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Effective 24-Hour Preparation for Radiologic Examination of the Colon
Symposium on Gastrointestinal Surgery
Effective 24-Hour Preparation for Radiologic Examination of the Colon
Wladimir Zezulin, M.D.
In order to improve the quality and efficiency of radiologic examinations of the colon in the Department of Diagnostic Radiology, we have conducted a pilot program of colonic preparation which represents a slightly modified version of the one developed by Brown. 2• 3 Our procedure consists of a 24-hour low-residue diet, increased hydration, and a saline type of cathartic (magnesium citrate) to clear the colonic mucosa prior to the administration of a contact type of evacuant (bisacodyl, Dulcolax) for more complete cleansing. I • 2 Several authors reported marked improvement in the diagnostic quality of barium enema examinations following similar preparation of the colon. 1. 2. 4 Two such series, one l with 388 patients and one with 2500 patients (only the results of first 200 were analyzed? claim good preparation results in 84.5 per cent l and 95 per cent2 respectively. These authors also are in agreement as to the low incidence of adverse effects, I. 2 and this appears to compare favorably with a control series of castor oil and cleansing enema preparation employed in 152 patients. I We have reviewed the results of our early consecutive cases of the program, and of 32 patients questioned, 22 patients did not have any complaints. Among the remaining 10 patients, 3 complained of abdominal cramps, 1 of severe abdominal pain, 1 of "abdominal burning," 6 of frequent bowel movements or diarrhea, and 1 of perianal burning. Thus, 67 per cent of patients did not express any complaints. At the time of our review, films of 27 such consecutive examinations were available and were independently classified by one of our staff radiologists as: excellent, 14; good, 10; and poor, 3. Good to excellent cleansing (considered diagnostic) was achieved in 89 per cent of cases. Poor preparation, present in 11 per cent of examinations, did not allow exclusion of intraluminal lesions. Analysis of our short initial series, our general impression with a larger number of cases, and the enthusiasm of referring clinicians appear in full agreement with the more extensive experience of other authors. Figures 1 to 4 are included to illustrate the appearance of our wellprepared cases. (Text continued on page 805.) Surgical Clinics of North America- Vol. 51, No.3, June 1971
799
800
WLADIMIR ZEZULIN
Figure 1.
Anteroposterior view of full normal colon.
PREPARATION FOR RADIOLOGIC EXAMINATION OF THE COLON
Figure 2.
Postevacuation film-good mucosal pattern of colon.
801
802
WLADIMIR ZEZULIN
Figure 3.
Small diverticulum of ascending colon.
PREPARATION FOR RADIOLOGIC EXAMINATION OF THE COLON
Figure 4. ing colon.
803
A and B, Two polyps, one with a stalk, and a diverticulum of the distal descend-
Table 1. 24-Hour Preparation of Colon for Barium Enema Necessary for Meaningful Diagnostic ResultsFor Referring Physicians
Four Basic Steps 1. Low-residue, non-fat diet 2. Overhydration of the patient 3. Saline type of cathartic (magnesium citrate) 4. Contact type evacuant (Du1colax) Causes for Failure 1. Insufficient overhydration 2. Chronic cathartic colon Contraindications 1. Known or suspected intestinal obstruction 2. Known colitis or excessive diarrhea: delete Du1colax (tablets and suppository) but follow the rest of the procedure 3. Other medical contraindications, such as suspected diverticulitis or acute abdominal surgical condition or severe generalized debility. (Discretion of referring physician) 4. Patients with colostomy: omit Dulcolax tablets and suppository.
804
WLADIMIR ZEZULIN
Table 2. Preparation Instructions for Barium Enema For patients 16 years and older Your doctor has requested an examination of your colon. Date of appointment. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Time _ _ _ _ _ _ _ _ __
If the examination is to be of greatest value, you must cooperate fully in preparing yourself as described below (to avoid repeat examination if possible), 'beginning at 8:00 A.M. the day before your appointment for barium enema examination. Please bring this instruction sheet with you when reporting for your examination. Eat and drink only the following: CHECK AS TIME
DIRECTIONS
8:00
A.M.
Breakfast-One (or two) boiled or poached eggs. One slice of bread or toast. Fruit juice, coffee or tea (without milk or cream)
10:00
A.M.
Drink at least one full glass or more of water
12:00 Noon
Light lunch-One cup of bouillon soup or tomato soup with crackers. One chicken or turkey white meat sandwich (no butter, mayonnaise or other additive), or lean meat sandwich. Clear fruit juice. One serving of plain Jell-o (no cream, fruit or other additive). One glass of skimmed milk
1:00
P.M . •
Drink at least one full glass or more of water
3:00
P.M.
Drink at least one full glass or more of water
5:00
P.M.
Supper-Eat only the following: One cup of clear soup. One glass of clear fruit juice. One serving of plain Jell-o (no cream, fruit or other additive)
6:00
P.M.
Drink one 10-ounce bottle of magnesium citrate (cold)
7:00
P.M.
Drink at least one full glass or more of water
8:00
P.M.
Take three Du1colax tablets with at least one full glass or more of water. Do not crush or chew tablets. Swallow them whole. Do not take tablets within one hour of antacids or milk.
12:00 Midnight 7:00
A.M.
Drink at least one full glass or more of water Day of Examination-Drink one and one-half glasses water. Use Du1colax suppository as follows: l. Unwrap suppository. 2. Insert suppository into the rectum, pointed end first, as high as possible. 3. Close thighs to aid in retaining suppository. 4. Retain suppository for at least 15 to 20 minutes, if possible. A bowel evacuation usually occurs in 15 minutes to one hour. 5. Be certain that assistance is available if needed.
COMPLETED
PREPARATION FOR RADIOLOGIC EXAMINATION OF THE COLON
805
At present we use two direction outlines for our modification of Brown's procedure of colonic preparation (Tables 1 and 2). Table 1 is for referring physicians. Table 2 lists instructions for patients.
CONCLUSION Consistent, good cleansing of the colon is of the utmost importance in achieving films of good quality and high accuracy from barium enema examinations. We believe that Brown's method of preparation (or its modification) offers an opportunity to improve significantly the results of colonic cleansing without undue hardship to the patient. A minimum of failures or poor preparations is unavoidable with any method. In such cases or when only a limited preparation of the colon is possible, the radiologist should clearly convey to the clinician the limitations of the examination he is reporting. The need for this unwelcome limitation and for repeat examinations will decrease with improved colonic preparation.
REFERENCES 1. Barnes, M. R: How to get a clean colon-with less effort. Radiology 91 :948-949 passim (Nov.) 1968.
2. Brown, G. R: A new approach to colon preparation for barium enema: Preliminary report. Univ. Michigan Med. Bull. 27:225-230,1961. 3. Brown, G. R: The Direct Air Contrast Colon Examination. Ft. Wayne, Indiana, Garland R. Brown, 1968,24 pp. 4. Sorrentino, A. P., Barnes, M. R., and Flack, H. L.: Solving the barium enema problemthe barium enema laxative kit. Amer. J. Hosp. Pharm. 26:432-435 (Aug.) 1969.
Effective 24-Hour Preparation for Radiologic Examination of the Colon
Wladimir Zezulin, M.D.
In order to improve the quality and efficiency of radiologic examinations of the colon in the Department of Diagnostic Radiology, we have conducted a pilot program of colonic preparation which represents a slightly modified version of the one developed by Brown. 2• 3 Our procedure consists of a 24-hour low-residue diet, increased hydration, and a saline type of cathartic (magnesium citrate) to clear the colonic mucosa prior to the administration of a contact type of evacuant (bisacodyl, Dulcolax) for more complete cleansing. I • 2 Several authors reported marked improvement in the diagnostic quality of barium enema examinations following similar preparation of the colon. 1. 2. 4 Two such series, one l with 388 patients and one with 2500 patients (only the results of first 200 were analyzed? claim good preparation results in 84.5 per cent l and 95 per cent2 respectively. These authors also are in agreement as to the low incidence of adverse effects, I. 2 and this appears to compare favorably with a control series of castor oil and cleansing enema preparation employed in 152 patients. I We have reviewed the results of our early consecutive cases of the program, and of 32 patients questioned, 22 patients did not have any complaints. Among the remaining 10 patients, 3 complained of abdominal cramps, 1 of severe abdominal pain, 1 of "abdominal burning," 6 of frequent bowel movements or diarrhea, and 1 of perianal burning. Thus, 67 per cent of patients did not express any complaints. At the time of our review, films of 27 such consecutive examinations were available and were independently classified by one of our staff radiologists as: excellent, 14; good, 10; and poor, 3. Good to excellent cleansing (considered diagnostic) was achieved in 89 per cent of cases. Poor preparation, present in 11 per cent of examinations, did not allow exclusion of intraluminal lesions. Analysis of our short initial series, our general impression with a larger number of cases, and the enthusiasm of referring clinicians appear in full agreement with the more extensive experience of other authors. Figures 1 to 4 are included to illustrate the appearance of our wellprepared cases. (Text continued on page 805.) Surgical Clinics of North America- Vol. 51, No.3, June 1971
799
800
WLADIMIR ZEZULIN
Figure 1.
Anteroposterior view of full normal colon.
PREPARATION FOR RADIOLOGIC EXAMINATION OF THE COLON
Figure 2.
Postevacuation film-good mucosal pattern of colon.
801
802
WLADIMIR ZEZULIN
Figure 3.
Small diverticulum of ascending colon.
PREPARATION FOR RADIOLOGIC EXAMINATION OF THE COLON
Figure 4. ing colon.
803
A and B, Two polyps, one with a stalk, and a diverticulum of the distal descend-
Table 1. 24-Hour Preparation of Colon for Barium Enema Necessary for Meaningful Diagnostic ResultsFor Referring Physicians
Four Basic Steps 1. Low-residue, non-fat diet 2. Overhydration of the patient 3. Saline type of cathartic (magnesium citrate) 4. Contact type evacuant (Du1colax) Causes for Failure 1. Insufficient overhydration 2. Chronic cathartic colon Contraindications 1. Known or suspected intestinal obstruction 2. Known colitis or excessive diarrhea: delete Du1colax (tablets and suppository) but follow the rest of the procedure 3. Other medical contraindications, such as suspected diverticulitis or acute abdominal surgical condition or severe generalized debility. (Discretion of referring physician) 4. Patients with colostomy: omit Dulcolax tablets and suppository.
804
WLADIMIR ZEZULIN
Table 2. Preparation Instructions for Barium Enema For patients 16 years and older Your doctor has requested an examination of your colon. Date of appointment. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Time _ _ _ _ _ _ _ _ __
If the examination is to be of greatest value, you must cooperate fully in preparing yourself as described below (to avoid repeat examination if possible), 'beginning at 8:00 A.M. the day before your appointment for barium enema examination. Please bring this instruction sheet with you when reporting for your examination. Eat and drink only the following: CHECK AS TIME
DIRECTIONS
8:00
A.M.
Breakfast-One (or two) boiled or poached eggs. One slice of bread or toast. Fruit juice, coffee or tea (without milk or cream)
10:00
A.M.
Drink at least one full glass or more of water
12:00 Noon
Light lunch-One cup of bouillon soup or tomato soup with crackers. One chicken or turkey white meat sandwich (no butter, mayonnaise or other additive), or lean meat sandwich. Clear fruit juice. One serving of plain Jell-o (no cream, fruit or other additive). One glass of skimmed milk
1:00
P.M . •
Drink at least one full glass or more of water
3:00
P.M.
Drink at least one full glass or more of water
5:00
P.M.
Supper-Eat only the following: One cup of clear soup. One glass of clear fruit juice. One serving of plain Jell-o (no cream, fruit or other additive)
6:00
P.M.
Drink one 10-ounce bottle of magnesium citrate (cold)
7:00
P.M.
Drink at least one full glass or more of water
8:00
P.M.
Take three Du1colax tablets with at least one full glass or more of water. Do not crush or chew tablets. Swallow them whole. Do not take tablets within one hour of antacids or milk.
12:00 Midnight 7:00
A.M.
Drink at least one full glass or more of water Day of Examination-Drink one and one-half glasses water. Use Du1colax suppository as follows: l. Unwrap suppository. 2. Insert suppository into the rectum, pointed end first, as high as possible. 3. Close thighs to aid in retaining suppository. 4. Retain suppository for at least 15 to 20 minutes, if possible. A bowel evacuation usually occurs in 15 minutes to one hour. 5. Be certain that assistance is available if needed.
COMPLETED
PREPARATION FOR RADIOLOGIC EXAMINATION OF THE COLON
805
At present we use two direction outlines for our modification of Brown's procedure of colonic preparation (Tables 1 and 2). Table 1 is for referring physicians. Table 2 lists instructions for patients.
CONCLUSION Consistent, good cleansing of the colon is of the utmost importance in achieving films of good quality and high accuracy from barium enema examinations. We believe that Brown's method of preparation (or its modification) offers an opportunity to improve significantly the results of colonic cleansing without undue hardship to the patient. A minimum of failures or poor preparations is unavoidable with any method. In such cases or when only a limited preparation of the colon is possible, the radiologist should clearly convey to the clinician the limitations of the examination he is reporting. The need for this unwelcome limitation and for repeat examinations will decrease with improved colonic preparation.
REFERENCES 1. Barnes, M. R: How to get a clean colon-with less effort. Radiology 91 :948-949 passim (Nov.) 1968.
2. Brown, G. R: A new approach to colon preparation for barium enema: Preliminary report. Univ. Michigan Med. Bull. 27:225-230,1961. 3. Brown, G. R: The Direct Air Contrast Colon Examination. Ft. Wayne, Indiana, Garland R. Brown, 1968,24 pp. 4. Sorrentino, A. P., Barnes, M. R., and Flack, H. L.: Solving the barium enema problemthe barium enema laxative kit. Amer. J. Hosp. Pharm. 26:432-435 (Aug.) 1969.