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.

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.

Topographic representation of the pharyngoesophageal segment during swallowing.

Motility of the pharyngoesophageal segment (PES) was monitored by cineradiography (50 frames a second) during barium swallow and analyzed by a computerized topographic mapping of sagittal wall motion. Through measurement of wall displacement on 20 consecutive levels of the PES, distention, contraction, and peristalsis were studied. Topographic mapping of three patients with normal PES motility, delayed opening of the cricopharyngeus, and incomplete opening of the cricopharyngeus, was performed. These topographic mappings show that "narrowing" at the level of the cricopharyngeus reflects expansion of the hypopharynx and cervical esophagus around the cricopharyngeus, rather than a true narrowing. In addition, analysis of wall motion demonstrated that abnormality of the circopharyngeus is often associated with abnormality of wall motion in the adjoining hypopharynx and cervical esophagus. Thus, topographic mapping of the cricopharyngeus is of value because it enables detailed analysis of wall motion during various pathologic conditions.

The pharynx. Structural disorders.

This article reviews the normal anatomy and common structural abnormalities of the pharynx. It should be read in conjunction with the next article by Dr. Jones because structural and functional disorders of the pharynx overlap. Topics discussed include principles of technique, anatomy, inflammatory disorders, benign and malignant tumors, and radiation damage.

Contrast evaluation of the pharynx and esophagus.

Swallowing requires the coordinated action of the alimentary tract from the oral cavity to the gastroesophageal junction. Any structural or functional abnormality along this pathway will interfere with swallowing. The "barium swallow" or pharyngoesophagogram requires examination of the oral cavity, pharynx, esophagus, and gastric cardia.

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.

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.

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.

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.

Value of digital fluoroscopy for the diagnosis of pneumatosis coli.

Two cases are presented of benign pneumatosis coli diagnosed on digital fluoroscopic barium enema examinations, in which the gas-filled cysts in the colonic wall were only recognized by postprocessing of the images (i.e. increasing the brightness and contrast settings) at the computer workstation. When digital barium enemas are performed, we therefore recommend image postprocessing to evaluate polypoid lesions in order to differentiate pneumatosis coli from true colonic neoplasms.

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.

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.

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.

Gallery of double-contrast terminology.

This article visually defines the descriptive terms commonly used in double-contrast gastrointestinal radiology. The terms are organized by whether they primarily refer to mucosal, wall, or extrinsic abnormalities.

Oral and pharyngeal dysphagia.

The swallowing tract extends from the lips to the gastric cardia. The barium swallow provides a global view of oral, pharyngeal, and esophageal motility and pharyngeal and esophageal morphology. Barium pharyngography is the best test to assess the functional capabilities of the pharynx. The barium swallow may be used as the sole diagnostic examination or as a guide to what procedure or intervention should be forthcoming.