A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group.

BACKGROUND: After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. METHODS: As part of the National Polyp Study, we offered colonoscopic examination and double-contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. Although barium enema was performed first, the endoscopist did not know the results. RESULTS: A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, we performed 862 paired colonoscopic examinations and barium-enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 139 of the 392 colonoscopic examinations in which one or more polyps were detected (rate of detection, 35 percent; 95 percent confidence interval, 31 to 40 percent). The proportion of examinations in which adenomatous polyps were detected by barium enema colonoscopy was significantly related to the size of the adenomas (P=0.009); the rate was 32 percent for colonoscopic examinations in which the largest adenomas detected were 0.5 cm or less, 53 percent for those in which the largest adenomas detected were 0.6 to 1.0 cm, and 48 percent for those in which the largest adenomas detected exceeded 1.0 cm. Among the 139 paired examinations with positive results on barium enema and negative results on colonoscopic examination in the same location, 19 additional polyps, 12 of which were adenomas, were detected on colonoscopic reexamination. CONCLUSIONS: In patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more effective method of surveillance than double-contrast barium enema.

Effect of barium sulfate on wound healing in the gastrointestinal tract of the rat.

PURPOSE: To study the effect of barium sulfate on wound healing in the gastrointestinal tract of the rat. MATERIALS AND METHODS: Sixty rats weighing approximately 320 g were divided into four groups: Fifteen control rats had gastric, small-bowel, and colonic incisions; 15 rats had gastric incision; 15 rats had small-bowel incision; and 15 rats had colonic incision. Barium sulfate was placed into the incision before closure in all rats except those in the control group, and the effects were documented clinically and histopathologically for 3 months. Autopsy was performed in five rats from each group at 1, 4, and 12 weeks. The incisions in the rats receiving barium sulfate were compared with those in the control rats. RESULTS: There was no difference in the clinical course (weight gain, activity, and viability) between the control and experimental groups. Early and late autopsy findings and histopathologic grading of healing and inflammatory response were similar for both the control and experimental groups. CONCLUSION: Under the conditions of this study, the effect of barium sulfate on visceral transmural wound healing in the gastrointestinal tract of the rat was minimal.

Traumatic diaphragmatic injuries: spectrum of radiographic findings.

Traumatic diaphragmatic injuries are usually caused by blunt trauma or penetrating injuries. The diagnosis may be delayed due to confusing clinical and radiographic findings. According to the results of a review of 25 cases, the diagnosis of diaphragmatic injury is more often delayed and requires more imaging studies in cases of blunt trauma than in cases of penetrating injury. Blunt injury is indicated by asymmetry of a hemidiaphragm or changing diaphragmatic levels, abdominal contents within the chest, diaphragmatic paresis, unexplained hemothorax, or multiple upper abdominal injuries. Penetrating injury is indicated by hemothorax or a missile or blade trajectory through or near the diaphragm. Usually, plain radiography shows initial evidence of traumatic diaphragmatic injury and prompts confirmatory imaging, which includes computed tomography, magnetic resonance imaging, barium studies, fluoroscopy, nuclear medicine, and ultrasound. Nevertheless, the diagnosis of traumatic diaphragmatic injury may be elusive and often can be made only during exploratory surgery.

Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise.

Earlier studies have shown that the cross-sectional area of the deglutitive upper esophageal sphincter (UES) opening in healthy asymptomatic elderly individuals is reduced compared with healthy young volunteers. The aim of this study was to determine the effect of a head-raising exercise on swallow-induced UES opening and hypopharyngeal intrabolus pressure in the elderly. We studied a total of 31 asymptomatic healthy elderly subjects by videofluoroscopy and manometry before and after real (19 subjects) and sham (12 subjects) exercises. A significant increase was found in the magnitude of the anterior excursion of the larynx, the maximum anteroposterior diameter, and the cross-sectional area of the UES opening after the real exercise (P < 0.05). These changes were associated with a significant decrease in the hypopharyngeal intrabolus pressure studied in 12 (real-exercise) and 6 (sham-exercise) subjects (P < 0.05). A similar effect was not found in the sham-exercise group. In normal elderly subjects, deglutitive UES opening is amenable to augmentation by exercise aimed at strengthening the UES opening muscles. This augmentation is accompanied by a significant decrease in hypopharyngeal intrabolus pressure, indicating a decrease in pharyngeal outflow resistance. This approach may be helpful in some patients with dysphagia due to disorders of deglutitive UES opening.

Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup.

BACKGROUND: The identification and removal of adenomatous polyps and post-polypectomy surveillance are considered to be important for the control of colorectal cancer. In current practice, the intervals between colonoscopies after polypectomy are variable, often a year long, and not based on data from randomized clinical trials. We sought to determine whether follow-up colonoscopy at three years would detect important colonic lesions as well as follow-up colonoscopy at both one and three years. METHODS: Patients were eligible if they had one or more adenomas, no previous polypectomy, and a complete colonoscopy and all their polyps had been removed. They were randomly assigned to have follow-up colonoscopy at one and three years or at three years only. The two study end points were the detection of any adenoma, and the detection of adenomas with advanced pathological features (defined as those > 1 cm in diameter and those with high-grade dysplasia or invasive cancer). RESULTS: Of 2632 eligible patients, 1418 were randomly assigned to the two follow-up groups, 699 to the two-examination group and 719 to the one-examination group. The percentage of patients with adenomas in the group examined at one and three years was 41.7 percent, as compared with 32.0 percent in the group examined at three years (P = 0.006). The percentage of patients with adenomas with advanced pathological features was the same in both groups (3.3 percent). CONCLUSIONS: Colonoscopy performed three years after colonoscopic removal of adenomatous polyps detects important colonic lesions as effectively as follow-up colonoscopy after both one and three years. An interval of at least three years is recommended before follow-up colonoscopy after both one and three years. An interval of at least three years is recommended before follow-up examination after colonoscopic removal of newly diagnosed adenomatous polyps. Adoption of this recommendation nationally should reduce the cost of post-polypectomy surveillance and screening.

Percutaneous enteral alimentation: gastrostomy versus gastrojejunostomy.

Scintigraphy was used to detect gastroesophageal reflux, determine whether percutaneous gastrostomy (PG) tubes cause reflux, and help in the choice between PG tubes versus percutaneous gastrojejunostomy (PGJ) tubes. During a 2-year period, 46 patients were evaluated with scintigraphy immediately before and 1 week after PG tube placement. Findings in the pre- and postplacement reflux studies were the same in 39 patients (85%). Proof of reflux on either study was considered an indication for conversion to the PGJ tube; at least one study was positive for reflux in 21 patients (46%). All patients were followed up for tube complications, pneumonia, and cause of death. During follow-up, six of 24 patients correctly maintained with PG tubes (25%) and 18 patients with PGJ tubes (39%) developed pneumonia, the cause of death in four of 24 patients with PG tubes (17%) and five of 18 patients with PGJ tubes (28%). The PG tube does not induce reflux, and scintigraphy is useful in selection of patients who can be safely maintained with the PG tube without an increase in the morbidity or mortality associated with reflux and aspiration.

Filling defects in the pancreatic duct on endoscopic retrograde pancreatography.

Filling defects in the pancreatic duct are a frequent finding during endoscopic retrograde pancreatography (ERP) and have a variety of causes. Some filling defects may be artifactual or related to technical factors and, once their origin is recognized, can be disregarded. Others may be due to acute changes of pancreatitis and should prompt more careful injection of contrast material into the duct. Intraluminal masses may represent calculi or a neoplasm, either of which may require surgery or endoscopic intervention. The exact nature of these filling defects may not be apparent on radiographs, and other studies may be needed. This article reviews our approach to the evaluation of filling defects in the pancreatic duct.

The National Polyp Study. Design, methods, and characteristics of patients with newly diagnosed polyps. The National Polyp Study Workgroup.

The National Polyp Study (NPS) is a multicenter prospective randomized trial designed to evaluate follow-up surveillance strategies in patients who have undergone polypectomy for the control of large bowel cancer. The study design was developed by a joint research committee from American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, and the American College of Gastroenterology. Subjects who met the eligibility criteria were randomized into two different treatment arms. Eligibility criteria included: removal of one or more adenomas; complete colonoscopy; no prior polypectomy, inflammatory bowel disease, or familial polyposis; and no history of colon cancer. The treatment arms consisted of a frequent follow-up (1 and 3 years after initial polypectomy) and a less frequent follow-up (3 years). Follow-up examinations included fecal occult blood tests, air-contrast barium enema, and colonoscopy. The latter was done on 9112 referred patients at the seven participating centers from November 1980 until February 1990 who had no history of polypectomy, colon cancer, familial polyposis, or inflammatory bowel disease. Of these patients, 4763 (52.3%) had no polyps; 549 (6.0%) had an invasive cancer; 776 (8.5%) had nonadenomatous polyps; 208 (2.3%) had incomplete examinations; 184 (2.0%) had other findings; and 2632 (28.9%) had one or more adenomas, of which 1418 (53.9%) were randomized to one of the two treatment arms. This article reports the background, rationale, objectives, methods, and organization of this study and includes patient characteristics on initial presentation. Future data provided by the NPS may help in the development of recommendations for surveillance guidelines for such patients. This study also provides a framework to address questions regarding the natural history of adenomas and their relationship with colorectal cancer.

CT of acquired abnormalities of the spleen.

Imaging considerations and features when assessing acquired abnormalities of the spleen with CT are described. Indexes of normal size and the implications of splenomegaly are discussed, as well as the CT appearances and types of neoplasia, cysts, traumatic injuries, infarction, and inflammatory changes.

Pharynx: value of oblique projections for radiographic examination.

The utility of oblique views for augmenting standard posteroanterior and lateral double-contrast radiography of the pharynx was examined. Over an 8-month period, two oblique views were added to the standard posteroanterior and lateral views of the pharynx during routine upper gastrointestinal studies in 102 patients divided into two groups. Group 1 consisted of 81 patients without suspected pharyngeal or esophageal disease who demonstrated what was considered to be normal anatomy on all radiographic views. Group 2 consisted of 21 patients who were known or suspected to have pathologic abnormality of the pharynx. The members of this latter group each demonstrated various abnormal pharyngeal anatomy on the standard views. In just over half of these cases the oblique projection contributed significant information not obtained with conventional views. Therefore, the authors conclude that oblique images are a beneficial addition to the diagnostic evaluation of patients highly suspected of having pharyngeal disease.

Gastrointestinal lipomas: a radiologic and pathologic review.

Lipomas of the gastrointestinal tract are an infrequent finding on radiologic examination; however, they occur often enough to warrant consideration in the differential diagnosis of mass lesions of the gut. In many instances, their morphologic characteristics allow the specific diagnosis of a lipoma. In this report, we review gastrointestinal lipomas with an emphasis on their radiologic and pathologic correlation.

Radiologic imaging of splenic anomalies.

Knowledge of the anatomy, embryology, and congenital anomalies of the spleen is needed in order to avoid pitfalls in the interpretation of abdominal imaging studies such as CT and sonography. For this reason, this pictorial essay illustrates the anatomy, embryology, and radiologic images of congenital anomalies of the spleen.

Display of CT studies on a two-screen electronic workstation versus a film panel alternator: sensitivity and efficiency among radiologists.

Prototype electronic workstations incorporated in networks linking computed tomographic (CT) and magnetic resonance imaging systems are being developed. The authors compared observer efficiency and sensitivity in reading body CT studies from a two-screen workstation (1,000-line monitors and 12-bit dynamic range in image memory) and conventional film panel alternator. The two-screen workstation displayed 32 images at a matrix resolution of 256 x 256 or eight images at a matrix resolution of 512 x 512 simultaneously. Ninety-six images with a matrix resolution of 512 x 512 could be displayed simultaneously at the film panel alternator. Four observers read images from 20 cases, 10 with repeat examinations, in a randomized viewing sequence. There was an average of 32 images per case. Reporting time was less with the film panel alternator (average, 5.08 minutes) than with the workstation (average, 6.66 minutes). There was improved sensitivity for all observers in reading from the film panel alternator (range, 1%-12%) (P less than .05). In complex cases evaluated by means of body CT, the current prototype two-screen electronic workstation is limited by display capabilities.