Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response.

Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm 2 /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results Of 181 patients (58 % male, mean 53 ±â€Š17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P  = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.

Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies.

BACKGROUND: Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. METHODS: After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. RESULTS: Eighty patients were referred and transported an average distance of 56 miles (range, 1-163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave's syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). CONCLUSIONS: Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable.

Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging.

It is difficult to identify normal peritoneal folds and ligaments at imaging. However, infectious, inflammatory, neoplastic, and traumatic processes frequently involve the peritoneal cavity and its reflections; thus, it is important to identify the affected peritoneal ligaments and spaces. Knowledge of these structures is important for accurate reporting and helps elucidate the sites of involvement to the surgeon. The potential peritoneal spaces; the peritoneal reflections that form the peritoneal ligaments, mesenteries, and omenta; and the natural flow of peritoneal fluid determine the route of spread of intraperitoneal fluid and disease processes within the abdominal cavity. The peritoneal ligaments, mesenteries, and omenta also serve as boundaries for disease processes and as conduits for the spread of disease.

Functional imaging of the pelvic floor.

The clinical treatment of patients with anorectal and pelvic floor dysfunction is often difficult. Dynamic cystocolpoproctography (DCP) has evolved from a method of evaluating the anorectum for functional disorders to its current status as a functional method of evaluating the global pelvic floor for defecatory disorders and pelvic organ prolapse. It has both high observer accuracy and a high yield of positive diagnoses. Clinicians find it a useful diagnostic tool that can alter management decisions from surgical to medical and vice versa in many cases. Functional radiography provides the maximum stress to the pelvic floor, resulting in levator ani relaxation accompanied by rectal emptying-which is needed to diagnose defecatory disorders. It also provides organ-specific quantificative information about female pelvic organ prolapse-information that usually can only be inferred by means of physical examination. The application of functional radiography to the assessment of defecatory disorders and pelvic organ prolapse has highlighted the limitations of physical examination. It has become clear that pelvic floor disorders rarely occur in isolation and that global pelvic floor assessment is necessary. Despite the advances in other imaging methods, DCP has remained a practical, cost-effective procedure for the evaluation of anorectal and pelvic floor dysfunction. In this article, the authors describe the technique they use when performing DCP, define the radiographic criteria used for diagnosis, and discuss the limitations and clinical utility of DCP.

Air (CO2) double-contrast barium enteroclysis.

In the 1980s and 1990s in North America and Europe, air (CO(2)) double-contrast barium enteroclysis took a back seat to biphasic methylcellulose double-contrast enteroclysis in the investigation of small-bowel diseases. The widespread application of capsule endoscopy in the 21st century has identified a number of limitations of radiologic examinations in the investigation of mucosal diseases of the small intestine. Evidence-based studies comparing barium, computed tomographic (CT), and magnetic resonance (MR) enteroclysis have shown that in spite of improvements in small-bowel examination methods using CT and MR, barium examinations remain superior in the depiction of mucosal abnormalities, particularly the apthoid lesions of early Crohn disease. Barium small-bowel examinations have been recommended in the patient with a negative CT or MR enteroclysis study where the pretest probability of Crohn disease is high. A recent prospective comparison of methylcellulose double-contrast barium enteroclysis to capsule endoscopy with review of the literature has shown that air enteroclysis depicts mucosal details better than does methylcellulose double-contrast enteroclysis because of the "washout" effect of methylcellulose on superficial mucosal features. Recent articles have shown that air enteroclysis compares favorably with wireless capsule endoscopy and double-balloon endoscopy in the diagnosis of mucosal abnormalities of the small bowel. This article describes the authors' technique of performing air double-contrast enteroclysis, its clinical indications, and its pitfalls.

Comparison of capsule endoscopy with enteroclysis in the investigation of small bowel disease.

PURPOSE: To compare results of capsule endoscopy with those of barium enteroclysis or CT enteroclysis. METHODS: Retrospective review of hospital records revealed 65 patients who had an enteroclysis and small bowel capsule endoscopy. The diagnostic yield of capsule endoscopy was compared with the enteroclysis using Fisher's exact test. RESULTS: The main indications were obscure gastrointestinal bleeding (n = 37) and suspected Crohn disease (n = 17). Radiologic studies included CT enteroclysis (n = 30), and fluoroscopic barium enteroclysis with carbon dioxide (n = 18) or with methylcellulose (n = 17). Capsule endoscopy had a higher diagnostic yield (8/17) compared to barium-methylcellulose cellulose enteroclysis (1/17) (P = 0.02). The diagnostic yield of capsule endoscopy was not significantly different compared with barium-carbon dioxide (12/18 vs. 10/18) enteroclysis or with CT enteroclysis (9/30 vs. 8/30). Vascular lesions were better assessed with capsule endoscopy. However, the CT enteroclysis found more lesions in patients with chronic abdominal pain. CONCLUSION: Barium-carbon dioxide enteroclysis and CT enteroclysis have similar diagnostic yields for small bowel disease compared to capsule endoscopy. Barium methylcellulose has an inferior diagnostic yield.

Conscious sedation for patients undergoing enteroclysis: comparing the safety and patient-reported effectiveness of two protocols.

OBJECTIVE: To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis. MATERIALS AND METHODS: We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl). RESULTS: All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n=106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n=25), and post-procedure vomiting without aspiration (n=1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n=45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n=13), and post-procedure vomiting without aspiration (n=1). 87% had only a vague recall of the procedure or of any discomfort. CONCLUSION: A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.

CT Enteroclysis.

Computed tomographic (CT) enteroclysis is a hybrid technique that combines the methods of fluoroscopic intubation-infusion small-bowel examinations with that of abdominal CT. The use of multidetector CT technology has made this a versatile examination that has evolved into two distinct technical modifications. CT enteroclysis can be performed by using positive enteral contrast material without intravenous contrast material and neutral enteral contrast material with intravenous contrast material. CT enteroclysis has been shown to be superior to other imaging tests such as peroral small-bowel examinations, conventional CT, and barium enteroclysis, except in the demonstration of early apthous ulcers of Crohn disease. CT enteroclysis is complementary to capsule endoscopy in the elective investigation of small-bowel disease, with a specific role in the investigation of Crohn disease, small-bowel obstruction, and unexplained gastrointestinal bleeding.

Radiologic investigations complement and add diagnostic information to capsule endoscopy of small-bowel diseases.

OBJECTIVE: The purpose of our study was to review how commonly performed radiologic examinations compare with capsule endoscopy in the investigation of small-bowel diseases, to analyze the limitations of capsule imaging, and to propose an algorithm for use of specific radiologic examinations to complement wireless capsule endoscopy. CONCLUSION: The diagnostic yield of capsule endoscopy is superior to that of radiologic examinations except air double-contrast enteroclysis for mucosal details. Radiologic investigations find new applications in clinical practice by complementing capsule endoscopy to overcome its limitations.

CT enteroclysis: techniques and applications.

CT enteroclysis overcomes the individual deficiencies of both barium enteroclysis and conventional CT and combines the advantages of both into one technique whose clinical applicability has been simplified and made more reliable with multidetector CT technology. This article examines the techniques of CT enteroclysis and presents an overview of its clinical applications relative to other methods of small bowel imaging.

CT of acute biliopancreatic limb obstruction.

OBJECTIVE: Our objective was to report the CT features of biliopancreatic limb (afferent loop) obstruction. CONCLUSION: Acute biliopancreatic limb obstruction has typical CT features. Given its high morbidity and rate of reoperation, it is useful to make this specific diagnosis instead of reporting the findings as postoperative small bowel obstruction.

Small-bowel complications of major gastrointestinal tract surgery.

OBJECTIVE: Gastrointestinal complications of major abdominal surgery often require radiologic assessment. The purpose of this article is to review the expected imaging findings and complications after commonly performed gastric and pancreatic surgery. CONCLUSION: It is important to understand the postsurgical anatomy to avoid misinterpreting an expected postoperative finding as a complication. Postoperative complications can be categorized as being related to adhesions, anastomosis, an enteric connection, and abnormal bowel position.

Surgery for chronic pancreatitis: cross-sectional imaging of postoperative anatomy and complications.

OBJECTIVE: Surgery is increasingly undertaken for intractable chronic pancreatitis. We evaluated the postsurgical anatomy and complications of surgical options including Whipple, Puestow, Frey's, and Beger's procedures. CONCLUSIONS: Knowledge of postsurgical anatomy is important to avoid misdiagnosing expected anatomy as complications on CT examinations. It is important to carefully assess the upper abdominal arteries to detect subtle but potentially lethal complications.

Gastrointestinal complications of bariatric Roux-en-Y gastric bypass surgery.

Obesity is rapidly becoming the most important public health issue in USA and Europe. Roux-en-Y gastric bypass is now established as the gold standard for treating intractable morbid or super obesity. We reviewed the imaging findings following this surgery in 234 patients. In this pictorial essay we present the CT and upper gastrointestinal contrast study appearances of the expected postoperative anatomy as well as a range of abdominal complications. The complications are classified into leaks, fistula and obstruction. Postoperative gastric outlet and small bowel obstruction can be caused by anastomotic stenosis, mesocolic tunnel stenosis, adhesions, stomal ulcer, obturation, intussusception and internal or external hernia. Small bowel obstruction may be of a simple, closed loop and/or strangulating type. The radiologist should be able to diagnose the type and possible cause of obstruction.

The multifaceted role of radiology in small bowel obstruction.

Small bowel obstruction is a common clinical condition, often presenting with signs and symptoms similar to those seen in other acute abdominal disorders. The diagnosis and treatment of this dynamic process continues to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the changes related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.

Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis.

BACKGROUND: Wireless capsule endoscopy (WCE) is a new technology for small bowel imaging. AIM: To report our initial experience with sensitivity of high quality enteroclysis in patients with small bowel ulcers detected by WCE. METHODS: Medical records of all patients referred for WCE from December, 2001 to April, 2002 at our institution were reviewed. All patients had negative upper and lower endoscopies and small bowel barium studies before WCE. RESULTS: There were 40 patients (19 female, mean age 57.3 yr) during this study period. Three patients had multiple small bowel ulcers detected by WCE. One with ileal ulcers and abdominal pain had an enteroclysis at another hospital before WCE. Review of the study at our institution showed that it was of excellent quality and was normal. Two patients with chronic iron deficiency anemia had multiple small bowel ulcers and were referred after WCE for a repeat small bowel barium study by biphasic enteroclysis performed by experienced GI radiologists. The radiologists were told in advance of the WCE findings. Both studies were considered technically to be of perfect quality. Despite this, both studies were negative. All 3 patients improved after therapy for Crohn's disease. CONCLUSIONS: Our data indicates that WCE may be more sensitive for small bowel ulcers than the best enteroclysis available.

Technical refinements in enteroclysis.

As the primary method of investigating the small bowel, enteroclysis remains a technique in evolution. Technical refinements have made the examination faster to perform, better tolerated by patients, and easier to interpret. More recently, its essential principle of volume challenge has been combined with the tremendous advantage of CT cross-sectional imaging with multiplanar reformatting to give rise to the exciting new techniques of CT enteroclysis and MR enteroclysis (see separate reviews in this issue). Through improvements in methodology and advancements in technology, the future of enteroclysis looks bright indeed.

Multidetector-row helical CT enteroclysis.

Currently, CT-E is not recommended as the first-line examination in patients when mucosal detail is required. Double-contrast barium air enteroclysis has advantages in demonstrating small mucosal abnormalities. The authors find CT-E of value in the work-up of patients with symptoms of intermittent small bowel obstruction, particularly those with a history of prior abdominal surgery; in the further work-up of selected patients with high-grade obstruction in whom general surgeons prefer initial conservative management (immediate postoperative small bowel obstruction, patients with history of prior abdominal surgery for malignant tumor, history of radiation treatment, and possible internal extraintestinal fistulae); in looking for complications of small bowel Crohn's disease; and in the patient with unexplained anemia or gastrointestinal bleeding. In a series of patients who had both abdominal CT and barium enteroclysis done, each examination provided unique and complimentary diagnostic information. Because CT-E combines the advantages of both methods of examination, is it the optimum imaging work-up in the investigation of small bowel disease? Further research and clinical experience will define the precise role of CT-E in the investigation of small bowel disease. Experience with this method of examination is limited to a few institutions, performed by investigators with interest in small bowel diseases. The addition of cross-sectional display and multiplanar reformatting made possible by multidetector-row helical CT to enteral volume change and the use of multifunctional nasointestinal catheters make CT-E an important tool in the investigation of small bowel disease. Experience has shown the increased reliability of any method of examining the small bowel that challenges intestinal wall distensibility by fluid enteral volume infusion.