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Maximal diagnostic potential of barium enema in the management of colon disease
MAXIMAL DIAGNOSTIC POTENTIAL OF BARIUM ENEMA IN THE MANAGEMENT OF COLON DISEASE* JAMES
A.
PERGUSON,
M.D.
Grand Rapids, Michigan
T
HE dangers which attend incompIete diagnostic efforts are particuIarIy serious when diseases of the Iarge bowe1 and its outIet are present. Too frequentIy, hemorrhoids which are present in so many patients are treated by removal with compIete disregard for more important Iesions of the rectum and coIon. CommonpIace errors of oversight can be obviated by carefu1 history-taking, thorough physica examination and deIiberate proctosigmoidoscopic examination. If any one of these diagnostic steps yieIds suggestive evidence of intrinsic abnormaIity, further investigation becomes mandatory. If a11 three procedures cIearIy indicate that the patient is norma in other respects, it is &II wise to empIoy one additiona1 diagnostic procedure before assuming that hemorrhoidectomy wiI1 constitute adequate treatment. This procedure, x-ray examination of the coIon during and following the injection of barium per rectum, constitutes a most important addition to the customary proctoIogic diagnostic steps. A series of 600 cases has been accumulated in which the standard diagnostic procedures have suggested no intrinsic abnormality and in which barium enema x-ray examination of the, coIon has been done and may be considered strictIy adjunctive. AI1 600 patients sought medica aid for the reIief of rea1 or fancied ana distress. If any patient had a history of change of bowe1 habit, tarry stooIs or weight Ioss, he was excIuded from this series. The presence of a paIp&Ie or visibIe tumor in the Iower bowe1 or of abnorma1 mucosa, Iumen or bowe1 content rendered subsequent x-ray examination mandatory. This patient, too, was not incIuded. It is emphasized that this study is not a survey in the usua1 sense of the word. It is an.attempt to assess the vaIue of the barium enema in a Iarge group of patients who, by thorough cIinica1 examination incIuding proctosigmoidoscopy, have shown no evidence of intrinsic coIon disease. The study was started on the arbitrary
premise that any patient forty years of age or over, who is considered under the criteria of the standard diagnostic procedures as a candidate for hemorrhoidectomy, must aIso be considered as a candidate for barium enema. There was at first some misgiving due to the fact that in dealing aImost entireIy with private patients there wouId be reluctance on the patient’s part to pay for a procedure which was not cIearIy indicated. This misgiving was promptly dispeIIed by the universa1 and ready wiIIingness of the patient to cooperate. The sharp Iimits of the study have widened aImost unnoticeabIy until its edges are indistinct and many individuaIs Iess than forty years of age are included. AI1 radiographic studies were done by quaIified roentgenoIogists. In seventy-four of the tota 600 cases compIeteIy unsuspected abnormaIities of the coIon were found. This group constitutes 12.3 per cent of the entire series. Seventy pdtients (I I .6 per cent) were found to have diverticuIosis of the coIon of minima1 to severe degree. Of these seventy, tweIve patients (2.0 per cent) showed evidence of diverticuIitis of varying degree, despite the fact that these patients were asymptomatic at the time. Four patients (0.66 per cent) were found to have intrinsic new growths of the coIon. There were three solitary poIypi of the coIon and one Iarge carcinoid of the cecum. Thus sixteen patients (2.7 per cent) had coIon abnormaIities of rea1 cIinica1 significance. A short rCsumi: regarding the ceca1 carcinoid is reported herein as a case in point: CASE
REPORT
H. L. No. 25283, a fifty-four year old white maIe, was first seen in this cIinic on November 21, 1949. At that time the chief compIaint was “piIes” of one year’s duration. There was a history of occasional fresh, red bIeeding from the rectum with bowe1 movement. No history of tarry or cIay-colored stooIs, weight loss, abdomina1 distress, change in normal bowe1 habit or jaundice was evinced. The patient’s appetite
* From the Ferguson-Droste-Ferguson RectaI CIinic and HospitaI, Grand Rapids, Mich.
November,
I 95 I
553
354
Ferguson-Diagnostic
PotentiaI
was exceIIetit and unchanged and no quaIitative food idiosyncrasy was present. PhysicaI examination showed the patient to be a we11deveIoped, we11nourished, white maIe of approximateIy his stated age. Genera1 examination reveaIed edentuIism and a right lower quadrant abdomina1 scar expIained as a resuIt of appendectomy twenty-two years before. AnorectaI examination reveaIed Iarge interna and externa1 hemorrhoids with active internal hemorrhoida bleeding. Proctosigmoidoscopic examination to 22 cm. reveaIed a norma mucosa and Iumen, with the exception of meIanosis coIi. Laboratory findings were as foIIows: Routine bIood and urine examinations were norma and the Kahn seroIogic reaction test was negative. Hemorrhoidectomy preceded by routine barium enema x-ray examination of the colon was advised. This procedure was done on November zznd, using the double contrast technic and a probabIe soft tissue mass within the tip of the cecum was reported. A confirmatory barium enema with air contrast was done on November 25th and a 3 cm., ovaI, poIypoid Iesion in the media1 portion of the tip of the cecum was unequivocaIIy reported. (Fig. I.) AbdominaI operation was advised and right coIectomy with ileotransverse coIostomy was
of Barium
Enema
carried out five days Iater. There was no evidence of IocaI or distant extension of the tumor. The patient’s recovery was uneventful. PathoIogic findings were as follows: GrossIy, the specimen consisted of a cecum, with a portion of ascending coIon 12 cm. in Iength and 15 cm. of dista1 iIeum. (Fig. 2.) In the dista1 portion of the cecum just under a smaI1 scar, presumabIy from removal of the appendix, was a round, smooth, eIevated 4 cm. firm tumor which was pushed out from beneath the mucosa but did not appear to be part of the mucosa. At one side of the tumor was a smaI1 indentation as though representing the appendicea base, aIthough this was not definite. MicroscopicaIIy, sections through the ceca1 tumor reveaIed a maIignant growth composed of thick intertwining cords of we11differentiated poIyhedra1 ceIIs of uniform pattern which were growing IuxuriantIy throughout the layers of the gut waI1, having reached the mesocoIon at their furthest extension. No transition from the gobIet ceIIs of the coIonic gIands to the tumor couId be demonstrated; rather the tumor appeared to have eroded through the mucosa at its center, with periphera1 undermining. There was remarkabIy IittIe inff ammation associated with the Iesion and the sateIIite lymph nodes were free of tumor tissue. American
Journal
of Surge y
Ferguson-Diagnostic
FIG. 2. Patient H. L., terminal piasm of cecal waI1.
Potential
Enema
555
iIeum, cecum and ascending colon showing neo-
PathoIogic diagnosis was carcinoid of the cecum. The histology of the tumor is typica for carcinoid and its location suggests an origin from the appendicea1 stump. SUMMARY
In a series of 600 patients with anorecta1 disease the history, physica examination and pr&tosigmoidoscopic examination ruIed out any suspicion of intrinsic coIon disease. Adjunctive barium enema studies, however, reveaIed that 12.3 per cent of these patients actuaIIy did have abnormalities of the coIon and that 2.7 per cent of the entire series had unsuspected and cIinicaIIy significant colon disease. Four operative procedures were performed. CoIotomy and poIypectomy were done in three patients and right coIectomy and iIeotransverse coIostomy were performed in one. The polypi, by pathoIogic study, have been compIeteIy excised and are benign in character. None of the patients with diverticuIosis and diverticuIitis required operation. It is reassuring that no carcinomas were discovered in this particuIar series. However, it is obvious that small asymptomatic carcinomas wiI1 be detected in no other way. CONCLUSIONS
The maxima1 diagnostic potentia1 of barium enema x-ray examination of the coIon is emphasized in this study of 600 carefuIIy screened patients. It is hoped that the procedure wiI1 become an integra1 part of the diagnostic armamentarium of a11those who dea1 with anorecta1 disease.
November, Igfx
of Barium
DISCUSSION GEORGE D. VAUGHN (Richmond, Va.): It is with a good dea1 of reIuctance that I voice my views on the routine use of barium enema studies in proctoIogic patients. Granted that it is a reIativeIy safe procedure, it is not without some attendant danger. There have been many cases reported of rupture of the bowe1 wal1, rupture of the diverticuIa and other compIications! and I do not believe that the examination IS to be entered into IightIy. The infahibility of barium enema studies has been greatIy overemphasized. In the past year fourteen clinic and private patients with known carcinoma of the rectosigmoid and sigmoid by sigmoidoscopic examination were examined by barium enema with air contrast in an effort to Iocate muItipIe Iesions. In two of these patients the radiologist was unabie to demonstrate the Iesion. Everyone agrees this is often true in the case of smaI1 polyps. Inasmuch as four patients of the 600 reported by Dr. Ferguson showed evidence of upper large bowe1 surgicaI pathoIogic disorder by radiographic studies, and these without subjective or objective signs or symptoms, it seems to me extremeIy important that in those patients who present even the miIdest suggestion of unknown bowe1 Iesions that we insist on further examination. A significant point in an attempt to anaIyze this paper is that if we were to take the first 600 people passing into this hote1 and have barium enema studies done the incidence wouId be even higher than reported by Dr. Ferguson, because there wouId be a few in that group who wouId
556
Ferguson-Diagnostic
PotentiaI
present some signs and symptoms and they wouId automaticaIIy have been excluded in Dr. Ferguson’s group. It wouId be an idea1 arrangement if everyone, particuIarIy those over forty years of age, couId have a barium enema examination, bronchogram, urogram and gastrointestina1 series done, but obviousIy this is not practica1. MICHAEL W. HOLEHAN (Memphis, Tenn.): I cannot let this go by without heartiIy endorsing everything Dr. Ferguson has said. The coIon, as you know, is a siIent organ. OccasionaIIy you have a few symptoms which wiI1 point out a maIignancy or the presence of a growth. I recommend that a very carefu1 history be taken of every patient regardIess of what he has. If there is the Ieast suggestion of a change in bowe1 habits, of bIood or mucous, I recommend that the patient have a thorough recta1 and high sigmoidoscopic examination. I disagree with Dr. Vaughn. People of this day and time are extremely cancer-conscious. AI1 you have to do is to raise a slight doubt that there might be some troubIe higher in the colon than you can reach with the sigmoidoscope and they wiI1 usuaIIy have an x-ray examination. When I say x-ray examination, I do not mean just any x-ray examination. Know your x-ray man. I have found that some x-ray men wiI1 give you a high percentage of Iesions which are confirmed at operation, whereas other cases of bad maIignancy are compIeteIy missed. Your patient must be thoroughIy prepared for examination. AI1 form of feces and everything have to be compIeteIy eIiminated, and these examinations must be very carefuIIy studied. I cannot recommend anything more highIy than the contrast enemas. Some x-ray
of Barium
Enema
men do not believe in this type of enema. I have known from experience over quite a few years of colon surgery and examinations that a contrast air enema wiI1 show up many lesions that the average x-ray man has missed. JAMES A. FERGUSON (closing): Dr. Vaughn mentioned the first 600 peopIe who waIk in the front door. I wouId Iike to refer to a pure survey type of colon study which came to my attention. I was Iooking for something Iike this for a comparison with this series and the reaIIy purest survey I could fmd was that which was done by Dr. Marie Ortmayer and Dr. Marie Conley in the cancer prevention center at Women’s and ChiIdren’s HospitaI in Chicago. The cancer prevention center admits onIy women who consider themseIves we11 and who have no symptoms suggesting cancer. Of the I ,o 14 patients examined onIy two such tumors, that is poIypi, were diagnosed by the roentgen method. One tumor was Iow in the ampulla and had been seen previousIy at proctoscopy. This case wo
American Journal of Surgery
A.
PERGUSON,
M.D.
Grand Rapids, Michigan
T
HE dangers which attend incompIete diagnostic efforts are particuIarIy serious when diseases of the Iarge bowe1 and its outIet are present. Too frequentIy, hemorrhoids which are present in so many patients are treated by removal with compIete disregard for more important Iesions of the rectum and coIon. CommonpIace errors of oversight can be obviated by carefu1 history-taking, thorough physica examination and deIiberate proctosigmoidoscopic examination. If any one of these diagnostic steps yieIds suggestive evidence of intrinsic abnormaIity, further investigation becomes mandatory. If a11 three procedures cIearIy indicate that the patient is norma in other respects, it is &II wise to empIoy one additiona1 diagnostic procedure before assuming that hemorrhoidectomy wiI1 constitute adequate treatment. This procedure, x-ray examination of the coIon during and following the injection of barium per rectum, constitutes a most important addition to the customary proctoIogic diagnostic steps. A series of 600 cases has been accumulated in which the standard diagnostic procedures have suggested no intrinsic abnormality and in which barium enema x-ray examination of the, coIon has been done and may be considered strictIy adjunctive. AI1 600 patients sought medica aid for the reIief of rea1 or fancied ana distress. If any patient had a history of change of bowe1 habit, tarry stooIs or weight Ioss, he was excIuded from this series. The presence of a paIp&Ie or visibIe tumor in the Iower bowe1 or of abnorma1 mucosa, Iumen or bowe1 content rendered subsequent x-ray examination mandatory. This patient, too, was not incIuded. It is emphasized that this study is not a survey in the usua1 sense of the word. It is an.attempt to assess the vaIue of the barium enema in a Iarge group of patients who, by thorough cIinica1 examination incIuding proctosigmoidoscopy, have shown no evidence of intrinsic coIon disease. The study was started on the arbitrary
premise that any patient forty years of age or over, who is considered under the criteria of the standard diagnostic procedures as a candidate for hemorrhoidectomy, must aIso be considered as a candidate for barium enema. There was at first some misgiving due to the fact that in dealing aImost entireIy with private patients there wouId be reluctance on the patient’s part to pay for a procedure which was not cIearIy indicated. This misgiving was promptly dispeIIed by the universa1 and ready wiIIingness of the patient to cooperate. The sharp Iimits of the study have widened aImost unnoticeabIy until its edges are indistinct and many individuaIs Iess than forty years of age are included. AI1 radiographic studies were done by quaIified roentgenoIogists. In seventy-four of the tota 600 cases compIeteIy unsuspected abnormaIities of the coIon were found. This group constitutes 12.3 per cent of the entire series. Seventy pdtients (I I .6 per cent) were found to have diverticuIosis of the coIon of minima1 to severe degree. Of these seventy, tweIve patients (2.0 per cent) showed evidence of diverticuIitis of varying degree, despite the fact that these patients were asymptomatic at the time. Four patients (0.66 per cent) were found to have intrinsic new growths of the coIon. There were three solitary poIypi of the coIon and one Iarge carcinoid of the cecum. Thus sixteen patients (2.7 per cent) had coIon abnormaIities of rea1 cIinica1 significance. A short rCsumi: regarding the ceca1 carcinoid is reported herein as a case in point: CASE
REPORT
H. L. No. 25283, a fifty-four year old white maIe, was first seen in this cIinic on November 21, 1949. At that time the chief compIaint was “piIes” of one year’s duration. There was a history of occasional fresh, red bIeeding from the rectum with bowe1 movement. No history of tarry or cIay-colored stooIs, weight loss, abdomina1 distress, change in normal bowe1 habit or jaundice was evinced. The patient’s appetite
* From the Ferguson-Droste-Ferguson RectaI CIinic and HospitaI, Grand Rapids, Mich.
November,
I 95 I
553
354
Ferguson-Diagnostic
PotentiaI
was exceIIetit and unchanged and no quaIitative food idiosyncrasy was present. PhysicaI examination showed the patient to be a we11deveIoped, we11nourished, white maIe of approximateIy his stated age. Genera1 examination reveaIed edentuIism and a right lower quadrant abdomina1 scar expIained as a resuIt of appendectomy twenty-two years before. AnorectaI examination reveaIed Iarge interna and externa1 hemorrhoids with active internal hemorrhoida bleeding. Proctosigmoidoscopic examination to 22 cm. reveaIed a norma mucosa and Iumen, with the exception of meIanosis coIi. Laboratory findings were as foIIows: Routine bIood and urine examinations were norma and the Kahn seroIogic reaction test was negative. Hemorrhoidectomy preceded by routine barium enema x-ray examination of the colon was advised. This procedure was done on November zznd, using the double contrast technic and a probabIe soft tissue mass within the tip of the cecum was reported. A confirmatory barium enema with air contrast was done on November 25th and a 3 cm., ovaI, poIypoid Iesion in the media1 portion of the tip of the cecum was unequivocaIIy reported. (Fig. I.) AbdominaI operation was advised and right coIectomy with ileotransverse coIostomy was
of Barium
Enema
carried out five days Iater. There was no evidence of IocaI or distant extension of the tumor. The patient’s recovery was uneventful. PathoIogic findings were as follows: GrossIy, the specimen consisted of a cecum, with a portion of ascending coIon 12 cm. in Iength and 15 cm. of dista1 iIeum. (Fig. 2.) In the dista1 portion of the cecum just under a smaI1 scar, presumabIy from removal of the appendix, was a round, smooth, eIevated 4 cm. firm tumor which was pushed out from beneath the mucosa but did not appear to be part of the mucosa. At one side of the tumor was a smaI1 indentation as though representing the appendicea base, aIthough this was not definite. MicroscopicaIIy, sections through the ceca1 tumor reveaIed a maIignant growth composed of thick intertwining cords of we11differentiated poIyhedra1 ceIIs of uniform pattern which were growing IuxuriantIy throughout the layers of the gut waI1, having reached the mesocoIon at their furthest extension. No transition from the gobIet ceIIs of the coIonic gIands to the tumor couId be demonstrated; rather the tumor appeared to have eroded through the mucosa at its center, with periphera1 undermining. There was remarkabIy IittIe inff ammation associated with the Iesion and the sateIIite lymph nodes were free of tumor tissue. American
Journal
of Surge y
Ferguson-Diagnostic
FIG. 2. Patient H. L., terminal piasm of cecal waI1.
Potential
Enema
555
iIeum, cecum and ascending colon showing neo-
PathoIogic diagnosis was carcinoid of the cecum. The histology of the tumor is typica for carcinoid and its location suggests an origin from the appendicea1 stump. SUMMARY
In a series of 600 patients with anorecta1 disease the history, physica examination and pr&tosigmoidoscopic examination ruIed out any suspicion of intrinsic coIon disease. Adjunctive barium enema studies, however, reveaIed that 12.3 per cent of these patients actuaIIy did have abnormalities of the coIon and that 2.7 per cent of the entire series had unsuspected and cIinicaIIy significant colon disease. Four operative procedures were performed. CoIotomy and poIypectomy were done in three patients and right coIectomy and iIeotransverse coIostomy were performed in one. The polypi, by pathoIogic study, have been compIeteIy excised and are benign in character. None of the patients with diverticuIosis and diverticuIitis required operation. It is reassuring that no carcinomas were discovered in this particuIar series. However, it is obvious that small asymptomatic carcinomas wiI1 be detected in no other way. CONCLUSIONS
The maxima1 diagnostic potentia1 of barium enema x-ray examination of the coIon is emphasized in this study of 600 carefuIIy screened patients. It is hoped that the procedure wiI1 become an integra1 part of the diagnostic armamentarium of a11those who dea1 with anorecta1 disease.
November, Igfx
of Barium
DISCUSSION GEORGE D. VAUGHN (Richmond, Va.): It is with a good dea1 of reIuctance that I voice my views on the routine use of barium enema studies in proctoIogic patients. Granted that it is a reIativeIy safe procedure, it is not without some attendant danger. There have been many cases reported of rupture of the bowe1 wal1, rupture of the diverticuIa and other compIications! and I do not believe that the examination IS to be entered into IightIy. The infahibility of barium enema studies has been greatIy overemphasized. In the past year fourteen clinic and private patients with known carcinoma of the rectosigmoid and sigmoid by sigmoidoscopic examination were examined by barium enema with air contrast in an effort to Iocate muItipIe Iesions. In two of these patients the radiologist was unabie to demonstrate the Iesion. Everyone agrees this is often true in the case of smaI1 polyps. Inasmuch as four patients of the 600 reported by Dr. Ferguson showed evidence of upper large bowe1 surgicaI pathoIogic disorder by radiographic studies, and these without subjective or objective signs or symptoms, it seems to me extremeIy important that in those patients who present even the miIdest suggestion of unknown bowe1 Iesions that we insist on further examination. A significant point in an attempt to anaIyze this paper is that if we were to take the first 600 people passing into this hote1 and have barium enema studies done the incidence wouId be even higher than reported by Dr. Ferguson, because there wouId be a few in that group who wouId
556
Ferguson-Diagnostic
PotentiaI
present some signs and symptoms and they wouId automaticaIIy have been excluded in Dr. Ferguson’s group. It wouId be an idea1 arrangement if everyone, particuIarIy those over forty years of age, couId have a barium enema examination, bronchogram, urogram and gastrointestina1 series done, but obviousIy this is not practica1. MICHAEL W. HOLEHAN (Memphis, Tenn.): I cannot let this go by without heartiIy endorsing everything Dr. Ferguson has said. The coIon, as you know, is a siIent organ. OccasionaIIy you have a few symptoms which wiI1 point out a maIignancy or the presence of a growth. I recommend that a very carefu1 history be taken of every patient regardIess of what he has. If there is the Ieast suggestion of a change in bowe1 habits, of bIood or mucous, I recommend that the patient have a thorough recta1 and high sigmoidoscopic examination. I disagree with Dr. Vaughn. People of this day and time are extremely cancer-conscious. AI1 you have to do is to raise a slight doubt that there might be some troubIe higher in the colon than you can reach with the sigmoidoscope and they wiI1 usuaIIy have an x-ray examination. When I say x-ray examination, I do not mean just any x-ray examination. Know your x-ray man. I have found that some x-ray men wiI1 give you a high percentage of Iesions which are confirmed at operation, whereas other cases of bad maIignancy are compIeteIy missed. Your patient must be thoroughIy prepared for examination. AI1 form of feces and everything have to be compIeteIy eIiminated, and these examinations must be very carefuIIy studied. I cannot recommend anything more highIy than the contrast enemas. Some x-ray
of Barium
Enema
men do not believe in this type of enema. I have known from experience over quite a few years of colon surgery and examinations that a contrast air enema wiI1 show up many lesions that the average x-ray man has missed. JAMES A. FERGUSON (closing): Dr. Vaughn mentioned the first 600 peopIe who waIk in the front door. I wouId Iike to refer to a pure survey type of colon study which came to my attention. I was Iooking for something Iike this for a comparison with this series and the reaIIy purest survey I could fmd was that which was done by Dr. Marie Ortmayer and Dr. Marie Conley in the cancer prevention center at Women’s and ChiIdren’s HospitaI in Chicago. The cancer prevention center admits onIy women who consider themseIves we11 and who have no symptoms suggesting cancer. Of the I ,o 14 patients examined onIy two such tumors, that is poIypi, were diagnosed by the roentgen method. One tumor was Iow in the ampulla and had been seen previousIy at proctoscopy. This case wo
American Journal of Surgery