Demonstration of differences in colonic volumes, transit, chyme consistency, and response to psyllium between healthy and constipated subjects using magnetic resonance imaging.

BACKGROUND: In functional gastrointestinal disorders a lack of objective biomarkers limits evaluation of underlying mechanisms. We aimed to demonstrate the utility of magnetic resonance imaging for this task using psyllium, an effective constipation treatment, in patients and controls. METHODS: Two crossover studies: (i) adults without constipation (controls, n = 9) took three treatments in randomized order for 6 days - maltodextrin (placebo), psyllium 3.5 g t.d.s and 7 g t.d.s., (ii) adults with chronic constipation (patients, n = 20) took placebo and psyllium 7 g t.d.s. for 6 days. MRI was performed fasting and postprandially on day 6. Measurements included small bowel and ascending colon water content, colonic volume, transit time, and MR relaxometry (T1, T2) to assess colonic chyme. Stool water percentage was measured. RESULTS: 7 g psyllium t.d.s. increased fasting colonic volumes in controls from median 372 mL (IQR 284-601) to 578 mL (IQR 510-882), and in patients from median 831 mL (IQR 745-934) to 1104 mL (847-1316), P < .05. Mean postprandial small bowel water was higher in controls and patients after 7 g psyllium t.d.s. vs placebo. Whole gut transit was slower in patients than controls (P < .05). T1 of the descending colon chyme (fasting) was lower in patients (213 ms, 176-420) than controls (440 ms, 352-884, P < .05) on placebo, but increased by 7 g psyllium t.d.s. (590 ms, 446-1338), P < .001. Descending colon T1 correlated with baseline stool water content and stool frequency on treatment. CONCLUSIONS AND INFERENCES: MRI measurements can objectively demonstrate the mode of action of therapy targeting intestinal fluid content in constipation.

[X-ray colonometry in the diagnosis of colonic dyskinesias and inflammatory diseases].

Clinical and X-ray studies were made in 316 patients, which revealed intestinal dyskinesia, chronic colitis, and nonspecific ulcerative colitis in 105, 133, and 78 patients, respectively. Irrigoscopy (administration of a contrast enema, examination of the mucosal contour, and double contrasting) was performed in all the patients, by analyzing X-ray planimetric indices. X-ray colonoplanimetry makes it possible to objectify the interpretation of the X-ray pattern in chronic inflammatory diseases of the large bowel and colonic dyskinesia.

A combined flexible sigmoidoscopy and double-contrast barium enema service: initial experience.

BACKGROUND: A service has been instituted offering a combined single-stage procedure of flexible sigmoidoscopy and double-contrast barium enema (FS/DCBE). The results have been reviewed in the first 80 patients to undergo this examination (45 male: 35 female; mean age 61.4 years). METHODS: Indications for investigation were abdominal pain or suspected diverticular disease (22 patients), altered bowel habit (19), rectal bleeding (17), iron deficiency anemia (6), and miscellaneous (16). FS was followed immediately by DCBE. Radiographs were reviewed by two radiologists unaware of the FS findings. RESULTS: The extent of FS was to the proximal sigmoid or sigmoid descending colon or splenic flexure in 12.5%, and mid or distal sigmoid in 37.5%. Biopsies were performed at FS in 26 patients (33%). In 67 (84%) of DCBEs the barium coating was assessed as satisfactory or better. FS yielded pathological findings not seen at DCBE in 21 patients (26%). DCBE demonstrated additional abnormalities within the range of the FS examination in 15 patients (19%), almost entirely due to its increased sensitivity for diverticular disease. CONCLUSION: FS/DCBE is feasible as a one-stage combined procedure. The quality of DCBE following FS is satisfactory, and the extra yield of FS and its potential for biopsy make the combined FS/DCBE a useful technique in the investigation of large bowel disease.

[Colonic motility]. / Dickdarmmotilität.

Colonic motility is provided by contraction of intramural smooth muscle under the control of the enteric and the extrinsic nervous system and humoral connections. In vivo measurement of colonic motility remains difficult because of the complexity of these interactions and anatomical considerations. The possibility that symptoms are due to colonic dysmotility should be considered in patients with normal barium enema and colonoscopy. Examples of this are patients with chronic constipation, irritable bowel syndrome or colonic symptoms associated with diabetes mellitus or diseases of the nervous system. A number of techniques have been developed to assess colonic motility. The simplest is to assess colonic transient with a single abdominal x-ray following ingestion of radio-opaque markers. This is cheap, reproducible and easy to perform. Normal values for age and sex are available. Colonic transit of both liquid and solid can be determined by scintigraphic measurement. This technique provides information about regional variations in colonic function; it is however relatively demanding and requires access to a gamma camera. Manometry provides a more direct assessment of colonic motor activity. Changes in the electrical potential of the colonic smooth muscle can be determined by electromyography. Both techniques are however difficult to perform, and are currently only used for research purposes. It is likely that the combination of techniques that examine transit with more direct measurement of motor function will provide further insights into the mechanisms responsible for colonic dysmotility.

Case report: persistent colonic spasm concealing a carcinoma--an uncommon diagnostic pitfall of the barium enema examination.

Colonic carcinomas may be missed on the barium enema examination for a variety of perceptive, technical, and interpretive reasons. We report an uncommon source of error-persistent bowel spasm resulting in concealment of an underlying carcinoma. Awareness of this association is necessary in the effort to minimize diagnostic pitfalls of the barium enema examination.

Painful irritable bowel syndrome and sigmoid contractions.

Fifteen patients with abdominal pain compatible with the irritable bowel syndrome (IBS) were examined by barium enema and pressure recording. Strong circular contractions of the sigmoid colon and pressure recordings correlated with the characteristic pain in 13 of the 15 patients. In 15 control patients no pain occurred. It is concluded that pain and high pressure are caused by strong circular sigmoidal contractions. Such findings enable the radiologist to contribute to the diagnosis of IBS.

Irritable bowel syndrome: is a barium enema necessary?

A retrospective analysis was made of 114 new patients attending a gastroenterology clinic, in whom the initial clinical diagnosis was irritable bowel syndrome. Barium enemas were performed in 84 patients (74%), 15 of whom were found to have significant other disease. In each case this would have been suspected from the routine haematological and biochemical screening tests. It is suggested that, in the investigation of patients under 50 years of age presenting to a gastroenterology clinic with a typical history of irritable bowel syndrome, a barium enema should only be performed if the clinical examination, sigmoidoscopy, rectal biopsy or routine blood tests are abnormal. This policy would reduce substantially the number of normal barium enemas performed.

Rectal fold thickness as an indicator of disease.

Rectal folds are seen best in the lateral view. Normal values for the thickness of the folds have been established by measuring these in patients with a diagnosis of irritable bowel syndrome who had no evidence of rectal disease. In severe ulcerative colitis the valves disappear, but they are present earlier in the disease. The first barium enema examination in patients with ulcerative colitis was assessed. When the valve thickness could be measured in these patients it showed values significantly greater than normal. It is uncommon for this finding to be the sole indicator of disease. Patients with Crohn's disease of the rectum showed no increase in the fold thickness. This observation may be helpful in distinguishing between these two forms of colitis.

The "air enema" in acute colitis.

The plain abdominal radiograph is an important investigation in acute colitis, but may fail to demonstrate the state of the colon owing to a lack of intracolonic gas. The extent of the colitis can be demonstrated by introducing air directly into the large bowel; the air also provides sufficient contrast to distinguish a granular from an ulcerated mucosa. The "air enema" may be used as an alternative to an unprepared barium enema. Its accuracy has been established by comparison with an unprepared barium enema in 10 patients with acute colitis.

Radiographic evaluation of spastic colon disease, diverticulosis, and diverticulitis.

Spastic colon disease is a syndrome consisting of abdominal pain and abnormal bowel function associated with thickening of the circular muscle layer of the colon. The condition may be related to changes in intraluminal pressure associated with a lifelong low residue diet. Radiologic features include thickening, crowding, irregularity, and distortion of the interhaustral folds of the sigmoid colon, which in the past have been incorrectly considered to be manifestations of acute diverticulitis. Spastic colon disease leads to diverticulosis which develops because of mucosal herniations through the weakened colonic wall. When a diverticulum perforates, acute diverticulitis ensues. Depending on how the subsequent inflammatory response is contained, a mural abscess, colonic narrowing or obstruction, an intra-abdominal abscess, or a fistula may occur and be demonstrated on barium enema examination.

Relevance of the barium follow-through examination in the diagnosis of adult celiac disease.

Significant changes on a standard barium follow-through examination in celiac disease have been determined by comparison with functional changes (irritable bowel syndrome), malabsorption without a villous lesion (chronic pancreatitis), and a villous abnormality without malabsorption (dermatitis herpetiformis). Patients with iron deficiency anemia formed the control group. Slight jejunal dilatation (26-30 mm) was found in 15% of the celiacs and 17% of the irritable bowel patients. Dilatation in excess of 30 mm and/or effacement of jejunal fold pattern occurred only with an abnormal jejunal biopsy, in 54% of the celiacs and 33% of the dermatitis herpetiformis patients. Patients with malabsorption by itself and 46% of the celiacs could not be distinguished from those with irritable bowel syndrome. The concept of a malabsorption pattern is considered invalid, and the diagnosis of celiac disease can be reliably established only by peroral jejunal biopsy.