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The small bowel enema
THE SMALL BOWEL ENEMA* W.
EDWARD FRENCH, M.D. Memphis,
Tennessee
T
HE purpose of this paper is to caII of roentattention to the importance genoIogic studies of the smaI1 intestine by means of the MiIIer-Abbott tube.in the diagnosis of Iesions of the smaI1 bowe1 and to present three cases in which the diagnosis was estabIished by this method. The MiIIer-Abbott tube has been shown to be of definite vaIue in deflation of the intestina1 tract in cases of obstruction, in preoperative preparation of patients for abdomina1 surgery, in study of the physioIogy of absorption and excretion of the intestina1 tract, and the tube has aIso proved usefu1 as a method for providing nutrition in certain diffIcuIt cases. The Iong doubIe Iumen tube is now proving to be of vaIue as an aid in estabIishing a diagnosis in certain obscure Iesions of the smaI1 intestine. The first report of deflation of the intestina1 tract by intubation was presented by KussmauI and Cahn2 in 1884. Pesquera6 in 1929 was probably the first to use a duodena1 tube in roentgenoIogic studies of the smaI1 intestine. In 1934 Abbott’ introduced a doubIe lumen tube that couId be passed into the smaI1 intestine. Many studies of the smaI1 bowe1 have been carried out since the introduction of the MiIIer-Abbott tube. WeItz4 in 1939 presented many exceIIent roentgenoIogic studies of the smaI1 intestine by means of a duodena1 tube. However, this method was unsatisfactory because of the Iength of the smaI1 intestine which resuIted in overlapping of the shadows. Boon4 reported severa cases in which the doubIe Iumen intestina1 tube was used in x-ray studies of smaI1 bowe1 Iesions other than obstruction. He reported that the MiIIer-Abbott tube couId be used in cases of partia1 obstruction caused by narrowing of the Iumen, * From the Department
October,
1949
anguIation, persistent spasm or other defects. GoIden, Leigh and Swenson2 reported that no deIeterious effects resulted from the injection of barium sulfate into a MiIIer-Abbott tube in diseases of the small intestine. They cIassify their uses of the MiIIer-Abbott tube in smaI1 intestina1 studies into: (I ) paraIytic iIeus, (2) obstruction, (3) simpIe obstruction without infIammation and (4) abnorma1 mucosa1 patterns such as occur in strangulation, inflammation, maIignancy and intussusception. Many authors”5 previousIy reported using a duodena1 tube for roentgenoIogic studies of Iesions of the smaI1 intestine. Schatzki,‘j however, in 1943 first used the phrase “smaI1 intestina1 enema.” He did much to establish the vaIue of this technic in discovering obscure Iesions of the smaI1 intestine. Schatzki Iisted severa advantages of the duodenal tube as a means of examining the small intestine, nameIy, (I) the smaI1 intestine can be seen in its entirety, (2) actua1 fXIing of smaI1 intestina1 loops can be observed roentgenoIogicaIIy, (3) perora1 examination usuaIIy resuIts in irreguIar, incompIete fiIIing of iIeum, (4) adequate examination of the iIeoceca1 vaIve can be accompIished and (5) the time required for examination is shortened. The “progress mea1” of barium is frequentIy used in studying Iesions of the smaI1 intestine. Competent radioIogists are abIe to foIIow a progress mea1 of barium by means of the fIuoroscope throughout the entire smaI1 intestine. Disadvantages of this method are that it is time-consuming usuaIIy requiring a haIf day or more, exposes the patient to repeated Auoroscopic examination and may be definiteIy harmfu1 in cases of mechanica obstruction. There are many patients in gastrointesti-
of Surgery of the University
307
of Tennessee,
Memphis, Tenn.
French-SmaII
508
naI cIinics who present vague abdomina1 compIaints and in whom after the routine roentgenoIogic gastrointestina1 studies and other Iaboratory procedures no diagnosis is made. Many of these patients are toId that no organic Iesion is present and the symptoms are attributed to functiona disturbances. Some of these patients return at a later date with a definite Iesion in which the diagnosis is reIativeIy easy. Many patients with vague abdomina1 compIaints shouId have smaI1 bowe1 enema studies when the usua1 roentgenoIogic examination faiIs to revea1 any organic disease. These smaI1 bowe1 studies can be easiIy carried out with the MiIIer-Abbott tube. CASE
REPORTS
CASE I. E. S., a fifty-four year oId white maIe, was admitted to the Baptist MemoriaI HospitaI with a history of epigastric pain of eight weeks’ duration. The pain was sudden in onset and very severe. At the time of onset he was hospitahzed elsewhere and a diagnosis of amebiasis was made. Treatment for amebiasis resuIted in a disappearance of most of the symptoms. The patient was discharged from the hospita1 and instructed to return for foIIowup studies. Upon admission to our service the patient did not appear acuteIy III other than the evidence of considerabIe weight 10s~. A mass was feIt in the left Iower quadrant of the abdomen. This mass was approximateIy 3 cm. in diameter, was not tender and was freeIy movabIe. The routine bIood and urine determinations were normaI. A scout film of the abdomen was made which demonstrated some air in the transverse coIon but this was not suggestive of obstruction. Barium enema studies of the coIon were negative. A gastrointestina1 series revealed an indefinite narrowing of one loop of smaI1 intestine. This finding was not diagnostic. A smaI1 bowe1 enema revealed a partia1 obstruction of jejunum suggestive of maIignancy. The patient was operated upon and a tumor of the jejunum was found. A jejuna1 resection was done and this was foIIowed by an uneventfu1 postoperative course. PathoIogic examination of the specimen showed it to be a carcinoid with metastasis to regiona Iymph nodes. CASEII. J. N., a sixty-seven year oId white
BoweI
Enema
male, was admitted to the John Gaston Hospita1 for hemorrhoidectomy. The patient gave a history of passing bIood from the rectum for three years. At the onset of the symptoms three years before the patient was admitted to another institution in shock as a result of bIeeding from the rectum. No cause of bIeeding was found after repeated barium enema and gastrointestina1 studies. The patient was discharged and readmitted to the same hospital a second time for the same condition, namely, shock from hemorrhage. Again a11x-ray studies were negative. The patient was seen in the University of Tennessee MedicaI CIinic two years after the first bIeeding episode. At this time his compIaint was that of epigastric pain. He was admitted to the hospita1 because of severe anemia. Repeated gastrointestina1 studies and barium enema examinations were negative. The onIy physica abnormality was interna and externa1 hemorrhoids. The patient was discharged and sent to the ProctoIogy CIinic for possibIe hemorrhoidectomy and was hospitalized on September 14, 1948. Upon admission a mass couId be feIt in the right Iower quadrant of the abdomen. Review of the previous gastrointestina1 series faiIed to show visuaIization of the termina1 iIeum. A smaI1 bowe1 enema was done and a cystic mass was seen to fiI1 with barium from the termina1 ileum. The mass appeared to arise from the pelvis. The patient was expIored and a cystic Iesion was found communicating with the terminal iIeum. The Iesion was considered inoperable. However, a biopsy was taken and the pathologic report was spindle ceI1 sarcoma. CASE III. I. M., a sixty year aid colored femaIe, was admitted to the John Gaston Hospita1 with a compIaint of cramping abdomina1 pain of one month’s duration and enIargement of the abdomen for three weeks. Constipation had existed for six months and there were no bowe1 movements for one week previous to admission. There was an irreguIar, indefInite mass in the region of the umbiIicus. Barium enema examination was negative and a scout fiIm of the abdomen reveaIed some diIated Ioops of smaI1 intestine which were suggestive of partia1 obstruction. A MiIIer-Abbott tube was used for deffation and a smaI1 bowe1 enema study was done. This reveaIed a non-obstructing Iesion in the iIeum. At expIoration an annuIar Iesion was found in the mid-iIeum.
American Journal of Surgery
French-SmaII This was removed and a side-to-side anastomosis was performed. Microscopic examination showed the Iesion to be a carcinoid of the ileum. COMMENT
In none of these cases was complete obstruction present. Two of the patients had been hospitalized previously and studied extensiveIy without the diagnosis being estabhshed. Their symptoms persisted for a long period of time. AI1 of these patients had repeated barium enema and gastrointestinal studies which were reported as negative. We do not advocate smaI1 bowe1 enema studies on every patient with vague abdominal complaints. It is not beIieved that this means of studying the smaI1 intestine should replace methods in common use; however, it is an additional method which shouId be used in certain cases. We beIieve that patients who continue to have gastrointestina1 complaints and in whom no diag-
October,
1949
BoweI
Enema
nosis is made by routine studies have smaI1 bowel enema studies. SUMMARY
AND
shouId
CONCLUSIONS
I. Emphasis is pIaced on the importance of the MiIler-Abbott tube in studying Iesions of the smaI1 intestine. 2. Three cases which iIIustrate the value of this method in estabIishing a diagnosis are presented. REFERENCES I. MILLER, T. and ABBOTT, W. 0.
Intestinal intubations: a practical technic. Am. J. M. SC., 187: $95, 1934.
2. GOLDEN, R., LEIGH, 0. and SWENSON, R. C. Roentgen ray examination with the MiIIer-Abbott tube. Radiology, 35: 521, 1940. 3. LEIGH. 0. and DIEFENDORF. R. 0. The MiIlerAbbott in surgery. J. A. MI A., I 17: 210, 1942. 4. BOON, T. H. Intubation of the small intestines. Lancet, I : 7, 1940. 5. PESQUERA, G. A. Method for direct visualization of lesions in smaI1 intestines. Am. J. Roenteenol. CY Rad. Tberapy, 22: 254, 1929. 6. SCHATZKI, R. Small intestinal enema. Am. J. Roentgenol. ti Rad. Therapy, so: 743, 1943.
EDWARD FRENCH, M.D. Memphis,
Tennessee
T
HE purpose of this paper is to caII of roentattention to the importance genoIogic studies of the smaI1 intestine by means of the MiIIer-Abbott tube.in the diagnosis of Iesions of the smaI1 bowe1 and to present three cases in which the diagnosis was estabIished by this method. The MiIIer-Abbott tube has been shown to be of definite vaIue in deflation of the intestina1 tract in cases of obstruction, in preoperative preparation of patients for abdomina1 surgery, in study of the physioIogy of absorption and excretion of the intestina1 tract, and the tube has aIso proved usefu1 as a method for providing nutrition in certain diffIcuIt cases. The Iong doubIe Iumen tube is now proving to be of vaIue as an aid in estabIishing a diagnosis in certain obscure Iesions of the smaI1 intestine. The first report of deflation of the intestina1 tract by intubation was presented by KussmauI and Cahn2 in 1884. Pesquera6 in 1929 was probably the first to use a duodena1 tube in roentgenoIogic studies of the smaI1 intestine. In 1934 Abbott’ introduced a doubIe lumen tube that couId be passed into the smaI1 intestine. Many studies of the smaI1 bowe1 have been carried out since the introduction of the MiIIer-Abbott tube. WeItz4 in 1939 presented many exceIIent roentgenoIogic studies of the smaI1 intestine by means of a duodena1 tube. However, this method was unsatisfactory because of the Iength of the smaI1 intestine which resuIted in overlapping of the shadows. Boon4 reported severa cases in which the doubIe Iumen intestina1 tube was used in x-ray studies of smaI1 bowe1 Iesions other than obstruction. He reported that the MiIIer-Abbott tube couId be used in cases of partia1 obstruction caused by narrowing of the Iumen, * From the Department
October,
1949
anguIation, persistent spasm or other defects. GoIden, Leigh and Swenson2 reported that no deIeterious effects resulted from the injection of barium sulfate into a MiIIer-Abbott tube in diseases of the small intestine. They cIassify their uses of the MiIIer-Abbott tube in smaI1 intestina1 studies into: (I ) paraIytic iIeus, (2) obstruction, (3) simpIe obstruction without infIammation and (4) abnorma1 mucosa1 patterns such as occur in strangulation, inflammation, maIignancy and intussusception. Many authors”5 previousIy reported using a duodena1 tube for roentgenoIogic studies of Iesions of the smaI1 intestine. Schatzki,‘j however, in 1943 first used the phrase “smaI1 intestina1 enema.” He did much to establish the vaIue of this technic in discovering obscure Iesions of the smaI1 intestine. Schatzki Iisted severa advantages of the duodenal tube as a means of examining the small intestine, nameIy, (I) the smaI1 intestine can be seen in its entirety, (2) actua1 fXIing of smaI1 intestina1 loops can be observed roentgenoIogicaIIy, (3) perora1 examination usuaIIy resuIts in irreguIar, incompIete fiIIing of iIeum, (4) adequate examination of the iIeoceca1 vaIve can be accompIished and (5) the time required for examination is shortened. The “progress mea1” of barium is frequentIy used in studying Iesions of the smaI1 intestine. Competent radioIogists are abIe to foIIow a progress mea1 of barium by means of the fIuoroscope throughout the entire smaI1 intestine. Disadvantages of this method are that it is time-consuming usuaIIy requiring a haIf day or more, exposes the patient to repeated Auoroscopic examination and may be definiteIy harmfu1 in cases of mechanica obstruction. There are many patients in gastrointesti-
of Surgery of the University
307
of Tennessee,
Memphis, Tenn.
French-SmaII
508
naI cIinics who present vague abdomina1 compIaints and in whom after the routine roentgenoIogic gastrointestina1 studies and other Iaboratory procedures no diagnosis is made. Many of these patients are toId that no organic Iesion is present and the symptoms are attributed to functiona disturbances. Some of these patients return at a later date with a definite Iesion in which the diagnosis is reIativeIy easy. Many patients with vague abdomina1 compIaints shouId have smaI1 bowe1 enema studies when the usua1 roentgenoIogic examination faiIs to revea1 any organic disease. These smaI1 bowe1 studies can be easiIy carried out with the MiIIer-Abbott tube. CASE
REPORTS
CASE I. E. S., a fifty-four year oId white maIe, was admitted to the Baptist MemoriaI HospitaI with a history of epigastric pain of eight weeks’ duration. The pain was sudden in onset and very severe. At the time of onset he was hospitahzed elsewhere and a diagnosis of amebiasis was made. Treatment for amebiasis resuIted in a disappearance of most of the symptoms. The patient was discharged from the hospita1 and instructed to return for foIIowup studies. Upon admission to our service the patient did not appear acuteIy III other than the evidence of considerabIe weight 10s~. A mass was feIt in the left Iower quadrant of the abdomen. This mass was approximateIy 3 cm. in diameter, was not tender and was freeIy movabIe. The routine bIood and urine determinations were normaI. A scout film of the abdomen was made which demonstrated some air in the transverse coIon but this was not suggestive of obstruction. Barium enema studies of the coIon were negative. A gastrointestina1 series revealed an indefinite narrowing of one loop of smaI1 intestine. This finding was not diagnostic. A smaI1 bowe1 enema revealed a partia1 obstruction of jejunum suggestive of maIignancy. The patient was operated upon and a tumor of the jejunum was found. A jejuna1 resection was done and this was foIIowed by an uneventfu1 postoperative course. PathoIogic examination of the specimen showed it to be a carcinoid with metastasis to regiona Iymph nodes. CASEII. J. N., a sixty-seven year oId white
BoweI
Enema
male, was admitted to the John Gaston Hospita1 for hemorrhoidectomy. The patient gave a history of passing bIood from the rectum for three years. At the onset of the symptoms three years before the patient was admitted to another institution in shock as a result of bIeeding from the rectum. No cause of bIeeding was found after repeated barium enema and gastrointestina1 studies. The patient was discharged and readmitted to the same hospital a second time for the same condition, namely, shock from hemorrhage. Again a11x-ray studies were negative. The patient was seen in the University of Tennessee MedicaI CIinic two years after the first bIeeding episode. At this time his compIaint was that of epigastric pain. He was admitted to the hospita1 because of severe anemia. Repeated gastrointestina1 studies and barium enema examinations were negative. The onIy physica abnormality was interna and externa1 hemorrhoids. The patient was discharged and sent to the ProctoIogy CIinic for possibIe hemorrhoidectomy and was hospitalized on September 14, 1948. Upon admission a mass couId be feIt in the right Iower quadrant of the abdomen. Review of the previous gastrointestina1 series faiIed to show visuaIization of the termina1 iIeum. A smaI1 bowe1 enema was done and a cystic mass was seen to fiI1 with barium from the termina1 ileum. The mass appeared to arise from the pelvis. The patient was expIored and a cystic Iesion was found communicating with the terminal iIeum. The Iesion was considered inoperable. However, a biopsy was taken and the pathologic report was spindle ceI1 sarcoma. CASE III. I. M., a sixty year aid colored femaIe, was admitted to the John Gaston Hospita1 with a compIaint of cramping abdomina1 pain of one month’s duration and enIargement of the abdomen for three weeks. Constipation had existed for six months and there were no bowe1 movements for one week previous to admission. There was an irreguIar, indefInite mass in the region of the umbiIicus. Barium enema examination was negative and a scout fiIm of the abdomen reveaIed some diIated Ioops of smaI1 intestine which were suggestive of partia1 obstruction. A MiIIer-Abbott tube was used for deffation and a smaI1 bowe1 enema study was done. This reveaIed a non-obstructing Iesion in the iIeum. At expIoration an annuIar Iesion was found in the mid-iIeum.
American Journal of Surgery
French-SmaII This was removed and a side-to-side anastomosis was performed. Microscopic examination showed the Iesion to be a carcinoid of the ileum. COMMENT
In none of these cases was complete obstruction present. Two of the patients had been hospitalized previously and studied extensiveIy without the diagnosis being estabhshed. Their symptoms persisted for a long period of time. AI1 of these patients had repeated barium enema and gastrointestinal studies which were reported as negative. We do not advocate smaI1 bowe1 enema studies on every patient with vague abdominal complaints. It is not beIieved that this means of studying the smaI1 intestine should replace methods in common use; however, it is an additional method which shouId be used in certain cases. We beIieve that patients who continue to have gastrointestina1 complaints and in whom no diag-
October,
1949
BoweI
Enema
nosis is made by routine studies have smaI1 bowel enema studies. SUMMARY
AND
shouId
CONCLUSIONS
I. Emphasis is pIaced on the importance of the MiIler-Abbott tube in studying Iesions of the smaI1 intestine. 2. Three cases which iIIustrate the value of this method in estabIishing a diagnosis are presented. REFERENCES I. MILLER, T. and ABBOTT, W. 0.
Intestinal intubations: a practical technic. Am. J. M. SC., 187: $95, 1934.
2. GOLDEN, R., LEIGH, 0. and SWENSON, R. C. Roentgen ray examination with the MiIIer-Abbott tube. Radiology, 35: 521, 1940. 3. LEIGH. 0. and DIEFENDORF. R. 0. The MiIlerAbbott in surgery. J. A. MI A., I 17: 210, 1942. 4. BOON, T. H. Intubation of the small intestines. Lancet, I : 7, 1940. 5. PESQUERA, G. A. Method for direct visualization of lesions in smaI1 intestines. Am. J. Roenteenol. CY Rad. Tberapy, 22: 254, 1929. 6. SCHATZKI, R. Small intestinal enema. Am. J. Roentgenol. ti Rad. Therapy, so: 743, 1943.