Utility of barium studies for patients with recurrent weight gain after Roux-en-Y gastric bypass.

AIM: To determine the utility of barium studies for detecting abnormalities responsible for recurrent weight gain after gastric bypass surgery. METHODS: A computerized search identified 42 patients who had undergone barium studies for recurrent weight gain after gastric bypass and 42 controls. The images were reviewed to determine the frequency of staple-line breakdown and measure the length/width of the pouch and gastrojejunal anastomosis. A large pouch exceeded 6 cm in length or 5 cm in width and a wide anastomosis exceeded 2 cm. Records were reviewed for the amount of recurrent weight gain and subsequent weight loss after additional treatment. RESULTS: Staple-line breakdown was present in 6/42 patients (14%) with recurrent weight gain. When measurements were obtained, 13/35 patients (37%) with recurrent weight gain had a large pouch, three (9%) had a wide anastomosis, and four (11%) had both, whereas 22/42 controls (52%) had a large pouch, one (2%) had a wide anastomosis, and two (5%) had both. Ten patients (24%) with recurrent weight gain underwent staple-line repair (n = 3) or pouch/anastomosis revision (n = 7). These 10 patients had a mean weight loss of 38.1 lbs versus a mean loss of 8.6 lbs in 19 patients managed medically. CONCLUSION: Only 14% of patients with recurrent weight gain after gastric bypass had staple-line breakdown, whereas 57% had a large pouch, wide anastomosis, or both. Not all patients with abnormal anatomy had recurrent weight gain, but those who did were more likely to benefit from surgical intervention than from medical management.

Gastric bezoars: reassessment of clinical and radiographic findings in 19 patients.

The aim of this study was to reassess the clinical and radiographic findings in a series of patients with gastric bezoars. Radiology files revealed 19 patients with bezoars; 10 patients had CT and 10 had endoscopy before or after the barium studies. 11 patients (58%) had risk factors for gastroparesis and 6 (32%) had had previous gastric surgery, including 3 having had a gastric bypass or vertical banded gastroplasty. 18 patients (95%) had symptoms; in 10 of those patients, symptoms were present for 1 week or less (53%). On barium studies, the bezoars were round or ovoid in 17 patients (89%) and irregular in 2 (11%); mottled in 10 (53%) and homogeneous in 9 (47%); and mobile in 15 (79%) and immobile in 4 (21%). Gastroparesis was observed at fluoroscopy in 8 (62%) out of 13 patients without gastric surgery. Symptoms improved/resolved in 12 (67%) out of 18 patients. Follow-up CT or endoscopy showed resolution of the bezoars in 8 (80%) out of 10 patients; the mean interval to resolution was 12 days. Our experience suggests that gastroparesis is the single most common cause of bezoars, accounting for the majority of cases. Partial gastric resection or bariatric surgery should also be recognized as a cause of bezoar formation. These lesions may be manifested on barium studies by a spectrum of findings, appearing as mottled or homogeneous, mobile or immobile masses, sometimes filling the gastric pouch after bariatric surgery. Affected individuals often have an acute clinical presentation with symptoms for 1 week or less, and some bezoars resolve rapidly on conservative medical treatment.

An 8-year review of barium studies in the diagnosis of gastroparesis.

AIM: To determine the utility of barium studies for diagnosing gastroparesis in patients with nausea, vomiting, or other related symptoms. MATERIALS AND METHODS: Radiology files revealed gastroparesis without gastric outlet obstruction on upper gastrointestinal tract barium studies in 50 patients with nausea, vomiting, and other related symptoms. Original reports and images were reviewed to determine whether gastric peristalsis was decreased/absent and to investigate gastric dilatation, fluid or debris, and delayed emptying of barium. Twenty patients (40%) had nuclear gastric emptying studies. Medical records were reviewed to determine the presentation, treatment, and course. The diagnosis of gastroparesis was considered accurate if patients with gastroparesis on barium studies responded to treatment. RESULTS: Forty-six patients (92%) had predisposing factors for gastroparesis, including narcotics and diabetes. Forty-five patients (90%) presented with nausea or vomiting, and 40 patients (80%) had one or more other symptoms, including bloating, early satiety, postprandial fullness, and abdominal pain. Barium studies revealed decreased gastric peristalsis in 46 (92%) of the 50 patients and absent peristalsis in four (8%); 46 patients (92%) had additional findings, including gastric dilatation in 30 (60%), delayed emptying of barium in 27 (54%), debris in 28 (56%; bezoars in three), and retained fluid in 13 (26%). Thirteen (65%) of 20 patients with nuclear gastric emptying studies had delayed emptying of solids and seven (35%) had normal emptying. Thirty-five (83%) of 42 patients treated for gastroparesis had symptomatic improvement versus two (25%) of eight patients not treated. CONCLUSION: Patients with nausea, vomiting, or other related symptoms who have gastroparesis without gastric outlet obstruction on barium studies can be treated for this condition on the basis of the clinical and radiographic findings.

Transient failure of opening of the lower oesophageal sphincter on upright oesophagrams: radiographic and clinical findings.

The purpose of our study was to determine the frequency, radiographic features, and clinical importance of transient failure of opening of the lower oesophageal sphincter (LOS) on upright double-contrast views of the oesophagus. A computerized search of radiology records identified 16 patients who had transient failure of opening of the LOS on upright views from biphasic oesophagrams or upper gastrointestinal tract examinations using high-density barium but normal opening of the LOS on prone views using low-density barium. The radiographic findings were reviewed and correlated with the clinical and manometric findings. In all cases, barium studies revealed tapered, beaklike narrowing of the distal oesophagus on upright double-contrast views, with a normal-appearing distal oesophagus, normal opening of the LOS, and intact peristalsis on prone single-contrast views. Only seven patients (44%) had dysphagia. Five of these patients had clinical follow-up, and the dysphagia improved or resolved without specific treatment for LOS dysfunction in four. The remaining patient had persistent dysphagia, but this individual had polymyositis as the likely cause for his dysphagia. Manometry revealed incomplete relaxation of the LOS in two patients and normal relaxation in one. Our experience suggests that failure of opening of the LOS may be observed as a transient finding of little clinical importance on upright double-contrast views of the oesophagus using high-density barium, with normal opening of the LOS on prone single-contrast views using low-density barium. It is important to be aware of this finding, so that it is not mistaken for achalasia or other abnormalities of the distal oesophagus.

Gastritis from NSAIDS to Helicobacter pylori.

Gastritis is a histologic diagnosis. To understand gastritis, the radiologist must have some working knowledge of gastric histology and pathology. Therefore, this article first describes normal histologic and radiologic anatomy. The pathology of gastritis is then presented to give the radiologist a basis for understanding the radiologic findings. Finally, gastritis is discussed from a clinical and radiologic perspective.

Detection of reflux esophagitis on double-contrast esophagrams and endoscopy using the histologic findings as the gold standard.

The purpose of our study was to determine the accuracy of double-contrast barium studies and endoscopy for detecting reflux esophagitis, using the endoscopic biopsy findings as the gold standard. A review of radiology, endoscopy, and pathology files showed 37 patients with reflux symptoms who underwent double-contrast barium studies and endoscopy with biopsy specimens from the esophagus. The radiographic images were reviewed in a blinded fashion and correlated with the endoscopic and histologic findings to determine the radiographic and endoscopic accuracies for detecting reflux esophagitis, using the endoscopic biopsy specimens as the gold standard. Double-contrast barium studies and endoscopy had low but comparable accuracies for detecting reflux esophagitis, with sensitivities of 35% and 39%, specificities of 79% and 71%, positive predictive values of 73% and 69%, and negative predictive values of 42% and 41%, respectively. When mucosa granularity was evaluated as an individual sign of esophagitis on double-contrast studies, this finding had a sensitivity of 35%, a specificity of 93%, a positive predictive value of 89%, and a negative predictive value of 46% for detecting reflux esophagitis. Our experience suggests that double-contrast barium studies and endoscopy have limited ability to detect reflux esophagitis, in particular mild esophagitis, when using the histologic findings as the gold standard. When radiographic abnormalities are detected, however, mucosal granularity is the single best sign of reflux esophagitis on double-contrast studies.

Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection.

The purpose of this study was to characterize the radiographic findings of antral gastritis and to determine whether there are differences in the appearance of antral gastritis in patients with and without Helicobacter pylori infection. A search of radiology, endoscopy and pathology files revealed 90 patients with antral gastritis on double contrast upper gastrointestinal tract studies who had endoscopy with testing for H. pylori. The barium studies were evaluated to further characterize the findings of antral gastritis without knowledge of the H. pylori status of the patients or of the endoscopy or pathology findings. The radiographic findings of antral gastritis included thickened folds in 67 patients (74%), polypoid antral gastritis (a subset of patients with thickened folds) in 6 (9%), antral erosions in 21 (23%), enlarged areae gastricae in 14 (16%), crenulation of the lesser curvature in 4 (4%), mucosal nodularity in 2 (2%), a hypertrophied antral-pyloric fold in 2 (2%) and antral striae in 1 (1%). 43 patients (48%) with antral gastritis were H. pylori positive and 47 patients (52%) were H. pylori negative. Thickened folds were detected in 39 H. pylori-positive patients (91%) with antral gastritis vs 28 H. pylori-negative patients (60%) (p<0.001); polypoid gastritis in 6 H. pylori-positive patients (14%) vs 0 H. pylori-negative patients (p<0.05); enlarged areae gastricae in 14 H. pylori-positive patients (33%) vs 0 H. pylori-negative patients (p<0.0001); and antral erosions in 2 H. pylori-positive patients (5%) vs 19 H. pylori-negative patients (40%) (p<0.0001). Our experience suggests that antral gastritis caused by H. pylori infection is associated with characteristic features on double contrast studies (including thickened folds, polypoid gastritis and enlarged areae gastricae) and that this condition is rarely associated with antral erosions. Thus, radiologists can often suggest whether the patient's gastritis is caused by H. pylori on the basis of radiographic findings.

Fecal impaction: a cause of isolated small bowel dilatation on abdominal radiographs.

OBJECTIVE: The purpose of this study was to assess the frequency of isolated small bowel dilatation on abdominal radiographs in patients with colonic fecal impaction and also to elucidate the cause of this finding. METHODS: A computerized search of radiology files revealed 515 patients with colonic fecal impaction on abdominal radiographs. The radiologic reports described isolated small bowel dilatation not related to other known causes of ileus or obstruction in 18 (3.5%) of the 515 patients. The films were reviewed to determine the distribution of fecal impaction and the degree and extent of small bowel dilatation. In 16 cases, medical records were reviewed to determine the clinical presentation, treatment, and course. Finally, follow-up radiographs were reviewed in four cases to determine the response to treatment of the impaction. RESULTS: All 16 patients with available medical records had abdominal symptoms. The average diameter of the dilated small bowel on abdominal radiographs was 3.7 cm. Fourteen patients (78%) had a diffuse colonic fecal impaction (nine) or a predominantly right-sided fecal impaction (five) that involved the cecum, and the remaining four (22%) had a left-sided colonic fecal impaction. All 12 patients with clinical follow-up had resolution of symptoms and all four with follow-up radiographs had resolution of small bowel dilatation after treatment of the underlying impaction. CONCLUSION: Fecal impaction should be considered in the differential diagnosis of small bowel dilatation on abdominal radiographs, as treatment of the underlying impaction usually produces a dramatic clinical response with resolution of the small bowel dilatation on follow-up radiographs.

Radiographic findings and complications after surgical or endoscopic repair of Zenker's diverticulum in 16 patients.

OBJECTIVE: The purpose of our study was to reassess the radiographic findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum. MATERIALS AND METHODS: Sixteen patients who underwent various procedures for repair of Zenker's diverticulum (diverticulectomy and cricopharyngeal myotomy in [n = 8], diverticulopexy and cricopharyngeal myotomy [n = 4], endoscopic stapling diverticulotomy [n = 3], and cricopharyngeal myotomy alone [n = 1]) had radiographic studies with water-soluble contrast material, barium, or both during the early postoperative period (n = 7), late postoperative period (n = 4), or both (n = 5). The radiologic reports and images were reviewed to determine the postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum. RESULTS: Radiographic studies revealed leaks during the early postoperative period in three (27%) of 11 patients after surgical repair of Zenker's diverticulum and in zero of three patients after endoscopic diverticulotomy. Pharyngeal dysfunction (pharyngeal paresis, decreased epiglottic tilt, laryngeal penetration, or tracheobronchial aspiration) was detected in seven (54%) of 13 patients after surgery and in one (33%) of three patients after endoscopic diverticulotomy; five of these eight patients had follow-up barium studies during the late postoperative period, and all five showed marked improvement in pharyngeal function. An extrinsic cricopharyngeal impression was detected in six (38%) of these 16 patients, a remnant diverticulum in four (25%), and mucosal beaking in three (19%). A suspended or inverted diverticulum was detected in one of the four patients who underwent surgical diverticulopexy. CONCLUSION: Radiologists should be aware of the various postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum so that appropriate interventions can be taken in patients with this condition.

Visualization of areae gastricae on double-contrast upper gastrointestinal radiography: relationship to age of patients.

OBJECTIVE: The purpose of this study was to determine whether the frequency of visualization of areae gastricae on double-contrast upper gastrointestinal tract examinations is related to a patient's age. MATERIALS AND METHODS: A total of 141 double-contrast upper gastrointestinal tract examinations with normal findings were reviewed for the presence or absence of areae gastricae on double-contrast images of the stomach. All images were evaluated by two radiologists who were blinded to the age of the patients. The data were then analyzed to determine if the frequency of visualization of areae gastricae on double-contrast studies was significantly related to the age of patients. RESULTS: The frequency of visualization of areae gastricae increased significantly with increasing age (p = 0.008). The youngest age group (20--29 years old) exhibited areae gastricae in only four (19%) of 21 cases, whereas the oldest age group (> or = 70 years old) exhibited areae gastricae in 19 (76%) of 25 cases. On average, the rate of visualization of areae gastricae on double-contrast studies increased by 9% per decade. CONCLUSION: Our data show that the frequency of visualization of areae gastricae on double-contrast upper gastrointestinal tract examinations increases significantly with increasing patient age. It is important for radiologists to be aware of the effect of aging on the delineation of areae gastricae on double-contrast studies.

Lymphoid hyperplasia of the stomach: radiographic findings in five adult patients.

OBJECTIVE: The purpose of our study was to report the radiographic findings of biopsy-proven lymphoid hyperplasia of the stomach in five adult patients. CONCLUSION: Lymphoid hyperplasia of the stomach is characterized by distinctive findings on double-contrast upper gastrointestinal tract barium examinations; all five patients had innumerable tiny (1--3 mm in diameter) round frequently umbilicated nodules that carpeted the mucosa of the gastric antrum or antrum and body. Three of these five patients had associated Helicobacter pylori gastritis. The diagnosis of gastric lymphoid hyperplasia, therefore, can be suggested on the basis of the radiographic findings.

Killian-Jamieson diverticula: radiographic findings in 16 patients.

OBJECTIVE: The purpose of this study was to reassess the findings of Killian-Jamieson diverticula (i.e., proximal lateral cervical diverticula) on pharyngoesophagograms and to compare the prevalence, clinical findings, and radiographic findings of Killian-Jamieson diverticula with those of Zenker's diverticulum. MATERIALS AND METHODS: A computerized search of radiology files revealed 16 patients with Killian-Jamieson diverticula and 26 patients with a Zenker's diverticulum. The double-contrast pharyngoesophagograms and medical records were reviewed retrospectively. RESULTS: Only three (19%) of 16 patients with Killian-Jamieson diverticula had symptoms attributable to the diverticula (suprasternal dysphagia in two and cough in one), and none had aspiration pneumonia. In contrast, 16 (62%) of 26 patients with a Zenker's diverticulum had suprasternal dysphagia and three patients (12%) had aspiration pneumonia. Twenty Killian-Jamieson diverticula were detected on pharyngoesophagograms in 16 patients, including 12 (75%) with unilateral left-sided diverticula and four (25%) with bilateral diverticula. The Killian-Jamieson diverticula had an average maximal dimension of 1.4 cm. Zenker's diverticulum was nearly four times as common as Killian-Jamieson diverticula and had an average maximal dimension of 2.5 cm. Three patients (11%) with a Zenker's diverticulum had reflux of barium from the diverticula into the hypopharynx with overflow aspiration. Finally, gastroesophageal reflux was detected in nearly twice as many patients with a Zenker's diverticulum as with Killian-Jamieson diverticula. CONCLUSION: Killian-Jamieson diverticula are less common and smaller than Zenker's diverticulum. Killian-Jamieson diverticula are less likely to cause symptoms and are less likely to be associated with overflow aspiration or gastroesophageal reflux than is Zenker's diverticulum.

Short-segment Barrett's esophagus: findings on double-contrast esophagography in 20 patients.

OBJECTIVE: The purpose of this study was to determine the findings of short-segment Barrett's esophagus on double-contrast esophagography. MATERIALS AND METHODS: A review of pathology and endoscopy data revealed 142 patients with short-segment Barrett's esophagus, which was defined as columnar epithelium in the distal esophagus extending 3 cm or less above the gastroesophageal junction at endoscopy with histopathologic confirmation of intestinal metaplasia. Twenty of these patients underwent double-contrast esophagography. These 20 patients comprised our study group. The original radiology reports and images were reviewed to determine the findings on double-contrast esophagography. Medical records were also reviewed to determine the clinical findings and treatment. RESULTS: Double-contrast esophagrams revealed hiatal hernias in 18 patients (90%), gastroesophageal reflux in 16 (80%), reflux esophagitis in seven (35%), peptic scarring or strictures in 11 (55%), and a reticular mucosal pattern in none. A total of 14 patients (70%) had morphologic findings of reflux disease with esophagitis alone (three patients), peptic scarring or strictures alone (seven patients), or both (four patients), but the remaining six (30%) had hiatal hernias or gastroesophageal reflux as the only radiographic finding. CONCLUSION: Double-contrast esophagography revealed morphologic findings of reflux disease with esophagitis, peptic scarring or strictures, or both in 70% of patients with short-segment Barrett's esophagus. Thus, the absence of esophagitis or peptic scarring or strictures on double-contrast esophagography does not exclude the possibility of short-segment Barrett's esophagus.

Congenital esophageal stenosis in adults: clinical and radiographic findings in seven patients.

OBJECTIVE: The purpose of this study was to determine the clinical and radiographic findings in seven adults with congenital esophageal stenosis. CONCLUSION: In young or middle-aged individuals, particularly men with long-standing dysphagia, an upper or mid esophageal stricture with multiple ringlike constrictions is a characteristic appearance of congenital esophageal stenosis on double-contrast esophagography.

Radiologic and endoscopic diagnosis of Crohn's disease.

This article reviews the radiologic and endoscopic diagnosis of Crohn's disease. Radiographic and endoscopic findings of Crohn's disease are discussed; a practical approach to the selection of radiologic modalities is presented; and the role of endoscopy in diagnosis and treatment is explained.

Cervical esophageal webs: association with gastroesophageal reflux.

BACKGROUND: We investigated whether there is a significant association between cervical esophageal webs and gastroesophageal reflux on pharyngoesophagography. METHODS: We studied 50 patients with cervical esophageal webs on pharyngoesophagrams and 50 control subjects. The control group was matched to the webs group for age, sex, and symptomatology. Patients with cervical esophageal webs and controls were compared to determine the prevalence of gastroesophageal reflux, hiatal hernias, reflux esophagitis, and abnormal esophageal motility. Pearson's chi-square test was used to determine any statistically significant differences in the frequencies of these findings between groups. RESULTS: Thirty-nine (78%) of 50 patients with cervical esophageal webs versus 27 (54%) of 50 patients in the control group had gastroesophageal reflux (p = 0.01). When patients were classified based on degree of gastroesophageal reflux, 22 (44%) of 50 patients with cervical esophageal webs versus 21 (42%) of 50 controls had mild reflux (p = 0.84), whereas 17 (34%) of 50 patients with webs versus six (12%) of 50 controls (p < 0.009) had moderate/marked reflux. Thus, the prevalence of moderate/marked gastroesophageal reflux was significantly greater in patients with webs than in the controls. However, no significant differences were found in the prevalence of mild gastroesophageal reflux, hiatal hernias, reflux esophagitis, or abnormal esophageal motility. CONCLUSION: We found a significant association between cervical esophageal webs and gastroesophageal reflux independent of age, sex, or symptomatology. Radiologists should be aware of this association, so that patients with cervical esophageal webs on pharyngoesophagography are evaluated for gastroesophageal reflux at the time of the barium study or advised to undergo further testing for gastroesophageal reflux disease.

Portal hypertensive gastropathy: radiographic findings in eight patients.

OBJECTIVE: The purpose of our study was to determine the findings of portal hypertensive gastropathy on barium studies in eight patients and whether there are useful radiographic criteria for diagnosing this condition. CONCLUSION: Our experience suggests that portal hypertensive gastropathy may manifest on barium studies as thickened nodular folds in the gastric fundus. Although varices or various forms of gastritis can also produce thickened gastric folds, portal hypertensive gastropathy should be suspected when this finding is detected in patients with known portal hypertension.

Adynamic ileus after caesarean section mimicking intestinal obstruction: findings on abdominal radiographs.

The purpose of this study was to determine the spectrum of findings and the frequency of apparent distal colonic obstruction on abdominal radiographs in women with obstructive symptoms following Caesarean section. A search of radiology files yielded 21 patients who had abdominal radiographs because of obstructive symptoms during the early post-operative period. The radiographs were reviewed retrospectively to characterize the bowel gas patterns in these patients. Medical records were also reviewed to determine the treatment and patient course. Abdominal radiographs showed findings suggestive of distal colonic obstruction in 15 patients (71%), small bowel obstruction in 2 (10%), adynamic ileus in 3 (14%) and a normal bowel gas pattern in 1 (5%). In all 15 patients with apparent distal colonic obstruction, there was minimal or no gas in the rectosigmoid, with an associated pelvic mass representing the enlarged post-partum uterus, which compressed the rectosigmoid and prevented it from filling with gas. All 21 patients had rapid clinical or radiographic improvement on conservative management, indicating a transient post-operative ileus. Radiologists should be aware of the limitations of abdominal plain radiographs following Caesarean section so that a post-operative ileus is not mistaken for a distal colonic obstruction and conservative measures can be undertaken to decompress the bowel until the ileus resolves.