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Accuracy of Retrograde Ileostomy Radiographic Examination for Detecting Small-Bowel Abnormalities

¹ Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
² Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —59-year-old man with total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy for ulcerative colitis presenting with nausea, vomiting, abdominal distention, and decreased output from ileostomy stoma. Frontal spot image from retrograde ileostomy examination with barium shows focal segment of tapered narrowing (small white arrow) in jejunum with complete retrograde obstruction. Findings are characteristic of obstructing adhesion. Surgery confirmed presence of postoperative adhesive band as cause of obstruction. Black arrow denotes tip of Foley catheter; large white arrows denote nasogastric tube in stomach.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —59-year-old man with total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy for ulcerative colitis presenting with nausea, vomiting, abdominal distention, and decreased output from ileostomy stoma. Lateral spot image after withdrawal of catheter (not shown) to stoma shows normal appearance of ileum abutting stoma with tapered narrowing of bowel (arrows) where it traverses fascial planes of anterior abdominal wall.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —40-year-old woman with total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy for ulcerative colitis presenting with nausea and vomiting. Frontal spot image from retrograde ileostomy examination shows barium filling dilated loop of distal ileum in right lower quadrant. Catheter tip (arrow) has been advanced into dilated ileal loop.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —40-year-old woman with total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy for ulcerative colitis presenting with nausea and vomiting. Steep left posterior oblique spot image after withdrawal of catheter tip (black arrow) to stoma shows focal area of narrowing and angulation (white arrow) in distal-most ileal loop compatible with partially obstructing adhesion. Filling of dilated small bowel is evident more proximally. Adhesion was lysed at surgery.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —32-year-old woman with total proctocolectomy and ileostomy for Crohn's disease presenting with nausea, vomiting, and abdominal distention. Frontal spot image from retrograde ileostomy examination shows barium filling several dilated loops of distal ileum in right lower quadrant. Catheter tip (arrow) has been advanced into dilated ileal loop.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —32-year-old woman with total proctocolectomy and ileostomy for Crohn's disease presenting with nausea, vomiting, and abdominal distention. Lateral spot image after withdrawal of catheter tip (not shown) to stoma shows 1-cm-long partially obstructing stricture (white arrows) in distal ileum abutting stoma with proximal dilatation, most likely secondary to ischemia or scarring from previous surgery. Stricture, which was not visualized at antegrade small-bowel follow-through study 4 days earlier, was resected at surgery. Stricture contrasts to normal tapering of prestomal loop where it traverses anterior abdominal wall in Figure 1B. Undissolved pill (black arrow) abuts stricture.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —50-year-old man with total proctocolectomy and ileostomy for Crohn's disease presenting with abdominal pain. Steep right posterior oblique spot image from retrograde ileostomy examination (with barium and air) shows evidence of Crohn's disease with linear ulcers and stricture (large arrows) in distal-most loop of ileum abutting stoma and skip segment of disease with aphthoid ulcers (small arrows) in loop of ileum more proximally. Abdominal pain was relieved by medical therapy for Crohn's disease.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —53-year-old woman with total proctocolectomy and ileostomy for Crohn's disease presenting with enteric discharge from vagina. She had received radiation therapy to pelvis for cervical carcinoma. Steep left posterior oblique spot image from retrograde ileostomy examination with water-soluble contrast material shows enterovaginal fistula (small white arrow) with barium passing from distal ileum into vagina (black arrows). Thickened folds (large white arrows) in adjacent loop of pelvic ileum are due to chronic radiation enteritis, which presumably was responsible for development of fistula. This fistula was repaired surgically.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —58-year-old man with total proctocolectomy and ileostomy for colorectal cancer presenting with abdominal pain. Right posterior oblique spot image from retrograde ileostomy examination with barium shows short segment of narrowing (white arrows) with smooth contour and tapered borders in distal ileum. Patient was thought to have ischemic stricture, but surgery revealed no evidence of stricture in distal small bowel. Patient therefore had false-positive findings on retrograde ileostomy study. Black arrow denotes tip of catheter.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —70-year-old man with proctocolectomy and ileostomy for gastrointestinal bleeding presenting with nausea, vomiting, and abdominal distention. Frontal spot image from retrograde ileostomy examination with barium shows normal-appearing loops of ileum without filling of more proximal small bowel. Infusion of barium was stopped because of leakage from stoma onto skin (large white arrows). Small white arrow denotes tip of catheter. Metallic densities (black arrows) overlying lumbar spine are embolization coils.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —70-year-old man with proctocolectomy and ileostomy for gastrointestinal bleeding presenting with nausea, vomiting, and abdominal distention. Frontal spot image from antegrade small-bowel follow-through study with barium 4 days after A shows focal segment of marked narrowing and angulation (arrow) in jejunum and proximal dilatation compatible with high-grade obstruction. Obstructing jejunal adhesion was lysed at surgery. Patient had false-negative findings on retrograde ileostomy study because of lack of opacification of proximal small bowel.

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