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Technique of the double contrast barium meal with examples of correlation with endoscopy
Clin. RadioL (1973) 24, 307-314 TECHNIQUE
OF T H E D O U B L E
EXAMPLES
OF
CONTRAST
CORRELATION
WITH
BARIUM
MEAL WITH
ENDOSCOPY
LOUIS KREEL,~ H A N S H E R L I N G E R and J O H N G L A N V I L L E +
~From the Departments of Radiology of Northwick Park Hospital, Harrow, London, and +Leeds (St. James's) University Hospital The technique of double contrast barium meal examination is presented. This requires a liquid barium of low viscosity and high concentration. Transient gastric atony is required to prevent entry of barium into overlying small bowel, but this must not be too prolonged or the duodenal cap and loop will not be shown. Moderate duodenal relaxation gives views comparable to hypotonic duodenography, but it does preclude follow-through examination of the small bowel as the transit time becomes greatly prolonged, The surface pattern of the stomach showing areae gastricae can be routinely demonstrated, and thus becomes the criterion of an adequate examination. Small gastric carcinomas of the order of 2-3 cm can be demonstrated, benign and malignant disease can be distinguished and the surface changes in such conditions as chronic erosive gastritis and Menetriere's disease can be visualised as well as the small "ulcers' following endoscopic biopsies.
THE high incidence of gastric carcinoma and the widespread use of endoscopy in Japan led to the realisation that the conventional barium meal was an inadequate examination for the detection of small lesions. This is particularly so for very shallow ulcers, flat or surface lesions and for distinguishing between benign and malignant ulcers (Shirakabe, 1971).
tration must be at least 100 w / v ~ with a viscosity of 15 - 20 c.p.s. I f used, gas tablets* or powder are given at this stage to be washed down by the initial swallow of barium. ANTERIOR WALL OF STOMACH.---The patient is then turned prone to face the table and is tilted to assume the horizontal prone position. If a naso-gastric tube has been inserted, then 150 ml of air is next injected. Flat, soft pads are placed under the abdomen and by slight rotation the anterior wall of the stomach is visualised and films METHOD taken (Fig. 1), using a high kilovoltage (100-110). To achieve an adequate examination of the With the patient remaining in the prone position, a stomach, each area must be viewed separately further 200 ml of barium, suspension, (to which a using a double contrast technique but also applying small amount of Siloxane** has been added) is direct compression to the barium-filled stomach in given, and while this is being done the oesophagus such areas where this is possible. Preparation.--The patient fasts in the usual is viewed and exposures taken. A further 150 ml way. Gas for the stomach can be achieved either by of air is injected down the naso-gastric tube and naso-gastric tube or from gas powder or tablets. * In the patient is then turned into the supine position the former case, the naso-gastric tube should be over the left side, so as to prevent barium entry inserted as the first maneouvre. 10-20 mgm of into the duodenum. POSTERIOR WALL OF STOMACH.--The patient Buscopan is then given intravenously and the is then rocked from side to side three or four patient is placed in front of the fluoroscopy table. times to wash the surface of the stomach with 50 ml of barium suspension is then swallowed barium. The patient must end this maneouvre under fluoroscopic control At present we use by lying momentarily on the left side to drain Baritop (Concept Pharmaceuticals), but we are in the barium into the gastric fundus before being the process of modifying other barium mixtures A film of the posterior to produce similar appearances. The concen- placed supine again. wall is then taken immediately (Fig.2), using low • The effervescenttablets are made in Japan and are supplied kilovoltage (70-80). Similar double contrast exby Concept Pharmaceuticals. posures are taken in the right anterior oblique and • * Siloxyl suspension as made by Concept Pharmaceuticals using 5 ml. of the suspension, which in fact, contains 125 mg. then in the left anterior oblique positions, each following t~urther side to side rocking. of Polymethylsilo×ane. 307
308
CLINICAL
RADIOLOGY
FIG. 1 Prone film taken after 50 ml o f barium and gas tablets (or 150 ml o f gas insufflated), with compression by a soft, fiat pad under the patient's abdomen.
Fio. 2 Double contrast supine view showing normal gastric pattern. The areae gastricae are shown over the posterior wall o f the gastric antrum and body o f the stomach.
FIG. 3
Semi-prone film with the table tilted to 45 ° showing mucosal pattern in the fundus.
TECHNIQUE OF THE DOUBLE CONTRAST BARIUM MEAL
309
FIG. 4
FIG. 5
Double contrast view o f the gastric fundus and daodennm in the erect position.
Double contrast view o f the duodenal cap, demonstrating radial lines, marginal indentations and a central fleck o f barium in duodenal ulcer disease.
FIG. 6
GASTRIC FUNDUs.--The patient is then turned prone and the table raised to a 45 ~ - 60 ° position. By rotating the patient it is possible to obtain an
Double contrast view o f duodenal loop and stomach, giving appearances in the duodenum similar to hypotonic dnodenography.
Active Constituents'
Sodium bicarbonate Tartatic acid Calcium carbonate
mg pet" lablet
35.0 35.0 5-0
Other constituents
Silicone Magnesium stearate Sodium carboxymethylcellulose Lactose
3.0 2"0 0.4 4.6
oblique double contrast view of the fundus (Fig. 3). Thereafter, the table is tilted to the horizontal position and the patient turned to lie supine to again wash the fundus with barium. The table is then rapidly b r o u g h t into the erect position for a further film of the stomach (Fig. 4). COMPRESSION FILMS.--Spot films with cone compression to bring the opposing walls of the gastric antrum and b o d y into contact with each other are best done in the erect or semi-erect position.
310
CLINICAL RADIOLOGY
FIG. 7 Double contrast view o f oesophagus.
FIG. 8 (A, B) Double contrast view o f large 'ulcer' crater with a rolled edge, areae gastricae up to the margin o f the lesion and absence of linear contractions towards the lesion. An ulcerating gastric carcinoma.
DUODENAL C A P . - - E r e c t compression films o f the d u o d e n a l cap at this stage usually show it well filled with a g o o d view o f the d u o d e n a l loop, a n d s p o t films in b o t h oblique views can be taken. Finally, supine d o u b l e c o n t r a s t views o f the duodenal cap (Fig. 5) and l o o p (Fig. 6) can be made, a n d the e x a m i n a t i o n should be c o n c l u d e d b y examining for hiatus hernia with the patient lying over a bolster. A w e l l - c o n d u c t e d e x a m i n a t i o n takes 1 0 - 15 minutes. OESOPI-IAGUS.--Double c o n t r a s t views o f the oesophagus can also be o b t a i n e d by examining the p a t i e n t in the erect oblique position. The b a r i u m should be gulped to distend the oesophagus, i f the patient stops swallowing, it will be seen that there is a short p e r i o d w h e n the b a r i u m is at the lower end o f the oesophagus a n d the u p p e r threequarters is distended b y gas. F i l m s are then t a k e n (Fig. 7). ILLUSTRATIVE CASES Case 1.--A female, aged 81 years, complained of painless vomiting for one month without haematemesis or previous dyspepsia. Haemoglobin was 8-3 G ~ and the faecal occult blood test was positive. Barium meal showed a large ulcer with a rolled edge (Fig. 8) and normal mucosa with areae gastricae up to the site of the ulcer; radiating folds were absent. Laparotomy demonstrated a deep malignant ulcer with liver metastases and peritoneal seedlings. Comment: Large ulcers can be demonstrated by any barium meal technique, but a double contrast examination is required if the edge and the adjacent mucosal pattern are to be visualised, in order to distinguish malignant from benign ulcers. Case 2.--A male, aged 33 years, complained of indigestion for four years, mostly after solid foods, with frequent vomiting There was partial relief from alkalies. He had several previous barium meals, with a gastric ulcer reported in 1968. A conventional barium meal was reported to show malignant infiltration. Gastroscopy showed massively hypertrophied
FIG. 8B.
TECHNIQUE OF THE DOUBLE CONTRAST BARUIM MEAL
311
meals, relieved by alkalies. Conventionalbarium meal showed a gastric residue, partial pyloric stenosis and chronic duodenal ulceration. A repeat barium meal using the double contrast technique demonstrated a 3 cm lesion in the gastric antrum, having the features of a type 2 lesion (Japan Gastroenterological Endoscopy Society, 1962) (Fig. 12). On endoscopy, the narrow rigid pyloric canal was seen as well as a flat ulcer without surrounding oedema, the typical appearance of a surface carcinoma. Comment: An excellent correlation was established between radiography and endoscopy in this flat ulcerating type of carcinomatous lesion. This lesion could not be visualised by conventional barium examination.
DISCUSSION
Fro. 9 Prone view demonstrating giant rugal hypertrophy in Menetriere's disease.
rugal folds, and many biopsies.taken from the antral region showed no evidence of malignancy. Repeat barium meal demonstrated the thickened folds in the prone film (Fig. 9), and by double contrast many small "ulcer craters" with surrounding oedema were shown (Fig. 10). This is considered to be a case of Menetriere's disease, the small "ulcers" probably being the sites of recent biopsy; the area appeared normal on further endoscopy. Comment: Although Menetriere's disease can usually be shown on conventional examinations, the demonstration of thick folds without true filling defects is unequivically demonstrated by this double contrast technique. The detail visible is, however, such that the small "ulcers" left after endoscopic biopsy can be seen and are similar to those described for chronic erosive gastritis (Prevot & Lasserich, 1959). Case 3.---A male, aged 69 years, was admitted with central abdominal pain and on examination there was central epigastric guarding and tenderness. Ulcer surgery had been carried out three years previously. Barium meal examination showed a depressed area in the gastric fundus (Fig. 11) which could not be obliterated by gas distension_ Endoscopic examination revealed a thickened, whitish plaque extending from the cardia to the ftmdus of the stomach. Comment: Failure of distension of the gastric fundus in a localised area indicated rigidity and the presence of an infiltrating lesion. Gas distension gives a good view of this area, which is often a 'blind' area on conventional barium meal examinations. Case 4.--A female, aged 72 years, presented with a twenty year history of periodic pain, occurring 2 - 3 hours after
I n J a p a n it has been shown that by the use of double contrast b a r i u m technique, Stage I gastric carcinomas of 2 - 3 c m in size can be detected. H a v i n g established the technique, it became possible to attain a pick-up rate of over 80% for such lesions, m a k i n g the b a r i u m meal almost as reliable as endoscopy. However, i n this c o u n t r y there has been n o real m o v e to a d o p t this technique except in a few special centres. The criterion of an adequate b a r i u m meal is m u c h more easily established in the case of the double contrast technique t h a n of a c o n v e n t i o n a l meal. The crux of the matter is, that with a double contrast technique, the gastric surface should be seen in m i n u t e detail. The visualisation of areae gastricae should be r o u t i n e and n o t just a n occasional achievement. One can thus say that an adequate b a r i u m meal examination requires the visualisation o f the areae gastricae. It is n o w realised that this is done by fine layering of b a r i u m of low viscosity a n d high concentration. Low viscosity b a r i u m in the gas-filled stomach can wash across the surface leaving a fine layer, b u t this will r u n away rapidly so that the film must follow the washing without delay. Quite clearly, the higher the barium concentration, the more adequately will the fine layer of b a r i u m o n the mucosal surface be seen. However, with increasing c o n c e n t r a t i o n of barium, there is increased viscosity preventing the rapid washing effect. The ideal b a r i u m would appear to be that which produces the correct balance between a sufficiently high c o n c e n t r a t i o n without u n d u e increase in viscosity. The other effect of high viscosity is to produce multiple b u b b l e formation while the b a r i u m is being '°sloshed" across the gastric surface. This can, to a certain degree, be overcome by the use of Siloxane to disperse the bubbles formed by this washing. The use of a " h y p o t o n i c " agent such as Buscopan is a n essential part of the technique. Barium escaping into the third part of the duo-
312
CLINICAL RADIOLOGY
FIG. I0
Small barium .17ecks surrotmded by halo of raised mucosa. Appearances .following multiple biopsies taken at endoscopy.
J
FIG. II
Deformity of the gastric fundus, due to a small plaque-like gastric carcinoma.
T E C H N I Q U E O17 THE D O U B L E C O N T R A S T B A R I U M MEAL
FIG. 12A.
313
FIO. 12•.
FIG. 12A and Fie. 12B Small gastric carcinoma (Japan type II) in the antrum, as indicated by arrows. Confirmed on endoscopy.
M A G N I F I E D VIEWS
denum and proximal jejunum would obscure gastric visualisation. On the other hand, if the gastric atony produced is too severe or prolonged no barium would enter the duodenum, making examination of this area impossible. Buscopan in in this respect is quite good, as it is short acting and allows successful examination of the duodenum. This carries with it a further advantage in that views of the duodenum, when later obtained, show it free of spasm producing a resemblance to hypotonic duodenogram. Double contrast views of the duodenal cap and loop are easily obtained due to
the large amount of gastric gas. This method of examination therefore also enhances the visualisation of the duodenal cap and loop. The use of smooth muscle relaxants such as Buscopan markedly slows barium transit through the small bowel. It thus becomes impracticable to do a follow-through examination once Buscopan has been injected. For the performance of the routine barium meal, there may be some objection to the use of a naso-gastric tube in spite of the ease and rapidity with which it can be passed. It has, however, been
314
CLINICAL RADIOLOGY
shown that this is the method of choice for producing the best mucosal pattern free of bubble formation. Gas powder or tablets are obviously more acceptable to patients, but clearly in special circumstances where high definition is imperative, a naso-gastric tube will be required. The obscuring effects of gas bubbles forming on the mucosal pattern can largely be overcome by the use of Siloxane. The difficulty of overcoming the "effects of mucus" is, however, largely speculative. Using a barium of low viscosity and a "washing" or "sloshing" technique of coating the gastric surface, the usual appearances ascribed to mucus are not seen and the whole issue then becomes irrelevant once areae gastricae are routinely shown. While this technique was largely developed to show early carcinomatous lesions, it quite clearly also gives detailed information of many other conditions. Old healed ulcer scars are easily demonstrated (Scott-Harden, 1973) as are small posterior wall ulcers. Surface lesions, such as gastric erosions can be shown, and the possibility of actually measuring the size of "mucosal folds" is presented. Quite clearly, the appearance of giant gastric rugal hypertrophy (Menetriere's disease) can be distinguished from gastric carcinoma. Gas distension with mucosal visualisation has a distinct advantage in detecting lesions in the fundus. Areas of rigidity and deformity can easily be seen, which again allows for their diagnosis at an earlier stage. Intrinsic deformity of the gastric ftmdal wall can be distinguished from extrinsic pressure defects~ A further advantage of this technique is that the appearance of gastric lesions as demonstrated by this method corresponds very closely to macroscopic appearances of the lesion and to the endoscopic view. This has led to a much better appreciation of the visual differences between benign and malignant lesions.
While the advantages of this technique are obvious to those who are determined to obtain maximum information, the objection will inevitably be raised that it is time-consuming and requires more films than a conventional barium examination. In Japan, it has been shown that this examination can be carried out rapidly enough to be used as a routine screening procedure, and no doubt with practise it would soon be possible to do a full examination in 8 - 12 minutes. While this technique as described is essentially concerned with the detection of changes on the mucosal films, it must be remembered that protruding lesions are best shown on compression. Compression views of the antrum and body of the stomach are thus done routinely to obtain this additional information.
CONCLUSION By the use of low viscosity, high concentration barium and gaseous distension, it is possible to perform routine double contrast barium meals in which mucosal surface views are shown. This leads to the detection of smaller lesions and to greater accuracy in distinguishing benign from malignant disease. Acknowledgement.--We wish to acknowledge the assistance of Richard Bowlby of the Department of Medical Illustration, Clinical Research Centre, Northwick Park Hospital, for the numerous prints in this publication.
REFERENCES PREVO%R. & LASSERmH,M. A. (1959). Rontgendiagnostik des Magen-Darmkanals George Thieme, Vcrlag, Stuttgart. SCOTT-HARDEN,W. G. (1973)_ Evaluation of Double Contrast Gastro-Duodenal Radiology. British Journal of Radiology, 46, February, 153. SmRAKABE, H. (1971). Double Contrast Studies of the Stomach Bunkodo Co. Ltd_, Tokyo, Japan.
OF T H E D O U B L E
EXAMPLES
OF
CONTRAST
CORRELATION
WITH
BARIUM
MEAL WITH
ENDOSCOPY
LOUIS KREEL,~ H A N S H E R L I N G E R and J O H N G L A N V I L L E +
~From the Departments of Radiology of Northwick Park Hospital, Harrow, London, and +Leeds (St. James's) University Hospital The technique of double contrast barium meal examination is presented. This requires a liquid barium of low viscosity and high concentration. Transient gastric atony is required to prevent entry of barium into overlying small bowel, but this must not be too prolonged or the duodenal cap and loop will not be shown. Moderate duodenal relaxation gives views comparable to hypotonic duodenography, but it does preclude follow-through examination of the small bowel as the transit time becomes greatly prolonged, The surface pattern of the stomach showing areae gastricae can be routinely demonstrated, and thus becomes the criterion of an adequate examination. Small gastric carcinomas of the order of 2-3 cm can be demonstrated, benign and malignant disease can be distinguished and the surface changes in such conditions as chronic erosive gastritis and Menetriere's disease can be visualised as well as the small "ulcers' following endoscopic biopsies.
THE high incidence of gastric carcinoma and the widespread use of endoscopy in Japan led to the realisation that the conventional barium meal was an inadequate examination for the detection of small lesions. This is particularly so for very shallow ulcers, flat or surface lesions and for distinguishing between benign and malignant ulcers (Shirakabe, 1971).
tration must be at least 100 w / v ~ with a viscosity of 15 - 20 c.p.s. I f used, gas tablets* or powder are given at this stage to be washed down by the initial swallow of barium. ANTERIOR WALL OF STOMACH.---The patient is then turned prone to face the table and is tilted to assume the horizontal prone position. If a naso-gastric tube has been inserted, then 150 ml of air is next injected. Flat, soft pads are placed under the abdomen and by slight rotation the anterior wall of the stomach is visualised and films METHOD taken (Fig. 1), using a high kilovoltage (100-110). To achieve an adequate examination of the With the patient remaining in the prone position, a stomach, each area must be viewed separately further 200 ml of barium, suspension, (to which a using a double contrast technique but also applying small amount of Siloxane** has been added) is direct compression to the barium-filled stomach in given, and while this is being done the oesophagus such areas where this is possible. Preparation.--The patient fasts in the usual is viewed and exposures taken. A further 150 ml way. Gas for the stomach can be achieved either by of air is injected down the naso-gastric tube and naso-gastric tube or from gas powder or tablets. * In the patient is then turned into the supine position the former case, the naso-gastric tube should be over the left side, so as to prevent barium entry inserted as the first maneouvre. 10-20 mgm of into the duodenum. POSTERIOR WALL OF STOMACH.--The patient Buscopan is then given intravenously and the is then rocked from side to side three or four patient is placed in front of the fluoroscopy table. times to wash the surface of the stomach with 50 ml of barium suspension is then swallowed barium. The patient must end this maneouvre under fluoroscopic control At present we use by lying momentarily on the left side to drain Baritop (Concept Pharmaceuticals), but we are in the barium into the gastric fundus before being the process of modifying other barium mixtures A film of the posterior to produce similar appearances. The concen- placed supine again. wall is then taken immediately (Fig.2), using low • The effervescenttablets are made in Japan and are supplied kilovoltage (70-80). Similar double contrast exby Concept Pharmaceuticals. posures are taken in the right anterior oblique and • * Siloxyl suspension as made by Concept Pharmaceuticals using 5 ml. of the suspension, which in fact, contains 125 mg. then in the left anterior oblique positions, each following t~urther side to side rocking. of Polymethylsilo×ane. 307
308
CLINICAL
RADIOLOGY
FIG. 1 Prone film taken after 50 ml o f barium and gas tablets (or 150 ml o f gas insufflated), with compression by a soft, fiat pad under the patient's abdomen.
Fio. 2 Double contrast supine view showing normal gastric pattern. The areae gastricae are shown over the posterior wall o f the gastric antrum and body o f the stomach.
FIG. 3
Semi-prone film with the table tilted to 45 ° showing mucosal pattern in the fundus.
TECHNIQUE OF THE DOUBLE CONTRAST BARIUM MEAL
309
FIG. 4
FIG. 5
Double contrast view o f the gastric fundus and daodennm in the erect position.
Double contrast view o f the duodenal cap, demonstrating radial lines, marginal indentations and a central fleck o f barium in duodenal ulcer disease.
FIG. 6
GASTRIC FUNDUs.--The patient is then turned prone and the table raised to a 45 ~ - 60 ° position. By rotating the patient it is possible to obtain an
Double contrast view o f duodenal loop and stomach, giving appearances in the duodenum similar to hypotonic dnodenography.
Active Constituents'
Sodium bicarbonate Tartatic acid Calcium carbonate
mg pet" lablet
35.0 35.0 5-0
Other constituents
Silicone Magnesium stearate Sodium carboxymethylcellulose Lactose
3.0 2"0 0.4 4.6
oblique double contrast view of the fundus (Fig. 3). Thereafter, the table is tilted to the horizontal position and the patient turned to lie supine to again wash the fundus with barium. The table is then rapidly b r o u g h t into the erect position for a further film of the stomach (Fig. 4). COMPRESSION FILMS.--Spot films with cone compression to bring the opposing walls of the gastric antrum and b o d y into contact with each other are best done in the erect or semi-erect position.
310
CLINICAL RADIOLOGY
FIG. 7 Double contrast view o f oesophagus.
FIG. 8 (A, B) Double contrast view o f large 'ulcer' crater with a rolled edge, areae gastricae up to the margin o f the lesion and absence of linear contractions towards the lesion. An ulcerating gastric carcinoma.
DUODENAL C A P . - - E r e c t compression films o f the d u o d e n a l cap at this stage usually show it well filled with a g o o d view o f the d u o d e n a l loop, a n d s p o t films in b o t h oblique views can be taken. Finally, supine d o u b l e c o n t r a s t views o f the duodenal cap (Fig. 5) and l o o p (Fig. 6) can be made, a n d the e x a m i n a t i o n should be c o n c l u d e d b y examining for hiatus hernia with the patient lying over a bolster. A w e l l - c o n d u c t e d e x a m i n a t i o n takes 1 0 - 15 minutes. OESOPI-IAGUS.--Double c o n t r a s t views o f the oesophagus can also be o b t a i n e d by examining the p a t i e n t in the erect oblique position. The b a r i u m should be gulped to distend the oesophagus, i f the patient stops swallowing, it will be seen that there is a short p e r i o d w h e n the b a r i u m is at the lower end o f the oesophagus a n d the u p p e r threequarters is distended b y gas. F i l m s are then t a k e n (Fig. 7). ILLUSTRATIVE CASES Case 1.--A female, aged 81 years, complained of painless vomiting for one month without haematemesis or previous dyspepsia. Haemoglobin was 8-3 G ~ and the faecal occult blood test was positive. Barium meal showed a large ulcer with a rolled edge (Fig. 8) and normal mucosa with areae gastricae up to the site of the ulcer; radiating folds were absent. Laparotomy demonstrated a deep malignant ulcer with liver metastases and peritoneal seedlings. Comment: Large ulcers can be demonstrated by any barium meal technique, but a double contrast examination is required if the edge and the adjacent mucosal pattern are to be visualised, in order to distinguish malignant from benign ulcers. Case 2.--A male, aged 33 years, complained of indigestion for four years, mostly after solid foods, with frequent vomiting There was partial relief from alkalies. He had several previous barium meals, with a gastric ulcer reported in 1968. A conventional barium meal was reported to show malignant infiltration. Gastroscopy showed massively hypertrophied
FIG. 8B.
TECHNIQUE OF THE DOUBLE CONTRAST BARUIM MEAL
311
meals, relieved by alkalies. Conventionalbarium meal showed a gastric residue, partial pyloric stenosis and chronic duodenal ulceration. A repeat barium meal using the double contrast technique demonstrated a 3 cm lesion in the gastric antrum, having the features of a type 2 lesion (Japan Gastroenterological Endoscopy Society, 1962) (Fig. 12). On endoscopy, the narrow rigid pyloric canal was seen as well as a flat ulcer without surrounding oedema, the typical appearance of a surface carcinoma. Comment: An excellent correlation was established between radiography and endoscopy in this flat ulcerating type of carcinomatous lesion. This lesion could not be visualised by conventional barium examination.
DISCUSSION
Fro. 9 Prone view demonstrating giant rugal hypertrophy in Menetriere's disease.
rugal folds, and many biopsies.taken from the antral region showed no evidence of malignancy. Repeat barium meal demonstrated the thickened folds in the prone film (Fig. 9), and by double contrast many small "ulcer craters" with surrounding oedema were shown (Fig. 10). This is considered to be a case of Menetriere's disease, the small "ulcers" probably being the sites of recent biopsy; the area appeared normal on further endoscopy. Comment: Although Menetriere's disease can usually be shown on conventional examinations, the demonstration of thick folds without true filling defects is unequivically demonstrated by this double contrast technique. The detail visible is, however, such that the small "ulcers" left after endoscopic biopsy can be seen and are similar to those described for chronic erosive gastritis (Prevot & Lasserich, 1959). Case 3.---A male, aged 69 years, was admitted with central abdominal pain and on examination there was central epigastric guarding and tenderness. Ulcer surgery had been carried out three years previously. Barium meal examination showed a depressed area in the gastric fundus (Fig. 11) which could not be obliterated by gas distension_ Endoscopic examination revealed a thickened, whitish plaque extending from the cardia to the ftmdus of the stomach. Comment: Failure of distension of the gastric fundus in a localised area indicated rigidity and the presence of an infiltrating lesion. Gas distension gives a good view of this area, which is often a 'blind' area on conventional barium meal examinations. Case 4.--A female, aged 72 years, presented with a twenty year history of periodic pain, occurring 2 - 3 hours after
I n J a p a n it has been shown that by the use of double contrast b a r i u m technique, Stage I gastric carcinomas of 2 - 3 c m in size can be detected. H a v i n g established the technique, it became possible to attain a pick-up rate of over 80% for such lesions, m a k i n g the b a r i u m meal almost as reliable as endoscopy. However, i n this c o u n t r y there has been n o real m o v e to a d o p t this technique except in a few special centres. The criterion of an adequate b a r i u m meal is m u c h more easily established in the case of the double contrast technique t h a n of a c o n v e n t i o n a l meal. The crux of the matter is, that with a double contrast technique, the gastric surface should be seen in m i n u t e detail. The visualisation of areae gastricae should be r o u t i n e and n o t just a n occasional achievement. One can thus say that an adequate b a r i u m meal examination requires the visualisation o f the areae gastricae. It is n o w realised that this is done by fine layering of b a r i u m of low viscosity a n d high concentration. Low viscosity b a r i u m in the gas-filled stomach can wash across the surface leaving a fine layer, b u t this will r u n away rapidly so that the film must follow the washing without delay. Quite clearly, the higher the barium concentration, the more adequately will the fine layer of b a r i u m o n the mucosal surface be seen. However, with increasing c o n c e n t r a t i o n of barium, there is increased viscosity preventing the rapid washing effect. The ideal b a r i u m would appear to be that which produces the correct balance between a sufficiently high c o n c e n t r a t i o n without u n d u e increase in viscosity. The other effect of high viscosity is to produce multiple b u b b l e formation while the b a r i u m is being '°sloshed" across the gastric surface. This can, to a certain degree, be overcome by the use of Siloxane to disperse the bubbles formed by this washing. The use of a " h y p o t o n i c " agent such as Buscopan is a n essential part of the technique. Barium escaping into the third part of the duo-
312
CLINICAL RADIOLOGY
FIG. I0
Small barium .17ecks surrotmded by halo of raised mucosa. Appearances .following multiple biopsies taken at endoscopy.
J
FIG. II
Deformity of the gastric fundus, due to a small plaque-like gastric carcinoma.
T E C H N I Q U E O17 THE D O U B L E C O N T R A S T B A R I U M MEAL
FIG. 12A.
313
FIO. 12•.
FIG. 12A and Fie. 12B Small gastric carcinoma (Japan type II) in the antrum, as indicated by arrows. Confirmed on endoscopy.
M A G N I F I E D VIEWS
denum and proximal jejunum would obscure gastric visualisation. On the other hand, if the gastric atony produced is too severe or prolonged no barium would enter the duodenum, making examination of this area impossible. Buscopan in in this respect is quite good, as it is short acting and allows successful examination of the duodenum. This carries with it a further advantage in that views of the duodenum, when later obtained, show it free of spasm producing a resemblance to hypotonic duodenogram. Double contrast views of the duodenal cap and loop are easily obtained due to
the large amount of gastric gas. This method of examination therefore also enhances the visualisation of the duodenal cap and loop. The use of smooth muscle relaxants such as Buscopan markedly slows barium transit through the small bowel. It thus becomes impracticable to do a follow-through examination once Buscopan has been injected. For the performance of the routine barium meal, there may be some objection to the use of a naso-gastric tube in spite of the ease and rapidity with which it can be passed. It has, however, been
314
CLINICAL RADIOLOGY
shown that this is the method of choice for producing the best mucosal pattern free of bubble formation. Gas powder or tablets are obviously more acceptable to patients, but clearly in special circumstances where high definition is imperative, a naso-gastric tube will be required. The obscuring effects of gas bubbles forming on the mucosal pattern can largely be overcome by the use of Siloxane. The difficulty of overcoming the "effects of mucus" is, however, largely speculative. Using a barium of low viscosity and a "washing" or "sloshing" technique of coating the gastric surface, the usual appearances ascribed to mucus are not seen and the whole issue then becomes irrelevant once areae gastricae are routinely shown. While this technique was largely developed to show early carcinomatous lesions, it quite clearly also gives detailed information of many other conditions. Old healed ulcer scars are easily demonstrated (Scott-Harden, 1973) as are small posterior wall ulcers. Surface lesions, such as gastric erosions can be shown, and the possibility of actually measuring the size of "mucosal folds" is presented. Quite clearly, the appearance of giant gastric rugal hypertrophy (Menetriere's disease) can be distinguished from gastric carcinoma. Gas distension with mucosal visualisation has a distinct advantage in detecting lesions in the fundus. Areas of rigidity and deformity can easily be seen, which again allows for their diagnosis at an earlier stage. Intrinsic deformity of the gastric ftmdal wall can be distinguished from extrinsic pressure defects~ A further advantage of this technique is that the appearance of gastric lesions as demonstrated by this method corresponds very closely to macroscopic appearances of the lesion and to the endoscopic view. This has led to a much better appreciation of the visual differences between benign and malignant lesions.
While the advantages of this technique are obvious to those who are determined to obtain maximum information, the objection will inevitably be raised that it is time-consuming and requires more films than a conventional barium examination. In Japan, it has been shown that this examination can be carried out rapidly enough to be used as a routine screening procedure, and no doubt with practise it would soon be possible to do a full examination in 8 - 12 minutes. While this technique as described is essentially concerned with the detection of changes on the mucosal films, it must be remembered that protruding lesions are best shown on compression. Compression views of the antrum and body of the stomach are thus done routinely to obtain this additional information.
CONCLUSION By the use of low viscosity, high concentration barium and gaseous distension, it is possible to perform routine double contrast barium meals in which mucosal surface views are shown. This leads to the detection of smaller lesions and to greater accuracy in distinguishing benign from malignant disease. Acknowledgement.--We wish to acknowledge the assistance of Richard Bowlby of the Department of Medical Illustration, Clinical Research Centre, Northwick Park Hospital, for the numerous prints in this publication.
REFERENCES PREVO%R. & LASSERmH,M. A. (1959). Rontgendiagnostik des Magen-Darmkanals George Thieme, Vcrlag, Stuttgart. SCOTT-HARDEN,W. G. (1973)_ Evaluation of Double Contrast Gastro-Duodenal Radiology. British Journal of Radiology, 46, February, 153. SmRAKABE, H. (1971). Double Contrast Studies of the Stomach Bunkodo Co. Ltd_, Tokyo, Japan.