Value of barium studies for predicting primary versus secondary non-Hodgkin's gastrointestinal lymphoma.

BACKGROUND: To determine the predictive value of a single lesion versus multifocal disease for differentiating primary and secondary gastrointestinal (GI) lymphoma on barium studies. METHODS: Our study group consisted of 90 cases of non-Hodgkin's GI lymphoma from the radiologic archives of the Armed Forces Institute of Pathology in which barium studies had been performed. Each of those studies was reviewed jointly by two of the authors to determine in a blinded fashion whether the patients had a single lesion or multifocal disease (defined as two or more discrete lesions). Medical and pathologic records were then reviewed to determine whether these patients had primary (defined as lymphoma arising in the GI tract) or secondary (defined as disseminated lymphoma with associated GI tract involvement) GI lymphoma. The final clinical diagnosis was then correlated with the radiographic findings to test the hypothesis that a single lesion is more likely to be associated with primary GI lymphoma and that multifocal disease is more likely to be associated with secondary GI lymphoma. RESULTS: Sixty-eight patients had a single lesion in the GI tract on barium studies; 52 (76%) of these patients had primary GI lymphoma and 16 (24%) had secondary GI lymphoma. Another 22 patients had multifocal disease on barium studies; 20 (91%) of these patients had secondary GI lymphoma and two (9%) had primary GI lymphoma. CONCLUSION: The predictive value of a single lesion for primary GI lymphoma on barium studies was 76%, and the predictive value of multifocal disease for secondary GI lymphoma was 91%. Thus, our data suggest that it is often possible to differentiate these two forms of GI lymphoma on the basis of the radiographic findings.

Diagnosis of colorectal neoplasms at double-contrast barium enema examination.

The double-contrast barium enema examination has been recognized as an option for colorectal cancer screening in Americans with average risk who are greater than 50 years of age. The purpose of this article is to review the principles for diagnosing colorectal neoplasms on double-contrast images and the spectrum of findings associated with these lesions. Colonic polyps can be sessile or pedunculated; their appearance depends on whether they are located on the dependent or nondependent wall of the bowel. Villous tumors may be flat, lobulated lesions, also known as "carpet" lesions, that are characterized by a finely nodular or reticular surface pattern, without a discrete mass. Colonic carcinomas may manifest as plaquelike, polypoid, semiannular ("saddle") or annular lesions. Colonic neoplasms sometimes are more difficult to detect in the region of the ileocecal valve or the distal rectum or in patients with severe diverticulosis. Careful double-contrast technique and meticulous scrutiny of the images therefore are required to optimize detection of these lesions.

Double-contrast barium enema examination technique.

This review article presents the principles for performing a safe, comfortable, and accurate double-contrast barium enema examination. The procedure is a flexible examination in which the fluoroscopist interacts with the patient, the controls of the fluoroscope, and the image on the television monitor. During a double-contrast examination, images of the colon are created by manipulating the patient, the barium pool, and the amount of air insufflated into the rectum. Fluoroscopy is essential for guiding the radiologist to obtain spot images with adequate technical factors. The fluoroscopist analyzes the luminal contour, the barium-coated mucosal surface en face, and the barium pool to detect abnormalities in the colon. With careful technique, a high-quality examination can be performed in most patients.

Ileal endometriosis: radiographic findings in five cases.

PURPOSE: To determine the radiographic findings in five patients with ileal endometriosis. MATERIALS AND METHODS: A search of radiology files revealed five patients with surgically proved endometriotic implants in the ileum at enteroclysis (three patients), at small-bowel follow-through (one patient), and at double-contrast barium enema study (one patient). The radiographic findings were reviewed retrospectively. Clinical, surgical, and histopathologic findings were also reviewed. RESULTS: All five patients were nulliparous women (mean age, 34.4 years; age range, 28-41 years). Four patients presented with abdominal and/or pelvic pain, but only one of these four had cyclic pain that coincided with menstruation. Barium studies revealed endometriotic implants in the terminal ileum within 10 cm of the ileocecal valve in four patients and in the mid-ileum in one. The radiographic findings consisted of extrinsic mass effect with variable spiculation and tethering of folds in two patients, annular lesions with spiculated folds and abrupt or tapered borders in two, and a plaque-like lesion in one. In four patients who underwent double-contrast barium enema studies, associated endometriotic implants were found in the rectosigmoid colon. CONCLUSION: Ileal endometriosis usually involves the terminal ileum within 10 cm of the ileocecal valve and manifests as a spectrum of findings on barium studies. Ileal endometriosis should therefore be considered when these findings are present in young, nulliparous women with abdominal or pelvic pain.

Gastric mucosa-associated lymphoid tissue lymphoma: radiographic findings in six patients.

PURPOSE: To determine the radiographic findings of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma on double-contrast upper gastrointestinal studies. MATERIALS AND METHODS: Pathology records, double-contrast upper gastrointestinal studies, and medical records of six patients with gastric MALT lymphoma were retrospectively reviewed. RESULTS: The most common clinical findings at presentation included epigastric pain (n = 6), dyspepsia (n = 4), and nausea and vomiting (n = 4). Double-contrast studies revealed rounded, often confluent nodules of varying size in four patients with low-grade MALT lymphoma. Nodularity was located in the gastric antrum (n = 2), body (n = 1), or body and fundus (n = 1). A fifth patient had a malignant-appearing 1-cm-diameter antral ulcer, and a sixth had a 10-cm-diameter polypoid, ulcerated mass in the gastric fundus. The latter patient was found to have high-grade MALT lymphoma with low-grade MALT lymphoma abutting the tumor. Five patients had associated Helicobacter pylori gastritis. Five patients had stage I disease, and one had stage IIB disease. At endoscopic follow-up (n = 4), marked regression of tumor occurred after treatment with antibiotics, chemotherapy, and/or radiation therapy. CONCLUSION: When low-grade MALT lymphoma is suspected on the basis of barium study results, endoscopic biopsy specimens should be obtained for a definitive diagnosis so these patients can be treated before the development of high-grade gastric lymphoma.

Carcinoma of the esophagus and esophagogastric junction: sensitivity of radiographic diagnosis.

OBJECTIVE: The purpose of this study was to determine the sensitivity of barium studies in revealing carcinoma of the esophagus and esophagogastric junction. MATERIALS AND METHODS: We retrospectively reviewed 50 cases of squamous cell carcinoma of the esophagus (n = 25) and adenocarcinoma of the esophagus (n = 14) or esophagogastric junction (n = 11) in which double-contrast (n = 46) or single-contrast (n = 4) barium studies had been done. The original radiology reports were reviewed to determine whether the lesions had been seen on barium studies and whether cancer had been diagnosed. Records were also reviewed to determine the number of patients who underwent esophageal endoscopy because of findings suggestive of cancer on barium studies at some point from January 1992 through December 1992. Pathology records were then reviewed to determine the number of true- and false-positive barium studies during this same period. RESULTS: Lesions were shown on barium studies in 49 (98%) of 50 patients, and carcinoma of the esophagus or esophagogastric junction was diagnosed or suspected in 48 patients (96%). In a separate part of the study, we found that endoscopy had been recommended to rule out malignant tumor in only 26 (1%) of 2484 patients who underwent barium studies at some point from January 1992 through December 1992. Endoscopy revealed cancer in 11 of those 26 patients; the remaining 15 were assumed to have false-positive radiologic examinations. Barium studies therefore had a positive predictive value of 42%. CONCLUSION: The double-contrast barium study is a sensitive technique for the diagnosis of carcinoma of the esophagus and esophagogastric junction. This high sensitivity can be achieved while recommending endoscopy in only about 1% of all patients who undergo barium studies.

Ectopic pancreas complicated by pancreatitis and pseudocyst formation mimicking jejunal diverticulitis.

Clinical symptoms are rarely produced by ectopic pancreas arising in the jejunum. We report a case of a patient with left lower quadrant abdominal pain due to jejunal ectopic pancreas complicated by acute pancreatitis and pseudocyst formation.

Colon cancer: morphology detected with barium enema examination versus histopathologic stage.

PURPOSE: To determine the relationship between the morphology of colon carcinomas detected with barium enema examination and the cancer stage. MATERIALS AND METHODS: Clinical, radiographic, endoscopic, surgical, and histopathologic findings were retrospectively reviewed in 152 patients with colon cancer detected with barium enema examination during a 2-year period. RESULTS: Eighty-six patients (57%) had lesions in the rectum and sigmoid and descending colon, and 66 (43%) patients had lesions more proximally in the colon. Lesions on the right side of the colon were less likely to cause symptoms than those on the left side. Eighty-one patients (53%) had annular or semiannular lesions, 57 (38%) had polypoid lesions, and 14 (9%) had plaquelike or carpet lesions. Six patients (4%) had Dukes stage A lesions; 84 (55%), Dukes stage B lesions; 42 (28%), Dukes stage C lesions; and 20 (13%), Dukes stage D lesions. CONCLUSION: Annular or semiannular carcinomas had higher rates of serosal invasion and lymph node metastasis than polypoid carcinomas, but the rates of liver metastases were comparable.

Guide to imaging of the small bowel.

The small intestine is a difficult organ to image. Its considerable length, the changing location of its many overlapping coils, and the often adverse effect of luminal fluids on the coating ability of barium necessitate the use of special techniques employing special barium formulations.

Helicobacter pylori gastritis: radiographic findings.

PURPOSE: To determine whether there are useful radiographic criteria for diagnosing Helicobacter pylori. MATERIALS AND METHODS: Radiographs from double-contrast upper gastrointestinal examinations of 88 patients with H pylori and 41 control subjects were blindly reviewed. The results were analyzed by means of receiver operating characteristic (ROC) curves. RESULTS: Thickened gastric folds were detected in 39 patients with H pylori (44%) and nine control subjects (22%). The area under the ROC curve was 0.62 (standard deviation [SD] = 0.05, P < .01). Among the 48 subjects with thickened gastric folds, polypoid gastritis with thickened, lobulated folds was detected in 24 patients with H pylori (62%) and four control subjects (44%). The area under the ROC curve was 0.59 (SD = 0.05, P < .01). No substantial differences were observed in the frequencies of gastric ulcers, erosive gastritis, gastric narrowing, duodenal ulcers, duodenitis, and duodenal narrowing in patients with and without H pylori. CONCLUSION: The presence of thickened gastric folds was the best radiographic criterion for differentiating subjects with from those without H pylori.

Giant ulcers of the esophagus in patients with human immunodeficiency virus: clinical, radiographic, and pathologic findings.

PURPOSE: To determine the causes of giant esophageal ulcers in patients with human immunodeficiency virus (HIV) and whether clinical or radiographic criteria can be used to differentiate the infections that cause these ulcers. MATERIALS AND METHODS: From January 1990 through December 1993, giant esophageal ulcers ( > or = 1 cm in diameter) were found in 21 HIV-positive patients (19 men and two women 23-66 years of age; mean, 39 years). The radiographic findings were reviewed and correlated with clinical, endoscopic, and pathologic findings. RESULTS: In 16 patients, the ulcers were caused by HIV, in three by cytomegalovirus (CMV), and in two by CMV and HIV. The clinical and radiographic findings were the same for the two types of ulcers. However, HIV ulcers responded to treatment with steroids, and CMV ulcers responded to treatment with ganciclovir. CONCLUSION: It is not possible to differentiate HIV from CMV ulcers on the basis of clinical or radiographic criteria; thus, endoscopy is necessary for a definitive diagnosis.

Enteroclysis in the evaluation of obscure gastrointestinal bleeding.

OBJECTIVE: The diagnostic yield of enteroclysis was retrospectively evaluated for patients with obscure bleeding from the gastrointestinal tract. MATERIALS AND METHODS: A total of 128 patients with obscure gastrointestinal bleeding were referred to our department for enteroclysis between 1988 and 1993. The original radiologic reports were reviewed to determine the radiographic findings in these patients. The radiographic findings then were correlated with medical, surgical, and pathologic findings. RESULTS: Thirty-two patients had lesions found at enteroclysis. Nineteen of those patients had confirmation of the radiographic diagnosis, primarily by pathologic examination of the surgical specimen. Five other patients were found at surgery to have had false-positive diagnoses at enteroclysis. Eight patients ceased to bleed without pathologic corroboration, but their clinical presentation and course supported the radiographic diagnosis. Thus, 27 (21%) of the 128 patients had confirmed or highly probable lesions seen at enteroclysis as the cause of obscure gastrointestinal bleeding. Seventeen patients (13%) had tumors involving the small bowel, and three (2%) had arteriovenous malformations in the jejunum. CONCLUSION: This study corroborates earlier reports that enteroclysis is a useful diagnostic test for examining the small intestine in patients with obscure gastrointestinal bleeding.

Diagnosis of gastric carcinoma: sensitivity of double-contrast barium studies.

OBJECTIVE: This study was undertaken to determine if the double-contrast upper gastrointestinal examination is a sensitive technique for diagnosing gastric carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the radiographs of 80 patients with pathologically proved gastric carcinoma who had double-contrast barium studies of the upper gastrointestinal tract between 1985 and 1992. The original radiologic reports were also reviewed to determine if the lesions had been detected on radiographic studies and if a diagnosis of gastric carcinoma had been made or suspected on the basis of the results. Subsequently, radiologic records were reviewed to identify all patients who had double-contrast studies during a recent 1-year period for whom endoscopy was recommended for evaluation of possibly malignant lesions. Pathologic records were also reviewed to determine the number of true-positive and false-positive cases in this group. RESULTS: The lesions were detected radiographically in all 80 patients. In one case, however, the lesion had been missed on another barium study 2 years earlier, so that we actually detected 79 (99%) of the 80 gastric carcinomas. Malignant neoplasm was diagnosed or suspected in 77 cases (96%). In two of the three cases in which gastric carcinoma was not mentioned in the radiologic reports, the lesion caused gastric outlet obstruction. A separate 1-year retrospective review revealed that only 54 (3.5%) of 1546 patients who had double-contrast studies during this period were referred for endoscopy because of radiographic findings that were equivocal or suggestive of tumor. The presence of gastric carcinoma was confirmed by endoscopy or surgery in 10 (19%) of those 54 patients. CONCLUSION: Our findings indicate that the double-contrast upper gastrointestinal examination is a sensitive technique for the diagnosis of gastric carcinoma. Furthermore, a high sensitivity can be achieved without having an inordinate number of patients undergo unnecessary endoscopy.

Polypoid lesions at the anorectal junction: barium enema findings.

Although the anorectal junction is easily accessible, this area may be difficult to evaluate both radiologically and endoscopically because it is relatively collapsed. This pictorial essay illustrates the barium enema radiographic findings and reviews the radiologic and endoscopic pitfalls in the diagnosis of lesions of the anorectal junction.