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The small bowel enema in the patient with an ileostomy
Clinical Radiology (1988) 39, 418-422
The Small Bowel Enema in the Patient with an Ileostomy V. J. KAY* and D. J. N O L A N
Department of Radiology, John Radcliffe Hospital, Oxford OX3 9DU
Fifty-nine patients with an ileostomy were studied who were examined by small bowel enema over a 10-year period. T w e n t y - t w o subsequently underwent surgery, nine for recurrent Crohn's disease, seven for obstruction due to adhesions or internal hernia and one for ovarian carcinoma. The remaining five patients with colonic Crohn's disease had panproctocolectomy or closure of the ileostomy. The small bowel enema is a reliable method for investigating the small intestine of patients with an ileostomy.
Following the pioneering work of Brooke (1951) ileostomy is now widely used in the management of inflammatory bowel disease, particularly in patients with ulcerative colitis in whom a colectomy is necessary. In Oxford the 'split ileostomy' is frequently used in the management of colonic Crohn's disease (Truelove et al., 1965; Lee, 1975). The purpose of the split ileostomy is to divert the faecal stream and stop the colon functioning. If as a result of this faecal diversion the colonic disease heals, the continuity of the bowel is restored. Patients may then remain in remission or, after further exacerbations of colonic disease, may require colectomy and permanent ileostomy formation. Ileostomy is not without its complications and revision of the stoma may be necessary. Mechanical small intestinal obstruction may occur as either an immediate post-operative or a late complication. The obstruction can be due to adhesions, internal hernia or to recurrence of Crohn's disease with stricture formation (Roy et al., 1970). It is often difficult to confirm the presence of obstruction in the patient with an ileostomy on plain abdominal radiographs (Goligher, 1983). The role of barium studies in the assessment of patients with ileostomy problems has had little evaluation. We use the small bowel enema routinely and find the technique very useful for investigating patients with suspected ileostomy complications.
(a)
PATIENTS AND METHODS During the last 10 years in Oxford, all patients with an ileostomy who require contrast studies have been investigated with small bowel enema examination. The technique we use is described in detail elsewhere (Sellink and Miller, 1982; Nolan and Cadman, 1987). We also include spot views of the ileum just proximal to the ileostomy and a lateral view of the ileostomy (Fig. 1). The notes of all patients with an ileostomy who had a small bowel enema examination performed between *Present address: Northampton General Hospital, Northampton. Correspondence to: D. J. Nolan, Department of Radiology,John RadcliffeHospital, Oxford OX3 9DU.
(b) Fig. 1 - Normal appearances. (a) A spot viewof the ileumproximalto the ileostomy. (b) A lateral view of the ileostomy showing barium passing freely into the ileostomybag.
SMALL BOWEL ENEMA
October 1976 and July 1986 were reviewed to determine whether the radiological findings were in agreement with the subsequent clinical course or operative findings.
419
the diagnosis and diseased intestine was resected in nine patients; in one of these retrograde examination was attempted first but the barium would not reflux past a stricture in the distal ileum (Fig. 2). The remaining 17 patients with abnormal radiological findings had differing degrees of intestinal obstruction.
RESULTS A total of 64 patients were examined; the case notes were available for 59 patients. The group consisted of 19 males and 40 females, with an age range of 21 to 85 years. The clinical conditions which led to the fashioning of an ileostomy in this group are presented in Table 1. The indications for performing a small bowel enema in these patients were the pre-operative assessment of the small bowel in the presence of colonic Crohn's disease and to confirm the diagnosis and determine the site and cause in suspected small bowel obstruction. The small bowel enema examinations showed no abnormality in 30 patients (Table 2). Twenty-four of these patients required no further surgery. One of this group subsequently developed convincing clinical evidence of recurrent Crohn's disease but this was not confirmed by radiology or surgery. The remaining six patients underwent surgery. Five had colonic Crohn's disease and were examined to exclude small intestinal disease prior to closure of a split ileostomy in three patients and panproctocolectomy in two. The small intestine was confirmed as normal in these five patients. The remaining patient, who was operated on because of a pelvic mass and persisting abdominal pain, proved to have an ovarian carcinoma that did not involve the small intestine. Abnormalities were shown in 29 patients (Table 3). Twelve showed evidence of recurrent Crohn's disease. The appearances were similar to those seen in other patients with Crohn's disease of the small intestine (Nolan and Gourtsoyiannis, 1980). Surgery confirmed
(a)
T a b l e 1 - Conditions leading to the f o r m a t i o n of an ileostomy
Condition
Number of patients
Crohn's disease Ulcerative colitis Abnormal motility with chronic constipation
34 24 1
Total
59
Table 2 - Patients with a n o r m a l small b o w e l e n e m a
Number of patients No operation Closure of split ileostomy Panproctocolectomy Laparotomy
24 3 2 1
Total
30
Table 3 - Patients with an a b n o r m a l small b o w e l e n e m a
Operation Recurrent Crohn's disease Obstruction due to: Adhesions Internal hernia
Conservative management
Total
9
3
12
3 4
10 0
13 4
(b) Fig. 2 - Recurrent Crohn's disease. (a) A retrograde examination showing obstruction in the ileum just proximal to the ileostomy (arrow), despite the use of hyoscine butylbromide (Buscopan). (b) A spot view from a small bowel enema examination on the same patient confirms the presence of a stricture with proximal dilatation.
420
CLINICAL RADIOLOGY
Seven of these patients underwent surgery. The obstruction proved to be due to adhesions (Figs 3, 4) in three patients and to para-ileostomy hernia formation (Figs 5, 6) in the remaining four. It was difficult to differentiate adhesions from internal hernia formation with confidence by radiology. The 10 who did not undergo operation were patients who previously had an ileostomy after panproctocolectomy for ulcerative colitis. Small bowel enema showed partial small intestinal obstruction in each case. Obstruction was considered due to adhesions and symptoms resolved on medical management. DISCUSSION
Proctocolectomy, more than any other abdominal operation, predisposes to intestinal obstruction (Goligher, 1984). Intestinal obstruction is an important cause of operation-related morbidity in patients with an ileostomy (Kennedy, 1987). The management of the patient with an ileostomy and suspected obstruction or recurrence of inflammatory bowel disease requires good radiological evaluation of the small intestine. The small bowel enema is a reliable method for investigating these patients and our results show a good correlation
(a)
Fig. 3 - Adhesions. Narrowing and deformity of a loop of ileum (arrow) is seen in a patient with an ileostomy who presented on two occasions with intestinal obstruction. The presence of adhesions involving a loop of ileum proximal to the ileostomy was confirmed at operation. Fig. 4 - Chronic obstruction due to adhesions. (a) Marked dilatation of the jejunum and proximal ileum in a patient with an ileostomy. (b) A spot view shows the area of transition between dilated intestine and collapsed intestine (arrow). An intact mucosal pattern is seen at the point of obstruction. At operation adhesions were found. (Reproduced from Nolan 1986, by kind permission.)
(b)
SMALL BOWEL ENEMA
421
(a)
Fig. 6 - Hernia through the lateral space around an ileostomy causing obstruction. A short segment of narrowing (arrow) was Constant. There is dilatation of the ileum and dilution of barium by excess fluid proximal to the narrowed area. The patient had a proctocolectomy and ileostomy for ulcerative colitis 5 years earlier and gave a 2-year history of symptoms suggesting intermittent small intestinal obstruction. Two barium follow-through examinations performed elsewhere were reported as normal and the patient had been reassured. (Reproduced from Nolan 1986, by kind permission.)
(b) Fig. 5 - Para-ileostomy hernia causing acute obstruction. (a) Distended jejunum outlined with barium in a patient who developed obstructive symptoms 1 week after proctocolectomy for ulcerative colitis. (b) A spot view taken after an interval shows a short segment of narrowing (arrow). Shortly afterwards the patient was operated on and a para-ileostomy hernia causing intestinal obstruction was found.
between the radiological appearances and the findings at operation and clinical follow-up. It is relatively easy to examine the small intestine in the patient with an ileostomy by using the retrograde small bowel enema (Fleischner et al., 1954; Sanders and Ho, 1976; Bartram, 1983; Zagoria et al., 1986), and others may favour this technique. The retrograde method is helpful in certain selected cases. We prefer the antegrade small bowel enema as it is easier to evaluate the flow of contrast through the small intestine and to demonstrate the degree of delay in patients with obstruction. Many of our patients were being investigated for suspected recurrent Crohn's disease; inflation
of a balloon catheter in a segment of inflamed, fibrotic and contracted ileum increases the risk of perforation. A normal small bowel enema examination is equally helpful as an obstructive lesion can be excluded with confidence. In patients with a split ileostomy for Crohn's disease, a normal examination is helpful when restoration of intestinal continuity is planned or proctocolectomy is being considered. Acknowledgements. We are pleased to acknowledge support of the Oxford Regional Research Committee. We thank Miss Nicola Green for assisting us with the project and for preparing the manuscript. The photographic prints were prepared by the Department of Medical Illustration, John Radcliffe Hospital.
REFERENCES Bartram, CI (1983). Radiology in Inflammatory Bowel Disease. pp. 11-12, Marcel Dekker/Butterworths, New York and London. Brooke, BN (1951). Total colectomy in one stage for ulcerative colitis. Lancet, i, 1197-1199. Fleischner, FG, Mandelstam, P & Banks, BM (1954). Roentgen observations of the ileostomy in patients with idiopathic ulcerative colitis: the well functioning ileostomy. Radiology, 63, 74-80. Goligher, JC (1983). Proctocolectomy and ileostomy for ulcerative colitis. In: Inflammatory Bowel Diseases, eds Allan, RN, Keighley,
422
CLINICAL RADIOLOGY
MRB, Alexander-Williams, J & Hawkins, C, pp. 24%255. Churchill Livingstone, Edinburgh. Goligher, JC (1984). Surgery of Anus, Rectum and Colon, 5th edn, pp. 908-910. Balliere Tindall, London. Kennedy, HJ (1987). Proctocolectomy and ileostomy for ulcerative colitis: its long-term consequences and current status. In: Surgery of Inflammatory Bowel Disorders. Clinical Surgery International Series, ed. Lee, ECG, pp. 52-58. Churchill Livingstone, Edinburgh. Lee, ECG (1975). Split ileostomy in the treatment of Crohn's disease of the colon. Annals of the Royal College of Surgeons of England, 56, 94-102. Nolan, DJ (1986). The barium infusion examination of the small intestine. In: Recent Advances in Radiology and Imaging - 8, eds Steiner, RE & Sherwood, T, pp. 149-164. Churchill Livingstone, Edinburgh. Nolan, DJ & Cadman, PJ (1987). The small bowel enema made easy. Clinical Radiology, 38, 295-301.
Nolan, DJ & Gourtsoyiannis, NC (1980). Cr.ohn's disease of the small intestine: a review of the radiological appearances in 100 consecutive patients examined by a barium infusion technique. Clinical Radiology, 30, 597-603. Roy, PH, Sauer, WG, Beahrs, OH & Farrow, GM (1970). Experience with ileostomies. Evaluation of long term rehabilitation in 497 patients. American Journal of Surgery, 119, 77-86. Sanders, D E & Ho, CS (1976). The small bowel enema: experience with 150 examinations. American Journal of Roentgenology, 127, 743-751. Sellink, JL & Miller, RE (1982). Radiology of the Small Bowel: Technique and Atlas, pp. 81-119. Martinus Nijhoff, The Hague. Truelove, SC, Ellis, H & Webster, CU (1965). Place of a doublebarrelled ileostomy in ulcerative colitis and Crohn's disease of the colon; a preliminary report. British Medical Journal, 1, 150-153. Zagoria, RJ, Gelfand, DW & Ott, DJ (1986). Retrograde examination of the small bowel in patients with an ileostomy. Gastrointestinal Radiology, 11, 97-101.
Book Reviews Orthopaedic Radiology. Edited by W. M. Park and S. P. F. Hughes. Blackwell Scientific, Oxford, 1987, 534 pp., 935 figs. £69.50.
1987 Year Book of Diagnostic Radiology. Edited by Bragg, Keats, Kieffler, Kirkpatrick, Koehler, Miller and Sorenson. Year Book Medical Publishers, Chicago, 1987, 582 pp., 306 figs. £35.50.
This multi-author (19 contributors) textbook written by radiologists and orthopaedic surgeons of principally British origin, attempts to fill a long standing gap on the medical bookshelves. Namely, a single book aiming to inform the orthopaedic surgeon of the range and relevance of the numerous imaging techniques currently available for the investigation of musculoskeletal disease and to enlighten the radiologist in the field of orthopaedics, a subject often neglected in radiological training. On the whole, the editors have succeeded in their intentions although the modest size of the book means it is far from comprehensive and should not be considered a reference book. The text is divided into two sections. The first is on 'The Principle of Diagnostic Imaging and Interpretation' with chapters on each of the main imaging modalifies. The second section is entitled 'Practical Clinical Problems' with chapters on orthopaedic disease and the various anatomical regions of interest e.g. spine, knee joint, etc. Like the proverbial curate's egg the book is good in parts with several chapters outstanding but, as with many multi-author works, the overall quality is patchy. A degree of repetition is unavoidable, however, with space at such a premium, some unnecessary duplication has occurred. For example, similar short sections on Blount's disease appear in three chapters and comparable line diagrams illustrating the diagnosis of carpal instability are included in two chapters. The standard of the illustrations is generally adequate and where contrast enhancement has been employed, as in the chapter on skeletal trauma, the figures are excellent. In a book of this quality of production it is irritating however, to find seven figures and one line diagram upside down, interposed or incorrectly labelled. It is 5 years since the untimely death of one of the respected editors, Bill Park, and the subsequent prolonged gestation in the publication of this book has undoubtedly lead to a number of deficiencies. Most notable are the only passing reference to ultrasound and no mention at all of magnetic resonance in the investigation of musculoskeletal disease. Also, of the 59 references given at the end of the chapter on computed tomography, not one is less than 6 years old. Nevertheless this is a clearly written book, understandable to both radiologists and orthopaedic surgeons which can be recommended to trainees of both specialities. It would probably be more appropriate for a hospital medical library than individual departmental libraries. M. Davies
Two years ago I had the pleasure of reviewing the 1985 Year Book of Diagnostic Radiology. Receiving the 1987 edition for an encore made the temptation to send an identical review, changing only the numerical facts, almost irresistible. Perhaps it was done to test the strength of my reaction to the Year Book expressed in the previous review but the continuing high standard of work has ensured my remaining a convert. This time there are 356 reviews grouped as usual into seven functional sections, each under an associate editor. Naturally there is a preponderence of reviews on articles generated in the USA but many are from a wide range of journals from other countries. The spread of topics follows current interest; nearly half of the 40 reviews in the neuroradiology section relate to magnetic resonance imaging and this subject features strongly in the 67 reviews on cardiovascular and interventional radiology where there are noticeably fewer reviews on DSA and bile duct stone removal. The associate editor of the abdomen section declared his policy of casting the net widely to include 'journals that are not always available to most radiologists', an approach which enhances the value of the Year Book - it is perhaps food for thought that one third of the articles reviewed from this journal are found in this section! There is information of practical every day use on almost every page, nearly all reviews are followed by the section editor's comments on the value of the article and even if one disagrees with these they certainly stimulate interest. A good review book will also draw attention to articles outside one's usual reading. As an example, in the section on thorax, 15 of the 67 reviews are on breast diagnosis and include two excellent review articles, one from Investigative Radiology and one from Journal of the American Medical Association. I would certainly have missed one if not both without this review. The section on radiation physics comprising of 25 reviews is a small mine of information. The musculoskeletal section, 39 reviews, is notable for its variety, and the 50 paediatric reviews for their practicality. For me this latter was typified by reviews on obstructive jaundice and gas in the hepatic portal veins from English centres but perhaps I'm biased! At £35.50 this book is an even better bargain than its predecessor, the lower price reflecting current world finance. I. Lavelle
The Small Bowel Enema in the Patient with an Ileostomy V. J. KAY* and D. J. N O L A N
Department of Radiology, John Radcliffe Hospital, Oxford OX3 9DU
Fifty-nine patients with an ileostomy were studied who were examined by small bowel enema over a 10-year period. T w e n t y - t w o subsequently underwent surgery, nine for recurrent Crohn's disease, seven for obstruction due to adhesions or internal hernia and one for ovarian carcinoma. The remaining five patients with colonic Crohn's disease had panproctocolectomy or closure of the ileostomy. The small bowel enema is a reliable method for investigating the small intestine of patients with an ileostomy.
Following the pioneering work of Brooke (1951) ileostomy is now widely used in the management of inflammatory bowel disease, particularly in patients with ulcerative colitis in whom a colectomy is necessary. In Oxford the 'split ileostomy' is frequently used in the management of colonic Crohn's disease (Truelove et al., 1965; Lee, 1975). The purpose of the split ileostomy is to divert the faecal stream and stop the colon functioning. If as a result of this faecal diversion the colonic disease heals, the continuity of the bowel is restored. Patients may then remain in remission or, after further exacerbations of colonic disease, may require colectomy and permanent ileostomy formation. Ileostomy is not without its complications and revision of the stoma may be necessary. Mechanical small intestinal obstruction may occur as either an immediate post-operative or a late complication. The obstruction can be due to adhesions, internal hernia or to recurrence of Crohn's disease with stricture formation (Roy et al., 1970). It is often difficult to confirm the presence of obstruction in the patient with an ileostomy on plain abdominal radiographs (Goligher, 1983). The role of barium studies in the assessment of patients with ileostomy problems has had little evaluation. We use the small bowel enema routinely and find the technique very useful for investigating patients with suspected ileostomy complications.
(a)
PATIENTS AND METHODS During the last 10 years in Oxford, all patients with an ileostomy who require contrast studies have been investigated with small bowel enema examination. The technique we use is described in detail elsewhere (Sellink and Miller, 1982; Nolan and Cadman, 1987). We also include spot views of the ileum just proximal to the ileostomy and a lateral view of the ileostomy (Fig. 1). The notes of all patients with an ileostomy who had a small bowel enema examination performed between *Present address: Northampton General Hospital, Northampton. Correspondence to: D. J. Nolan, Department of Radiology,John RadcliffeHospital, Oxford OX3 9DU.
(b) Fig. 1 - Normal appearances. (a) A spot viewof the ileumproximalto the ileostomy. (b) A lateral view of the ileostomy showing barium passing freely into the ileostomybag.
SMALL BOWEL ENEMA
October 1976 and July 1986 were reviewed to determine whether the radiological findings were in agreement with the subsequent clinical course or operative findings.
419
the diagnosis and diseased intestine was resected in nine patients; in one of these retrograde examination was attempted first but the barium would not reflux past a stricture in the distal ileum (Fig. 2). The remaining 17 patients with abnormal radiological findings had differing degrees of intestinal obstruction.
RESULTS A total of 64 patients were examined; the case notes were available for 59 patients. The group consisted of 19 males and 40 females, with an age range of 21 to 85 years. The clinical conditions which led to the fashioning of an ileostomy in this group are presented in Table 1. The indications for performing a small bowel enema in these patients were the pre-operative assessment of the small bowel in the presence of colonic Crohn's disease and to confirm the diagnosis and determine the site and cause in suspected small bowel obstruction. The small bowel enema examinations showed no abnormality in 30 patients (Table 2). Twenty-four of these patients required no further surgery. One of this group subsequently developed convincing clinical evidence of recurrent Crohn's disease but this was not confirmed by radiology or surgery. The remaining six patients underwent surgery. Five had colonic Crohn's disease and were examined to exclude small intestinal disease prior to closure of a split ileostomy in three patients and panproctocolectomy in two. The small intestine was confirmed as normal in these five patients. The remaining patient, who was operated on because of a pelvic mass and persisting abdominal pain, proved to have an ovarian carcinoma that did not involve the small intestine. Abnormalities were shown in 29 patients (Table 3). Twelve showed evidence of recurrent Crohn's disease. The appearances were similar to those seen in other patients with Crohn's disease of the small intestine (Nolan and Gourtsoyiannis, 1980). Surgery confirmed
(a)
T a b l e 1 - Conditions leading to the f o r m a t i o n of an ileostomy
Condition
Number of patients
Crohn's disease Ulcerative colitis Abnormal motility with chronic constipation
34 24 1
Total
59
Table 2 - Patients with a n o r m a l small b o w e l e n e m a
Number of patients No operation Closure of split ileostomy Panproctocolectomy Laparotomy
24 3 2 1
Total
30
Table 3 - Patients with an a b n o r m a l small b o w e l e n e m a
Operation Recurrent Crohn's disease Obstruction due to: Adhesions Internal hernia
Conservative management
Total
9
3
12
3 4
10 0
13 4
(b) Fig. 2 - Recurrent Crohn's disease. (a) A retrograde examination showing obstruction in the ileum just proximal to the ileostomy (arrow), despite the use of hyoscine butylbromide (Buscopan). (b) A spot view from a small bowel enema examination on the same patient confirms the presence of a stricture with proximal dilatation.
420
CLINICAL RADIOLOGY
Seven of these patients underwent surgery. The obstruction proved to be due to adhesions (Figs 3, 4) in three patients and to para-ileostomy hernia formation (Figs 5, 6) in the remaining four. It was difficult to differentiate adhesions from internal hernia formation with confidence by radiology. The 10 who did not undergo operation were patients who previously had an ileostomy after panproctocolectomy for ulcerative colitis. Small bowel enema showed partial small intestinal obstruction in each case. Obstruction was considered due to adhesions and symptoms resolved on medical management. DISCUSSION
Proctocolectomy, more than any other abdominal operation, predisposes to intestinal obstruction (Goligher, 1984). Intestinal obstruction is an important cause of operation-related morbidity in patients with an ileostomy (Kennedy, 1987). The management of the patient with an ileostomy and suspected obstruction or recurrence of inflammatory bowel disease requires good radiological evaluation of the small intestine. The small bowel enema is a reliable method for investigating these patients and our results show a good correlation
(a)
Fig. 3 - Adhesions. Narrowing and deformity of a loop of ileum (arrow) is seen in a patient with an ileostomy who presented on two occasions with intestinal obstruction. The presence of adhesions involving a loop of ileum proximal to the ileostomy was confirmed at operation. Fig. 4 - Chronic obstruction due to adhesions. (a) Marked dilatation of the jejunum and proximal ileum in a patient with an ileostomy. (b) A spot view shows the area of transition between dilated intestine and collapsed intestine (arrow). An intact mucosal pattern is seen at the point of obstruction. At operation adhesions were found. (Reproduced from Nolan 1986, by kind permission.)
(b)
SMALL BOWEL ENEMA
421
(a)
Fig. 6 - Hernia through the lateral space around an ileostomy causing obstruction. A short segment of narrowing (arrow) was Constant. There is dilatation of the ileum and dilution of barium by excess fluid proximal to the narrowed area. The patient had a proctocolectomy and ileostomy for ulcerative colitis 5 years earlier and gave a 2-year history of symptoms suggesting intermittent small intestinal obstruction. Two barium follow-through examinations performed elsewhere were reported as normal and the patient had been reassured. (Reproduced from Nolan 1986, by kind permission.)
(b) Fig. 5 - Para-ileostomy hernia causing acute obstruction. (a) Distended jejunum outlined with barium in a patient who developed obstructive symptoms 1 week after proctocolectomy for ulcerative colitis. (b) A spot view taken after an interval shows a short segment of narrowing (arrow). Shortly afterwards the patient was operated on and a para-ileostomy hernia causing intestinal obstruction was found.
between the radiological appearances and the findings at operation and clinical follow-up. It is relatively easy to examine the small intestine in the patient with an ileostomy by using the retrograde small bowel enema (Fleischner et al., 1954; Sanders and Ho, 1976; Bartram, 1983; Zagoria et al., 1986), and others may favour this technique. The retrograde method is helpful in certain selected cases. We prefer the antegrade small bowel enema as it is easier to evaluate the flow of contrast through the small intestine and to demonstrate the degree of delay in patients with obstruction. Many of our patients were being investigated for suspected recurrent Crohn's disease; inflation
of a balloon catheter in a segment of inflamed, fibrotic and contracted ileum increases the risk of perforation. A normal small bowel enema examination is equally helpful as an obstructive lesion can be excluded with confidence. In patients with a split ileostomy for Crohn's disease, a normal examination is helpful when restoration of intestinal continuity is planned or proctocolectomy is being considered. Acknowledgements. We are pleased to acknowledge support of the Oxford Regional Research Committee. We thank Miss Nicola Green for assisting us with the project and for preparing the manuscript. The photographic prints were prepared by the Department of Medical Illustration, John Radcliffe Hospital.
REFERENCES Bartram, CI (1983). Radiology in Inflammatory Bowel Disease. pp. 11-12, Marcel Dekker/Butterworths, New York and London. Brooke, BN (1951). Total colectomy in one stage for ulcerative colitis. Lancet, i, 1197-1199. Fleischner, FG, Mandelstam, P & Banks, BM (1954). Roentgen observations of the ileostomy in patients with idiopathic ulcerative colitis: the well functioning ileostomy. Radiology, 63, 74-80. Goligher, JC (1983). Proctocolectomy and ileostomy for ulcerative colitis. In: Inflammatory Bowel Diseases, eds Allan, RN, Keighley,
422
CLINICAL RADIOLOGY
MRB, Alexander-Williams, J & Hawkins, C, pp. 24%255. Churchill Livingstone, Edinburgh. Goligher, JC (1984). Surgery of Anus, Rectum and Colon, 5th edn, pp. 908-910. Balliere Tindall, London. Kennedy, HJ (1987). Proctocolectomy and ileostomy for ulcerative colitis: its long-term consequences and current status. In: Surgery of Inflammatory Bowel Disorders. Clinical Surgery International Series, ed. Lee, ECG, pp. 52-58. Churchill Livingstone, Edinburgh. Lee, ECG (1975). Split ileostomy in the treatment of Crohn's disease of the colon. Annals of the Royal College of Surgeons of England, 56, 94-102. Nolan, DJ (1986). The barium infusion examination of the small intestine. In: Recent Advances in Radiology and Imaging - 8, eds Steiner, RE & Sherwood, T, pp. 149-164. Churchill Livingstone, Edinburgh. Nolan, DJ & Cadman, PJ (1987). The small bowel enema made easy. Clinical Radiology, 38, 295-301.
Nolan, DJ & Gourtsoyiannis, NC (1980). Cr.ohn's disease of the small intestine: a review of the radiological appearances in 100 consecutive patients examined by a barium infusion technique. Clinical Radiology, 30, 597-603. Roy, PH, Sauer, WG, Beahrs, OH & Farrow, GM (1970). Experience with ileostomies. Evaluation of long term rehabilitation in 497 patients. American Journal of Surgery, 119, 77-86. Sanders, D E & Ho, CS (1976). The small bowel enema: experience with 150 examinations. American Journal of Roentgenology, 127, 743-751. Sellink, JL & Miller, RE (1982). Radiology of the Small Bowel: Technique and Atlas, pp. 81-119. Martinus Nijhoff, The Hague. Truelove, SC, Ellis, H & Webster, CU (1965). Place of a doublebarrelled ileostomy in ulcerative colitis and Crohn's disease of the colon; a preliminary report. British Medical Journal, 1, 150-153. Zagoria, RJ, Gelfand, DW & Ott, DJ (1986). Retrograde examination of the small bowel in patients with an ileostomy. Gastrointestinal Radiology, 11, 97-101.
Book Reviews Orthopaedic Radiology. Edited by W. M. Park and S. P. F. Hughes. Blackwell Scientific, Oxford, 1987, 534 pp., 935 figs. £69.50.
1987 Year Book of Diagnostic Radiology. Edited by Bragg, Keats, Kieffler, Kirkpatrick, Koehler, Miller and Sorenson. Year Book Medical Publishers, Chicago, 1987, 582 pp., 306 figs. £35.50.
This multi-author (19 contributors) textbook written by radiologists and orthopaedic surgeons of principally British origin, attempts to fill a long standing gap on the medical bookshelves. Namely, a single book aiming to inform the orthopaedic surgeon of the range and relevance of the numerous imaging techniques currently available for the investigation of musculoskeletal disease and to enlighten the radiologist in the field of orthopaedics, a subject often neglected in radiological training. On the whole, the editors have succeeded in their intentions although the modest size of the book means it is far from comprehensive and should not be considered a reference book. The text is divided into two sections. The first is on 'The Principle of Diagnostic Imaging and Interpretation' with chapters on each of the main imaging modalifies. The second section is entitled 'Practical Clinical Problems' with chapters on orthopaedic disease and the various anatomical regions of interest e.g. spine, knee joint, etc. Like the proverbial curate's egg the book is good in parts with several chapters outstanding but, as with many multi-author works, the overall quality is patchy. A degree of repetition is unavoidable, however, with space at such a premium, some unnecessary duplication has occurred. For example, similar short sections on Blount's disease appear in three chapters and comparable line diagrams illustrating the diagnosis of carpal instability are included in two chapters. The standard of the illustrations is generally adequate and where contrast enhancement has been employed, as in the chapter on skeletal trauma, the figures are excellent. In a book of this quality of production it is irritating however, to find seven figures and one line diagram upside down, interposed or incorrectly labelled. It is 5 years since the untimely death of one of the respected editors, Bill Park, and the subsequent prolonged gestation in the publication of this book has undoubtedly lead to a number of deficiencies. Most notable are the only passing reference to ultrasound and no mention at all of magnetic resonance in the investigation of musculoskeletal disease. Also, of the 59 references given at the end of the chapter on computed tomography, not one is less than 6 years old. Nevertheless this is a clearly written book, understandable to both radiologists and orthopaedic surgeons which can be recommended to trainees of both specialities. It would probably be more appropriate for a hospital medical library than individual departmental libraries. M. Davies
Two years ago I had the pleasure of reviewing the 1985 Year Book of Diagnostic Radiology. Receiving the 1987 edition for an encore made the temptation to send an identical review, changing only the numerical facts, almost irresistible. Perhaps it was done to test the strength of my reaction to the Year Book expressed in the previous review but the continuing high standard of work has ensured my remaining a convert. This time there are 356 reviews grouped as usual into seven functional sections, each under an associate editor. Naturally there is a preponderence of reviews on articles generated in the USA but many are from a wide range of journals from other countries. The spread of topics follows current interest; nearly half of the 40 reviews in the neuroradiology section relate to magnetic resonance imaging and this subject features strongly in the 67 reviews on cardiovascular and interventional radiology where there are noticeably fewer reviews on DSA and bile duct stone removal. The associate editor of the abdomen section declared his policy of casting the net widely to include 'journals that are not always available to most radiologists', an approach which enhances the value of the Year Book - it is perhaps food for thought that one third of the articles reviewed from this journal are found in this section! There is information of practical every day use on almost every page, nearly all reviews are followed by the section editor's comments on the value of the article and even if one disagrees with these they certainly stimulate interest. A good review book will also draw attention to articles outside one's usual reading. As an example, in the section on thorax, 15 of the 67 reviews are on breast diagnosis and include two excellent review articles, one from Investigative Radiology and one from Journal of the American Medical Association. I would certainly have missed one if not both without this review. The section on radiation physics comprising of 25 reviews is a small mine of information. The musculoskeletal section, 39 reviews, is notable for its variety, and the 50 paediatric reviews for their practicality. For me this latter was typified by reviews on obstructive jaundice and gas in the hepatic portal veins from English centres but perhaps I'm biased! At £35.50 this book is an even better bargain than its predecessor, the lower price reflecting current world finance. I. Lavelle