Clinical Impact of the Introduction of Pediatric Intussusception Air Enema Reduction Technology in a Low- to Middle-Income Country Using Low-Cost Simulation-Based Medical Education.

INTRODUCTION: Pediatric intussusception is a common cause of bowel obstruction in infants. Air enema (AE) reduction is routine first-line management in many countries; however, there is a high rate of operative intervention in low- and middle-income countries. The aims of the study were to use simulation-based medical education with an intussusception simulator to introduce AE reduction to Myanmar and to assess its effect on provider behaviors and the resulting clinical care. METHODS: Clinical evaluation was conducted by comparing clinical outcomes data for children with intussusception 12 months before implementation with that from 12 months subsequent to implementation. These included the following: AE success rates, recurrence rates, length of stay, intestinal resection, and operative intervention rates. An educational workshop was developed that used a low-cost mannequin to facilitate practice at the reduction of intussusception using AE. Curriculum evaluation was performed through 5-point rating scale self-assessment in several domains. Data analysis was performed with Mann-Whitney U test, Student t test, or Wilcoxon signed-ranks test as appropriate; a P value of less than 0.05 was considered to be significant. RESULTS: After implementation, there was a significant reduction in the overall operative intervention rates [82.5% (85/103) vs. 58.7% (44/75), P = 0.006]. Intestinal resection rates increased [15.3% (13/85) vs. 35.9% (14/39), P = 0.02]. The success rate with attempted AE reduction was 94.4% (34/36), with a recurrence rate of 5.6% (2/36). The simulation-based medical education workshop was completed by 25 local participants. There was a significant difference in the confidence of performing (1.9 vs. 3.6, P ≤ 0.0001) or assisting (2.8 vs. 3.7, P = 0.018) an AE reduction before and after the workshop. CONCLUSIONS: Simulation-based educational techniques can be successfully applied in a low- and middle-income country to facilitate the safe introduction of new equipment and techniques with significant beneficial impact on provider behaviors and the resulting clinical care.

[Recurrence of uncomplicated intestinal intussusception. Can it be treated as an outpatient?] / Recurrencia de la invaginación intestinal no complicada. ¿Es posible el manejo ambulatorio?

OBJECTIVES: To estimate the recurrence rate of intussusception after successful enema reduction and to analyze the costs of hospital admission with the current management of this pathology. MATERIAL AND METHODS: A retrospective study over 5 years of 97 patients with confirmed diagnosis of intussusception was undertaken. Medical records were evaluated for patient demographic, clinical and radiological data. Patients with enema-reduced intussusception were selected and data respecting to timing and outcome of recurrences, and length of stay were analyzed. Recurrence was defined as a new episode of intussusception within 72 hours of the initial presentation. Costs were calculated using hospital-specific data. RESULTS: During the study period there were 81/97 children with successful enema reduction. Mean length of stay was 35 hours in the conservative treatment group. There were 8 episodes of recurrence, 5 of them within the first 24 hours (6.17%), for an overall recurrence rate of 9.88%. 7 children were treated by repeated enema and only one patient needed surgery for persistent illness. Assuming the overall recurrence rate of 9.88%, it would require hospitalizing 16 patients to identify a single recurrence with a cost of 1,723.75 € per patient. CONCLUSIONS: Given the low recurrence rate for enema-reduced intussusception and the possibility of repeated enema for their treatment in most of recurrences, we strongly advocated for the outpatient management as a safe and cost-effective alternative.

OBJETIVOS: Estimar la tasa de recurrencia en la invaginación intestinal tras reducción con hidroenema. Analizar los costes de estancia hospitalaria según el manejo actual de esta patología. MATERIAL Y METODOS: Estudio retrospectivo de los 97 pacientes con diagnóstico ecográfico de invaginación intestinal en los últimos 5 años. Revisamos datos demográficos, clínicos y ecográficos. Seleccionamos los casos tratados de forma conservadora, analizando las recurrencias, su tratamiento y la estancia hospitalaria. Consideramos recurrencia a un nuevo episodio de invaginación intestinal en las siguientes 72 horas a la reducción. Los costes fueron calculados según los grupos relacionados por diagnóstico en base a datos específicos del centro. RESULTADOS: En los 81/97 (83,5%) pacientes con tratamiento conservador se diagnosticaron 8 episodios de recurrencia, 5 en las primeras 24 horas. En 7 casos se resolvió la recurrencia con hidroenema, mientras que 1 requirió tratamiento quirúrgico por recidivas persistentes. La media de estancia hospitalaria fue de 35 horas en el grupo de tratamiento conservador (81/97 pacientes). La tasa global de recurrencia fue del 9,88%, (6,17% antes de 24 horas), siendo necesario el ingreso de 16 pacientes para el diagnóstico de un caso de recurrencia en las primeras 24 horas. Según estos resultados, y los costes hospitalarios/24 horas, el manejo ambulatorio supondría un ahorro de 1.723,75 €/paciente. CONCLUSIONES: Dado que el riesgo de recurrencia en la invaginación intestinal no complicada es bajo y su tratamiento es conservador en la mayoría de los casos, estaría justificada la implantación de un protocolo de manejo ambulatorio como alternativa segura y costo-efectiva.

Oral 5-Aminosalicylate, Mesalamine Suppository, and Mesalamine Enema as Initial Therapy for Ulcerative Proctitis in Clinical Practice with Quality of Care Implications.

Background. Ulcerative proctitis (UP) is typically treated initially with oral 5-aminosalicylate ("5-ASA"), mesalamine suppository, or mesalamine enema ("UP Rx"). Little is known about their effectiveness in practice. Methods. Using a US health insurance database, we identified new-onset UP patients between January 1, 2005, and December 31, 2007, based on the following: (1) initiation of UP Rx; (2) endoscopy in prior 30 days resulting in diagnosis of UP; and (3) no prior encounters for ulcerative colitis or Crohn's disease. We examined the incidence of therapy escalation and total costs in relation to initial UP Rx. Results. We identified 548 patients: 327 received mesalamine suppository, 138 received oral 5-ASA, and 83 received mesalamine enema, as initial UP Rx. One-third receiving oral 5-ASA experienced therapy escalation over 12 months, 21% for both mesalamine suppository and enema. Mean cumulative total cost of UP Rx over 12 months was $1552, $996, and $986 for patients beginning therapy with oral 5-ASA, mesalamine enema, and mesalamine suppository, respectively. Contrary to expert recommendations the treatments were often not continued prophylactically. Conclusions. Treatment escalation was common, and total costs of therapy were higher, in patients who initiated treatment with oral 5-ASA. Further study is necessary to assess the significance of these observations.

MR colonography with a fecal tagging technique and water-based enema for the assessment of inflammatory bowel disease.

PURPOSE: To assess the usefulness of MR colonography (MRC) with a fecal tagging technique and water-based enema in patients with inflammatory bowel disease (IBD). MATERIALS AND METHODS: Twenty-two patients with suspected or known IBD underwent MRC with a 1.5-T MR system (Siemens Symphony) using a phased-array coil. A fecal tagging technique was performed by oral administration of dense barium sulfate (200 ml) at major meals starting 2 days before the MRI. After a water enema (2000-2500 ml), the MR protocol was carried out, starting with HASTE and true-FISP sequences. Coronal T1w 3D VIBE (2.0 mm thick) was obtained before and 60 s after intravenous administration of Gd chelate. MR images were evaluated by consensus agreement of two observers in terms of image quality and by searching for bowel abnormalities. MRC findings were correlated with our gold standard-conventional colonoscopy (incomplete in 6/22 patients) with histopathological analysis, and surgery (performed in 8/22 subjects). RESULTS: The MR imaging protocol was completed in all of the investigated subjects. In terms of image quality, 128 out of 132 colon segments (97 %) were considered diagnostic on MR examinations by the two reviewers; signs of bowel inflammation were identified in 74 and 72 % of colon segments of patients with ulcerative colitis (n = 6) and Crohn's disease (n = 15), respectively. In 13/15 patients with Crohn's disease, involvement of both the large and small bowel was demonstrated on MR imaging; perianal abscesses and fistulas were also identified in 2 and 3 of these patients, respectively. In one patient with normal MRC, a diagnosis of IBD could not be confirmed. CONCLUSION: MRC with a fecal tagging technique and water-based enema is a promising minimally invasive technique for evaluating the bowel in patients with a suspected or established diagnosis of IBD.

Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials).

BACKGROUND: Computed tomographic colonography (CTC) is a relatively new diagnostic test that may be superior to existing alternatives to investigate the large bowel. OBJECTIVES: To compare the diagnostic efficacy, acceptability, safety and cost-effectiveness of CTC with barium enema (BE) or colonoscopy. DESIGN: Parallel randomised trials: BE compared with CTC and colonoscopy compared with CTC (randomisation 2 : 1, respectively). SETTING: A total of 21 NHS hospitals. PARTICIPANTS: Patients aged ≥ 55 years with symptoms suggestive of colorectal cancer (CRC). INTERVENTIONS: CTC, BE and colonoscopy. MAIN OUTCOME MEASURES: For the trial of CTC compared with BE, the primary outcome was the detection rate of CRC and large polyps (≥ 10 mm), with the proportion of patients referred for additional colonic investigation as a secondary outcome. For the trial of CTC compared with colonoscopy, the primary outcome was the proportion of patients referred for additional colonic investigation, with the detection rate of CRC and large polyps as a secondary outcome. Secondary outcomes for both trials were miss rates for cancer (via registry data), all-cause mortality, serious adverse events, patient acceptability, extracolonic pathology and cost-effectiveness. RESULTS: A total of 8484 patients were registered and 5384 were randomised and analysed (BE trial: 2527 BE, 1277 CTC; colonoscopy trial: 1047 colonoscopy, 533 CTC). Detection rates in the BE trial were 7.3% (93/1277) for CTC, compared with 5.6% (141/2527) for BE (p = 0.0390). The difference was due to better detection of large polyps by CTC (3.6% vs. 2.2%; p = 0.0098), with no significant difference for cancer (3.7% vs. 3.4%; p = 0.66). Significantly more patients having CTC underwent additional investigation (23.5% vs. 18.3%; p = 0.0003). At the 3-year follow-up, the miss rate for CRC was 6.7% for CTC (three missed cancers) and 14.1% for BE (12 missed cancers). Significantly more patients randomised to CTC than to colonoscopy underwent additional investigation (30% vs. 8.2%; p < 0.0001). There was no significant difference in detection rates for cancer or large polyps (10.7% for CTC vs. 11.4% for colonoscopy; p = 0.69), with no difference when cancers (p = 0.94) and large polyps (p = 0.53) were analysed separately. At the 3-year follow-up, the miss rate for cancer was nil for colonoscopy and 3.4% for CTC (one missed cancer). Adverse events were uncommon for all procedures. In 1042 of 1748 (59.6%) CTC examinations, at least one extracolonic finding was reported, and this proportion increased with age (p < 0.0001). A total of 149 patients (8.5%) were subsequently investigated, and extracolonic neoplasia was diagnosed in 79 patients (4.5%) and malignancy in 29 (1.7%). In the short term, CTC was significantly more acceptable to patients than BE or colonoscopy. Total costs for CTC and colonoscopy were finely balanced, but CTC was associated with higher health-care costs than BE. The cost per large polyp or cancer detected was £4235 (95% confidence interval £395 to £9656). CONCLUSIONS: CTC is superior to BE for detection of cancers and large polyps in symptomatic patients. CTC and colonoscopy detect a similar proportion of large polyps and cancers and their costs are also similar. CTC precipitates significantly more additional investigations than either BE or colonoscopy, and evidence-based referral criteria are needed. Further work is recommended to clarify the extent to which patients initially referred for colonoscopy or BE undergo subsequent abdominopelvic imaging, for example by computed tomography, which will have a significant impact on health economic estimates. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95152621.

CT colonography for investigation of patients with symptoms potentially suggestive of colorectal cancer: a review of the UK SIGGAR trials.

This paper argues for the use of CT colonography (CTC) to investigate patients with symptoms potentially suggestive of colorectal cancer. It describes the rationale for the UK Special Interest Group in Gastrointestinal and Abdominal Radiology (SIGGAR) randomised controlled trials that compared CTC with barium enema (BE) or colonoscopy for diagnosis of colorectal cancer or large polyps in symptomatic patients. Diagnostic outcomes from the trials are detailed for both intra- and extracolonic disease, along with psychological reactions of patients to the tests, and cost-effectiveness of the different diagnostic strategies. The author concludes that BE should be replaced by CTC immediately and that CTC is a sensitive, acceptable and equally cost-effective alternative to colonoscopy in patients in whom colonoscopy is contraindicated or undesirable.

Computed tomographic colonography versus barium enema for diagnosis of colorectal cancer or large polyps in symptomatic patients (SIGGAR): a multicentre randomised trial.

BACKGROUND: Barium enema (BE) is widely available for diagnosis of colorectal cancer despite concerns about its accuracy and acceptability. Computed tomographic colonography (CTC) might be a more sensitive and acceptable alternative. We aimed to compare CTC and BE for diagnosis of colorectal cancer or large polyps in symptomatic patients in clinical practice. METHODS: This pragmatic multicentre randomised trial recruited patients with symptoms suggestive of colorectal cancer from 21 UK hospitals. Eligible patients were aged 55 years or older and regarded by their referring clinician as suitable for radiological investigation of the colon. Patients were randomly assigned (2:1) to BE or CTC by computer-generated random numbers, in blocks of six, stratified by trial centre and sex. We analysed the primary outcome-diagnosis of colorectal cancer or large (≥10 mm) polyps-by intention to treat. The trial is an International Standard Randomised Controlled Trial, number 95152621. FINDINGS: 3838 patients were randomly assigned to receive either BE (n=2553) or CTC (n=1285). 34 patients withdrew consent, leaving for analysis 2527 assigned to BE and 1277 assigned to CTC. The detection rate of colorectal cancer or large polyps was significantly higher in patients assigned to CTC than in those assigned to BE (93 [7.3%] of 1277 vs 141 [5.6%] of 2527, relative risk 1.31, 95% CI 1.01-1.68; p=0.0390). CTC missed three of 45 colorectal cancers and BE missed 12 of 85. The rate of additional colonic investigation was higher after CTC than after BE (283 [23.5%] of 1206 CTC patients had additional investigation vs 422 [18.3%] of 2300 BE patients; p=0.0003), due mainly to a higher polyp detection rate. Serious adverse events were rare. INTERPRETATION: CTC is a more sensitive test than BE. Our results suggest that CTC should be the preferred radiological test for patients with symptoms suggestive of colorectal cancer. FUNDING: NIHR Health Technology Assessment Programme, NIHR Biomedical Research Centres funding scheme, Cancer Research UK, EPSRC Multidisciplinary Assessment of Technology Centre for Healthcare, and NIHR Collaborations for Leadership in Applied Health Research and Care.

Intussusception in children: cost-effectiveness of ultrasound vs diagnostic contrast enema.

PURPOSE: The aim of the study was to compare the cost-effectiveness of different imaging strategies for the diagnosis of pediatric intussusception using a decision analytic model. METHODS: A Markov decision model was constructed to model effects of radiation exposure at the time of intussusception in a hypothetical cohort of 2-year-old children. The 2 strategies compared were ultrasound followed conditionally by contrast enema (US/CE) vs contrast enema (CE) alone. The model simulated short-term and long-term outcomes of the patients, calculating the average quality-adjusted life years (QALYs) and health care costs associated with each arm. RESULTS: The use of ultrasound as a first-line diagnostic modality would result in a decrease of 79.3 and 59.7 cases of radiation-induced malignancy per 100,000 male and female children evaluated, respectively. For male and female children with intussusception, US/CE was both the most costly initial imaging strategy and the most effective compared with CE. The incremental cost-effectiveness ratios of US/CE to CE was $70,100 (boy) and $92,227 (girl) per quality-adjusted life years gained. CONCLUSIONS: In a Markov decision model of pediatric acute intussusception, initial US/CE was both the most costly and the most effective strategy.

Barium meal follow through with pneumocolon: screening test for chronic bowel pain.

AIM: To study the sensitivity, specificity and cost effectiveness of barium meal follow through with pneumocolon (BMFTP) used as a screening modality for patients with chronic abdominal pain of luminal origin in developing countries. METHODS: Fifty patients attending the Gastroenterology Unit, SMS Hospital, whose clinical evaluation revealed chronic abdominal pain of bowel origin were included in the study. After routine testing, BMFT, BMFTP, contrast enhanced computed tomography (CECT) of the abdomen, barium enema and colonoscopy were performed. The sensitivity, specificity and cost effectiveness of these imaging modalities in the detection of small and/or large bowel lesions were compared. RESULTS: Out of fifty patients, structural pathology was found in ten. Nine out of these ten patients had small bowel involvement while seven had colonic involvement alone or in combination with small bowel involvement. The sensitivity of BMFTP was 100% compared to 88.89% with BMFT when detecting small bowel involvement (BMFTP detected one additional patient with ileocecal involvement). The sensitivity and specificity of BMFTP for the detection of colonic pathology were 85.71% and 95.35% (41/43), respectively. Screening a patient with chronic abdominal pain (bowel origin) using a combination of BMFT and barium enema cost significantly more than BMFTP while their sensitivity was almost comparable. CONCLUSION: BMFTP should be included in the investigative workup of patients with chronic abdominal pain of luminal origin, where either multiple sites (small and large intestine) of involvement are suspected or the site is unclear on clinical grounds. BMFTP is an economical, quick and comfortable procedure which obviates the need for colonoscopy in the majority of patients.

Long-term results of antegrade colonic enema in adult patients: assessment of functional results.

PURPOSE: This retrospective study reviewed long-term results in a large group of adult patients treated with antegrade colonic enema and antegrade colonic enema combined with a colostomy. METHODS: Retrospective chart review identified 80 patients (64 females, mean age 51) surgically treated between 1993 and 2007 for fecal incontinence or constipation. Surgical treatments included 69 appendicostomies, 13 tapered ileum, 3 cecal tube, and 25 appendicostomy/neoappendicostomy combined with a colostomy. A 44-item questionnaire was mailed considering bowel regimen, complications, bowel function, social function, and quality of life. RESULTS: Sixty-nine patients were available for follow-up (mean follow-up, 75 months). Thirty patients (38 percent) had surgical complications. Forty-three patients (62 percent) were still performing antegrade continence enema and 8 patients (12 percent) no longer needed it. Accordingly, treatment was successful in 51 patients (74 percent). Twenty-seven patients (63 percent) had side effects. Evaluation of bowel function, social function, and quality of life all showed significant improvement. Antegrade continence enema was successful in patients with neurologic disabilities (67 percent), anorectal injury (53 percent), idiopathic fecal incontinence (50 percent), and idiopathic fecal constipation (42 percent). Antegrade continence enema was successful in patients with constipation, incontinence, and mixed symptoms. Results did not differ between appendicostomy, neoappendicostomy, and the combined appendicostomy/neoappendicostomy and colostomy. CONCLUSION: Long-term results were favorable in most patients treated with antegrade continence enema for fecal incontinence or constipation.

Computed tomographic air-contrast enema imaging for presurgical examination of colon tumors: assessment with colon phantoms and in patients.

PURPOSE: We investigated the mechanism of colon wall deformities in phantoms and assessed the relation between pathological T staging and wall deformity in patients using computed tomography (CT) enema imaging. MATERIALS AND METHODS: We performed multidetector-row CT in mass-containing phantoms with no structural deformities and in 36 patients with colon tumors. In the phantoms, we compared images on double-contrast barium (DCB) and CT enema studies, and we compared wall deformities on CT enema studies and the actual phantom structure. In patients, we compared wall deformities on CT enema studies and T staging. RESULTS: Images from CT enema and DCB studies were identical in the phantom, and all profile images showed geometrical basal indentations. In patients, the grade of deformity increased with invasion depth; and the diagnostic accuracy of T staging was 82.5%. Geometrical basal indentation and poor colon expansion were the primary reasons for overestimating T staging on CT enema imaging. CONCLUSION: Although CT enema imaging allows reasonable diagnostic accuracy of T staging, wall deformity is thought to be consistent with tumor infiltration and other factors. We recommend evaluating T staging using not only CT enema imaging but also other techniques, such as virtual endoscopy, axial imaging, and multiplanar reformation imaging.

Epidemiology, pathogenesis, and management of Clostridium difficile infection.

Clostridium difficile infection is an important health problem worldwide and leads to increased morbidity and mortality, particularly among the elderly population. Antibiotics, especially those with a broad spectrum, often trigger the infection; hence the use of unnecessary antibiotics should be avoided. Mild to moderate cases respond to metronidazole or vancomycin. Severe cases may require bowel resection. Chronic relapsing cases require a prolonged course of antibiotics, immunoglobulin, probiotics, and, occasionally, feces enema. This review provides a comprehensive update on pathogenesis and management of Clostridium difficile infection for health professionals all over the world.

Modes of presentation and pathways to diagnosis of colorectal cancer in Queensland.

OBJECTIVE: To describe the process of colorectal cancer diagnosis in Queensland, and to determine factors associated with time to diagnosis. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of 1996 patients with colorectal cancer recruited through the Queensland Cancer Registry. Data were collected by computer-assisted telephone interview between May 2003 and August 2005. MAIN OUTCOME MEASURES: Time to diagnosis: pre-presentation time (time from first noticing a symptom to first presenting to a doctor); and post-presentation time (time between the first presentation and diagnosis). RESULTS: Most patients (90%) had experienced symptoms before being diagnosed with colorectal cancer; only 2% of patients were diagnosed by faecal occult blood testing. Older participants and those who experienced abdominal pain had the shortest time from symptom onset to their first doctor consultation, while participants with a change in bowel habit, or rectal bleeding, and those without private health insurance tended to wait longer to see a doctor. Participants who experienced abdominal pain were diagnosed more quickly, whereas those who experienced a change in bowel habit, women, and those without private health insurance experienced a longer time to diagnosis. CONCLUSIONS: The strong association between not having health insurance and longer post-presentation times is concerning. The other hypothesised predictors of time to diagnosis were not as strongly associated as we anticipated.

Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique.

PURPOSE: Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation. METHODS: Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles' operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H(2)-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap. RESULTS: During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P<0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P<0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6-40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux. CONCLUSIONS: Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy.

An assessment of bisacodyl-based bowel preparation for colonoscopy in children.

BACKGROUND: The most commonly used methods for bowel preparation are polyethylene glycol-electrolyte lavage solution (PEG-ELS) and sodium phosphate. Both are problematic in children. The use of bisacodyl together with fleet enema has been suggested as an alternative; however, its use without dietary restriction is inferior to other preparations. We aimed to study the effect of bisacodyl together with fleet enema and a half day of clear fluid diet. METHODS: Ninety-eight children (aged 30 months to 12 years) were studied prospectively according to the following protocol: on the day prior to the colonoscopy, the patient received a 5-mg bisacodyl tablet at noon and started a clear fluid diet. An additional bisacodyl tablet was taken in the evening by patients more than 5 years old. Two pediatric fleet enemas were performed, on the evening before and on the morning of the procedure. The patients were compared with 26 historical control patients that had been prepared with PEG-ELS solution. RESULTS: The compliance of the bisacodyl group was excellent (100%), compared with 88% of the control group. Ninety-five percent of the bisacodyl group had good to excellent bowel preparation, compared with 88% of the PEG-ELS group. CONCLUSIONS: This method is safe and appropriate for use in children younger than 12 years.

La radiología del colon por enema en el siglo XXI / Radiology of barium enema in the XXI century

Antecedentes: En los últimos años se ha introducido nuevos métodos para el estudio del colon. Objetivo: Analizar las distintas alternativas actuales para el diagnóstico de la patología colónica y el rol que el colon por enema (CxE) tiene en la actualidad, comparado con la videocolonoscopía (VCC), la colonoscopía virtual (CV) y la tomografía computada (TC). Material y métodos: Análisis de distintas series de la literatura que evalúan el papel de los diferentes métodos de estudio del colon. Resultados: Como estudio de catastro, la VCC y la CV fueron superiores en el diagnóstico de adenomas comparados con el CxE, que demostró una sensibilidad de alrededor del 50 por ciento según el tamaño de las lesiones con respecto a la VCC. Para pacientes sintomáticos, los resultados fueron similares. En pacientes ancianos, la TC mostró una sensibilidad comparable al CxE, no mostró el 2 por ciento de las lesiones radiológicas, sin las limitaciones de la preparación y la posibilidad de diagnóstico extracolónico. El CxE tiene utilidad en la colonoscopía incompleta pero compitiendo con la CV que tiene superior sensibilidad (50 contra 89 por ciento). Tiene mejor sensibilidad que la VCC en enfermedad diverticular (42 contra 18 casos), pero en patología asociada en colon sigmoideo, la sensibilidad es del 32 al 49 por ciento según el tamaño de las lesiones. La radiología aventaja a la VCC y CV en costo, siendo un 75 por ciento más económica. En series consultadas la indicación de CxE se ha reducido un 30 por ciento en los últimos 5 años. Conclusiones: El CxE tiene limitadas sus indicaciones en la actualidad y su utilización ha disminuido, siendo su futuro de indicación más restringida por el desarrollo y difusión de la VCC, el mejoramiento de la TC y el desarrollo de nuevos procedimientos como la CV.

Background: New methods to study the colon have been introduced in recent years. Objective: To assess current different alternatives to study colonic diseases, and the barium enema (BE) role compared to videocolonoscopy (VCO), virtual colonoscopy (VC), and computed tomography (CT). Material and methods: Analysis of different series of the bibliography that evaluate the various methods of colon study. Results: In the screening studies, the VCO and the VC were superior for the diagnosis of adenomas compared with BE which demostrated a sensitivity of around 50 per cent, according to polyp size, with respect to the VCO. For symptomatic patients, the results were similar. In elderly patients, the CT showed a comparable sensitivity with BE, did not show 2 per cent of the radiological injuries, but without the limitations of the preparation and the possibility of extracolonic diagnosis. BE is useful in incomplete colonoscopy, however, compete with VC, which has superior sensitivity (50 vs. 89 per cent). BE has better sensitivity than VCO in diverticular disease (42 vs. 18 cases), but in associated in sigmoid colon pathology, sensitivity is 32 to 49 per cent according to the size of the polyps. Radiology surpasses VCO and VC in cost, being 75 per cent less expensive. According to reviewed series, the indication of BE has been reduced by 30 per cent in the last 5 years. Conclusions: currently, BE has limited indications, which will be more restricted in the future due to the development and diffusion of VCO, the improvement of the CT and the development of new procedures, such as the VC.

Digital rectal examination compares favourably with conventional water-soluble contrast enema in the assessment of anastomotic healing after low rectal excision: a cohort study.

BACKGROUND: Assessment of healing after low colorectal, colo-anal or ileo-pouch anal anastomosis is routinely performed with a water-soluble contrast enema (WSCE) prior to the reversal of the defunctioning stoma. Interpretation of these radiographs is sometimes difficult and imprecise. As these anastomoses are within the reach of a simple digital rectal examination (DRE), this approach is proposed as an effective and accurate adjunct. PATIENTS AND METHODS: This is a prospective cohort study recruiting patients who had undergone a low colorectal, colo-anal or ileo-pouch anal anastomosis with a diversion stoma. Anastomotic healing was assessed with a DRE in the clinic followed by the conventional WSCE. Anastomotic defects on digital examination and leaks on WSCEs were studied. RESULTS: There were 195 patients recruited with a total of 202 paired assessments from 182 patients over 45 months. Six months after closure of the study, 174 patients had their stomas reversed. Thirteen examinations with WSCE showed pathology but were normal on digital examination (false positive rate of 6.4% for WSCE). These patients had their stomas reversed with no subsequent problems. Seven patients had an abnormal DRE but had a normal enema study (false negative rate of 3.5% for WSCE). These were large defects with pus and allowed the tip of the examining finger through. Delayed reversal of the stomas in these patients probably avoided continuing pelvic sepsis. The DRE was accurate in all instances except in the detection of a minor fistula in three patients. The sensitivity of the DRE in the detection of anastomotic pathology was 98.4%. CONCLUSION: The DRE yields additional and reliable information compared with the conventional water-soluble enema study in the assessment of anastomotic healing prior to stoma closure. In the experienced surgeon, it yielded more useful clinical information than the enema study.

Accuracy of radiographic assessment for the diagnosis of invasion depth in small invasive colorectal cancer.

Radiographic findings of 113 submucosally invasive colorectal cancers (CRCs) 10 mm. 47 CRCs had invaded the submucosa superficially while 66 CRCs had invaded deeply. The concordance rate in the assessment of radiology was 90.3% in smooth surface, 92.9% in central barium fleck, 90.3% in fold convergency and 79.6% in eccentric rigidity. Positive predictive value of central barium fleck for deep submucosal invasion was significantly higher in CRCs>10 mm than in those 10 mm. These findings suggest that barium radiography is a procedure which can give useful information in prediction of invasion depth in CRCs