Pulmonary staging in colorectal cancer--is computerised tomography the answer?

INTRODUCTION: Pulmonary staging in colorectal cancer (CRC) has traditionally been carried out by means of plain chest radiograph (CXR), although computerised tomography (CT) imaging of the chest is increasingly being performed for this purpose. The aim of this study was to assess the value of pre-operative thoracic CT for pulmonary staging in CRC. PATIENTS AND METHODS: Data were collected prospectively on all patients referred into hospital over a 20-month study period for double contrast barium enema evaluation of symptoms suggestive of an underlying CRC. Patients with a CRC went on to have a staging intravenous, contrast-enhanced CT of the chest, abdomen and pelvis prior to an out-patient appointment with a colorectal surgeon. The CXRs of those patients in whom a radiological abnormality was seen on thoracic CT were reviewed blindly by an independent consultant radiologist. RESULTS: A total of 403 barium enemas were performed, of which 38 demonstrated a CRC (9%). In those patients diagnosed with CRC, nine (24%) had an abnormality on thoracic CT. Four patients with positive thoracic CTs had chemotherapy and or radiotherapy with no surgery. One patient underwent colectomy, and 2 patients who had primary lung tumours as opposed to metastases also underwent colectomies. One patient received palliative care only. In addition, one of the patients underwent multiple, non-diagnostic thoracic investigations prior to a diagnosis of sarcoidosis being made and then proceeding to surgery. An independent consultant radiologist reviewed seven out of the nine CXRs of patients with an abnormality on thoracic CT without knowledge of the clinical diagnosis, and reported three of the CXRs to be normal. CONCLUSIONS: Thoracic CT appears to improve the accuracy of pulmonary staging in CRC allowing a more appropriate level of intervention. However, CT is likely to identify more benign radiological abnormalities than CXR alone, and investigations should not occur to the detriment of treating the primary tumour.

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer.

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.

Detection of colorectal carcinoma on double contrast barium enema when double reporting is routinely performed: an audit of current practice.

PURPOSE: To determine the sensitivity of double contrast barium enema (DCBE) in the detection of colorectal carcinoma (CRC) when double reporting is routinely performed. METHOD AND MATERIALS: Over a 1-year period all patients with a diagnosis of CRC within a large teaching hospital were identified. Using computer records, any patient with CRC who had had a DCBE within 5 years of diagnosis was identified. During this time period all DCBE were double reported by the radiographer or radiology trainee who performed the enema and by a consultant radiologist specializing in gastrointestinal radiology. RESULTS: Over the 1-year period 169 patients were identified with a diagnosis of CRC. Seventy patients had had a DCBE within the preceding 5 years. Sixty-four patients had had CRC diagnosed on the DCBE. One patient had a sessile polyp diagnosed, which was removed at colonoscopy and found to be an invasive adenocarcinoma. In five cases (7%) the CRC was not diagnosed on DCBE. In three cases the lesions could be seen retrospectively, in one case the lesion could not be seen and in one case the examination had been incomplete. CONCLUSION: In our series the miss-rate for CRC was 7%. Previous studies have shown miss-rates of 15-24%. These studies have not routinely employed double reporting. Our results suggest that double reporting of DCBE significantly reduces the miss-rate and that this reduction is due to fewer perceptive errors.

Air versus carbon dioxide insufflation in double contrast barium enemas: the role of active gaseous drainage.

Air has been traditionally used as the negative contrast agent in double contrast barium enema (DCBE) examinations, but causes abdominal pain in the 24 h following the procedure. The frequency of post-procedural pain is less when carbon dioxide (CO2) is used as the negative contrast agent. We evaluated patients following DCBE examinations (using either air or CO2) by means of a questionnaire, to determine whether active drainage of gas altered the post-procedural pain. There was no difference in the pain experienced in the groups receiving CO2 with either active or passive drainage, or in the group receiving air with active drainage. Compared with the other groups there was a significantly higher incidence and severity of pain in the group receiving air and passive drainage. We conclude that active drainage of air following a DCBE examination is as effective as using CO2 in reducing post-procedural pain and swelling.

Diaphragmatic herniation of the large bowel.

We present 19 patients who were found to have colonic herniation into the chest via the oesophageal hiatus on barium enema. This was demonstrated by showing the position of the hernia and its intimate association with the oesophagus at barium swallow. In nearly all cases there was a co-existent partially volved hernia of the stomach. It is concluded that in adults, colonic herniation into the chest noted at routine barium enema can occur via the oesophageal hiatus and is invariably associated with herniation of the stomach which in many cases is partially volved. The patients are usually elderly and female and are unlikely to present subsequently as an emergency.

Barium enemas are a headache.

The frequency of headache after Picolax (sodium picosulphate, Nordic Ltd) preparation for barium enema was investigated and its association with dehydration, as assessed by haemoconcentration, was determined. Eleven out of 41 patients (26.8%) complained specifically of headaches. Although patients with and without headaches developed significant increases in haemoglobin concentration after Picolax preparation, the rise in haemoglobin in those with headaches was significantly greater than in those without (P less than 0.05). In both groups the haemoglobin concentration returned to normal after a bowel washout. These results suggest an association between dehydration and headache developing after a Picolax regimen. It may be possible to prevent this symptom by advising on the intake of specific volumes of fluid during preparation for barium enema.

Flap-valve theory of anorectal continence.

The most important component of continence is considered to be the puborectalis muscle which is reputed to function by creating a flap-valve mechanism in which the anterior rectal wall occludes the upper and canal. To elucidate this, anal and rectal pressures were measured simultaneously together with external anal sphincter and puborectalis electromyogram and synchronously superimposed on an image intensifier displaying the rectum outlined by barium. We studied 13 subjects at rest, and during a Valsalva manoeuvre. There was a significant rise in rectal and sphincter pressures (P less than 0.005) and external sphincter and puborectalis EMG (P less than 0.005). In a further 13 patients Valsalva manoeuvres were performed during proctography alone. In all subjects the anterior rectal wall was always clearly separated from the upper sphincter despite a maximal effort and a rectum filled with sufficient liquid to produce a desire to defaecate. These findings question the flap-valve theory of continence and suggest the puborectalis functions by sphincteric occlusion of the anal canal.

Audit on the use of the barium enema.

All 1358 referrals for barium enemas at Bristol Royal Infirmary in 1981 were studied. The overall diagnostic yield for colonic or distal ileal pathology was 33% with 75 (5.5%) cancers detected. General practitioner requested enemas constituted 25.8% of the total undertaken and their diagnostic yield was equal to hospital outpatient requested enemas. Medical and surgical diagnostic yields were similar for both inpatient and outpatients though the indications varied. Women predominated by 3:2 in all age groups. In the under 40's the yield was low (19.8%) except for inflammatory bowel disease. When related to symptoms the lowest yield was obtained for the investigation of abdominal pain (25%), particularly in women, except in those admitted as inpatients. The clinicians were wrong in diagnosing abdominal or pelvic masses as being of colonic origin in over 50% of cases. It is suggested that yield could be improved by being more selective in patients under 40, more use being made of suitable faecal occult blood testing, and ultrasonic scanning of abdominal masses before barium enema.

Oesophageal function tests: are they of value?

Oesophageal function was assessed in 15 unselected control patients, eight patients with systemic sclerosis, 10 diabetics with autonomic neuropathy and 24 diabetic controls, by water bolus transit time derived from oesophageal scintigraphy, barium swallow and by timing the transit of a barium sulphate-filled capsule through the oesophagus. Water transit times and capsule transit times were significantly prolonged in patients with systemic sclerosis and diabetics with autonomic neuropathy, compared with controls. Barium swallow was abnormal in seven of eight patients with systemic sclerosis, whereas water transit time was abnormal in all eight and capsule transit time was abnormal in six of seven. Nine of 10 patients with diabetic autonomic neuropathy had abnormal barium swallows and water transit times but all 10 had prolonged capsule transit times. Eleven of 24 diabetic controls had abnormal barium swallows and water transit times, but 21 had abnormally prolonged capsule transit times. Six of 15 controls had abnormal barium swallows, four had abnormal water transit times and 12 had abnormal capsule transit times. In conclusion, water and capsule transit times are sensitive tests of oesophageal function and are as effective as barium swallow in detecting oesophageal motility disorders associated with systemic sclerosis and diabetic autonomic neuropathy. Capsule transit time is cheaper, involves a smaller radiation exposure than oesophageal scintigraphy and may be more sensitive.

The role of decubitus films in double-contrast barium enemas.

Five hundred barium enemas were reviewed to find the influence of the decubitus films on the radiologist's report. In two cases they demonstrated abnormalities that had not been seen on any other film. In 21 out of 43 cases they resolved a diagnostic problem that had arisen when viewing the other films. They were of greatest value in differentiating possible polyps from faecal residue in patients with imperfect bowel preparation.