27, 1985 •Department of Diagnostic Radiology, Division of Gastrointestinal Radiology. Henry Ford Hospital '^Department of Diagnostic Radiology, Henry Ford Hospital Address reprint requests to Dr Halpert, Departmenl of Diagnostic Radiology, l^^" ' . ! Ford Hospital, 2799 W Crand Blvd, Detroit, Ml 48202. 116 Enteroclysis Fig 1 Acceptable static image from routine small bowel follow-through examina-tion shows partial filling of jejunal loops and overlapping ileal loops. barium column in the distal small bowel and produce sig-nificant ileal hypotonia at the head of the column. When this occurs, the column must be moved through the last several loops of small bowel solely by means of the hydrostatic pres-sure of the infusion pump. As a result, not only does the banum move slowly, but the patient also experiences more discomfort. Except for patients who have active inflamma-tory bowel disease or significant mechanical obstruction, we recommend a full colonic bowel preparation before the en-teroclysis examination. Side Effects and Complications No complications have been associated with the small bowel enteroclysis examination in the three years we have used the "fiethod. Side effects are uncommon and generally mild. Oc-casionally, diarrhea is reported after the examination, secon-dary to the fluid volume infused into the gastrointestinal tract. A few patients may vomit because of duodenal gastric re-"ux during the examination, but the use of the electric pump, *hich permits continuous, controlled barium delivery to the Jejunum, greatly lowers the incidence of reflux. Fig 2 Routine overhead image from normal enteroclysis examination demonstrates adequate distention of all loops of small bowel including the ileum. Fig 3 Optimal placement of tube beyond ligament of Treitz. Upper arrow dem-onstrates gastroesophageal junction, and lower arrow indicates level of ligament of Treitz. Tip of tube is just distal to ligament. 117 Halpert, Feczko, Keller, and lorio * Fig 4 Male patient who presented with chronic abdominal pain. Spot image from enteroclysis examination reveals an ovoid polypoid lesion in distal ileum (black arrow) as well as nodular irregularity just distal to this (white ar-row). Histological evaluation of resected specimen confirmed presence of carcinoid. Clinical Indications Chronic abdominal pain Because of its ability to distend loops of small bowel in a controlled manner, enteroclysis should be used in the diag-nostic examination of patients who present with chronic abdominal pain that may indicate focal stenotic small bowel lesions (6). Inflammatory or malignant strictures, adhesive bands, focal ischemic changes or narrowing secondary to lesions such as carcinoid (Fig 4) are optimally demonstrated by enteroclysis. In addition, polypoid lesions causing inter-mittent intussusception as well as early metastatic disease can usually be shown to advantage. Both are easily missej by SBFT. Enteroclysis is also used to evaluate the small bowel in patients suspected of having or known to have Crohn's disease. Because SBFT often cannot accurately evaluate the extent of disease, many gastroenterologists rely on entero-clysis as the primary diagnostic method. Proximal or skip lesions can be well demonstrated (Fig 5), and the possibility of finding fistulous connections is also increased. Small bowel obstruction There is disagreement among both radiologists and surgeons about the role of enteroclysis in patients who present with clinical and radiographic findings of small bowel obstruc-tion. Some advocate enteroclysis examination for all such patients, while others do not agree (7). The aim ofthe small bowel contrast examination in this clinical setting is to con-firm the clinical suspicion ofthe obstructive lesion, identify the level of the lesion, and demonstrate radiographically its Male patient who presented with chronic abdominal pain. Fmding* .^^  previous endoscopic and radiographic evaluations were normal, ^'"''.'rffjc-graph obtained during enteroclysis examination revealed area of . ^ gj ture in middle jejunum. Surgical resection of this area revealed is" and focal involvement of Crohn's disease. ^ j * patient '"•^^muco^ 118 Enteroclysis ... hvsical characteristics to offer a more definitive diagnosis PI (j). Although enteroclysis can best achieve these goals, : J^^Q is most profitable in minor to moderate degrees of ''[,5truction in which the exact localization of the obstruc-site may be unclear on the SBFT. 5gFT examination using water soluble contrast material is occasionally performed in patients who are suspected of hav-ing small bowel obstruction. While this procedure may be helpful in demonstrating the presence of an obstructive pro-cess by noting the delayed passage of contrast material into the colon, marked dilution of the contrast agent occurs be-causeof the retained fluid above an obstructive lesion. More-over, the high osmolality of water soluble contrast material draws additional fluid into the gut and makes visualization ofthe bowel unlikely. In most patients, the precise level and nature of the obstructive process cannot be determined. Routine SBFT examination using barium is somewhat more helpful in demonstrating the level and nature ofthe obstruc-tive lesion. The use of barium wil l not aggravate the clinical problem; both animal and human studies have demonstrat-ed that inspissation of barium in the small bowel does not occur (8). Gastrointestinal bleeding Enteroclysis examination can be very useful in the evalua-tion of acute or chronic gastrointestinal bleeding in patients in whom endoscopic and radiographic examination of the upper and lower gastrointestinal tract has failed to identify a bleeding site. Although the small bowel is the source of chronic gastrointestinal bleeding in relatively few patients. M l . ^'^ ^ patient who presented with intermittent severe abdominal pain. Spot int '"^"^^P'' from enteroclysis examination shows area of focal narrowing, ct mucosa, and some evidence of wall thickening in proximal jejunum. *cfed specimen demonstrated fibrotic changes secondary to focal ischemic disease. Fig 7 Male patient who presented with intermittent gastrointestinal bleeding. Upper and lower tract radiographic and endoscopic examinations revealed no source of bleeding. Findings of small bowel follow-through examina-tions were interpreted as normal. Examination of small bowel using enteroclysis was performed, and small polypoid filling defect was identi-fied in the distal ileum (arrow). This area was surgically resected, and patho-logical examination of specimen disclosed a submucosal hematoma of un-certain origin. Following surgery, bleeding ceased. its potential as a bleeding source greatly increases when all other types of diagnostic studies have been negative. Even when findings of SBFT are negative, enteroclysis has been able to identify bleeding sources in the small bowel such as Meckel's diverticulum, primary or metastatic malignant lesions of the small bowel, or Crohn's disease (5,9) (Fig 7). Inconclusive small bowel follow-through examinations Examination ofthe small bowel using enteroclysis is extreme-ly effective at confirming or excluding questionable lesions identified by findings of routine SBFT examination (Fig 8). In our institution, enteroclysis is most commonly used for those patients whose SBFT examinations are inconclusive. Radiographs ofthe small bowel obtained intermittently dur-ing the routine SBFT procedure may have a false positive interpretation. Areas of focal spasm may be interpreted as stenotic lesions; air bubbles or food that present as filling 119 Halpert, Feczko, Keller, and lorio B Fig 8 Voung woman referred for evaluation of possible small bowel lymphoma. Representative radiograph from small bowel follow-through examination (A) demonstrates numerous nodular irregularities in middle jejunum, resulting in diagnosis of possible lymphoma. Spot radiograph from enteroclysis examination (B) demonstrates normal appearing jejunum. , Diner WC, jptestine: Revi South Med J 2, Pesquera GS. intestine. AJF 3 SellinkJL. Ex tubation. Leii 4, Maglinte DC foilow-throu: 144:737-9. 5, Sanders SE, aminations. defects may be erroneously interpreted as polypoid process-es. Conversely, because lesions may be hidden in the barium column or may occur in nonbarium filled loops, findings of the routine SBFT examination can commonly be incorrectly interpreted as normal. In addition, both the head and tail of the barium column may look grossly abnormal due to par-tial filling and peristaltic activity rather than for pathological reasons. Discussion Use of small bowel enteroclysis is increasing. In 1984, of 932 SBFT examinations performed in our department, 73 were enteroclysis studies (7.8%). By contrast, 18 and 37 enteroclysis examinations were performed in 1982 and 1983, respectively. During 1984, only 23.9% of SBFT but 41.1%' of enteroclysis examinations revealed demonstrable abnor-malities. The major disadvantage of enteroclysis, the degree of patient discomfort associated with the peroral passage of a jejunal tube as well as the increased irradiation, mustbe weighed against the improved diagnostic sensitivity ofthe study. The frequency of failure to position the tube correct-ly is quite low (6.4% in 1984). With experience, corred placement can be successfully accomplished in a few minutes. Because enteroclysis is a much more sensitive method than routine SBFT examination for small bowel diagnostic evalua-tion, its use is increasing at a dramatic rate. Clinical situa-tions in which the examination is warranted continue to expand. Acknowledgment We would like to acknowledge Debra Jubenville, Medical Secretary, for her preparation of this manuscript. 120 Enteroclysis References n ner WC, Hoskins EOL, Navab F. Radiologic examination of the small ' ^(ipg. Review of 402 cases and discussion of indications and methods, south MedJ 1984;77:68-74. p sQuera GS A method for the direct visualization of lesions in the small ^ intestine. A)R 1929;22:254-7. Sellink JL. Examination of the small intestine by means of duodenal in-^ tubation. Leiden: Stenfert Kroese, 1971. f^laglinte DDT, Burney BT, Miller RE. Lesions missed on small bowel follow-through: Analysis and recommendations. Radiology 1982; 144:737-9. r Sanders SE, Ho CS. The small bowel enema: Experience with 150 ex-aminations. AJR 1976;127:743-51. 6. Maglinte DDT, Peterson LA, Vahey TN, Miller RE, Chernish SM. Entero-clysis in partial small bowel obstruction. Am J Surg 1984;147:325-9. 7. Caroline DF, Herlinger H, Laufer I, Kressel HY, Levine MS. Small-bowel enema in the diagnosis of adhesive obstructions. AJR 1984;142:1133-9. 8. Nelson SW, Christoforidis AJ, Roenigk WJ. Barium suspensions versus water-soluble iodine compounds in the study of obstruction ofthe small bowel. An experimental study of physiological characteristics and radio-graphic value. Radiology 1963;80:252-4. 9. Maglinte DDT, Elmore MF, Isenberg M, Dolan PA. Meckel diverticulum: Radiologic demonstration by enteroclysis. AJR 1980;134:925-32. ontinue' )t. 121 

Enteroclysis for the Examination of the Small Bowel

https://scholarlycommons.henryford.com/cgi/viewcontent.cgi?article=3146&amp;context=hfhmedjournal

Enteroclysis for the Examination of the Small Bowel

Abstract

Similar works

Full text

Available Versions

Henry Ford Health System Scholarly Commons