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1
Department of Radiology, McMaster University Medical Centre, 1200 Main St. W.,
Hamilton, Ontario L8N 3Z5, Canada.
2
Present address: Department of Radiology, Royal Berkshire Hospital, London
Rd., Reading Berkshire RG3 5AN, England.
Received May 10, 1999;
accepted after revision October 3, 2000.
Address correspondence to A. L. Brown.
Abstract
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SUBJECTS AND METHODS. During a 30-month period, a prospective study was performed in 103 patients (79 women, 24 men) to determine the ease and completeness of DCBE immediately after failed colonoscopy and any additional useful information provided by the enema. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult).
RESULTS. DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE.
CONCLUSION. Immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases, often adds vital diagnostic information, and eliminates repeated bowel preparation and unnecessary delay in diagnosis.
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Colonoscopy is often the only method used for colonic assessment [1, 8]. However, approximately 6-26% of colonoscopic examinations performed by experienced endoscopists are incomplete and fail to reach the cecum, and repeated colonoscopy has a subsequent completion rate of only 50% [1, 9,10,11,12]. In our institution, the completion rate for colonoscopy is 91%, based on an internal audit of 5000 cases. With evidence that one third of all colorectal cancers lie proximal to the splenic flexure and that colonic neoplasms are changing distribution in the large bowel with more occurring proximally, complete colonic examination is important [13, 14].
DCBE achieves higher cecal examination rates than colonoscopy, which contributes to its advantage in evaluation of the right colon, and provides complementary information to that of colonoscopy [1, 5, 15].
At our institution DCBE is performed immediately after incomplete colonoscopy at the discretion of the referring endoscopist when complete colonic assessment is deemed necessary. Although same-day flexible sigmoidoscopy combined with DCBE has been used, same-day incomplete colonoscopy and DCBE have not, to our knowledge, been described [6, 16,17,18]. The purpose of this study was to evaluate the ease, completeness, and clinical usefulness of DCBE performed immediately after incomplete colonoscopy.
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In 103 patients (3%), DCBE examination was performed on the same day after incomplete colonoscopy at the discretion of the referring endoscopist. The patient group comprised 79 women and 24 men who were 18-88 years old (mean age, 62 years).
All colonoscopies were performed by experienced endoscopists with the assistance of a trained nursing team. Various models of Olympus 1680-mm videoendoscopes (Carsen Group, Markham, Ontario, Canada) were used with air insufflation and IV sedation. Over-tube stiffening devices and alternative instruments were used to facilitate the examination at the discretion of the endoscopist. Hot biopsy or snare polypectomy was performed in some patients.
Routine bowel preparation consisted of 20-mg bisacodyl (Dulcolax; Boehringer Ingelheim, Burlington, Ontario, Canada) orally after lunch the day before the examination, 10-mg metoclopramide (Maxeran; Marior Merell Dow, Laval, Quebec, Canada) orally after the evening meal, and 2-4 L orally of a polyethylene glycol-electrolyte solution until bowel movements were clear. This is also our standard preparation for barium enema.
A preliminary report of incomplete colonoscopic findings was recorded on the barium enema request form. A detailed final colonoscopic report was issued without knowledge of the findings at DCBE.
After supervised recovery of the patient from sedation, DCBE was performed by a staff radiologist, clinical fellow, or radiology resident working under the supervision of the gastrointestinal staff radiologist. A combination of spot images and overhead and decubitus images were obtained on one of two digital fluoroscopic units (models 1694 and 1600; General Electric Medical Systems, Milwaukee, WI). Polybar Plus barium suspension (E-Z-EM, Montreal, Quebec, Canada) was used in all cases with carbon dioxide insufflation. IV hyoscine butylbromide (Buscopan; Boehringer Ingelheim) was administered at the discretion of the supervising radiologist. DCBE examinations were reported in the usual manner under the supervision of a gastrointestinal staff radiologist with knowledge of the clinical information and incomplete colonoscopic findings.
The anatomic level reached, cause of failure, and findings at incomplete colonoscopy were recorded. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult) on the basis of the radiologist's experience with DCBE. The completeness of immediate DCBE and additional information provided by the enema were also documented. Any procedure-related complications were noted.
All patient charts were retrieved at the end of the study period and individual treatment outcomes recorded. The reference standard used was based on a combination of colonoscopic, radiologic, and histopathologic findings.
All patients gave their informed consent for the procedures. No institutional review board approval was sought because this study was a survey of existing clinical practice.
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The reasons given by the colonoscopist for failure to achieve complete colonoscopy were redundancy or tortuosity of the colon in 54 patients (52%), pain or spasm in 29 patients (28%), fixed bowel loops in 21 patients (20%), diverticula in 13 patients (12%), and colonic narrowing or obstruction in 11 patients (11%). In 30 patients (29%) there were multiple reasons for failure. Inadequate bowel preparation was the solitary cause of incomplete colonoscopy in only one patient. Fifty-seven patients (55% [52 women, five men]) had undergone previous abdominal or pelvic surgery and 46 patients (45% [27 women, 19 men]) had not. Of those patients in whom fixed bowel loops contributed to failure of colonoscopy, 17 (81%) of 21 had undergone previous surgery.
DCBE performed immediately after incomplete colonoscopy revealed the entire colon in 97 patients (94%). The cecum was reached in 91 of these patients and an ileocolic anastomosis was reached in the remaining six patients. DCBE was incomplete in six patients (6%). Barium reached the rectosigmoid colon in three patients (3%) and the descending, splenic, and transverse colon in one patient (1%) each. Failure of barium to reach the cecum was a result of obstruction caused by disease (n=3) and incontinence of barium (n=3).
The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult) in 88 of 103 patients. This information was not recorded at the time of the examination in 15 patients. The mean score was 5.0.
All DCBE examinations were adequate for diagnostic evaluation. Significant additional diagnostic information was provided by findings of the immediate DCBE in 14 patients (14%) and DCBE excluded disease in the colonic segments not examined endoscopically in the remainder.
In eight patients, the abnormalities revealed on DCBE were not seen or suspected on colonoscopy. Five malignant neoplasms (two colorectal carcinomas, two synchronous carcinoid tumors in one patient, and one lymphoma), one obstructing diverticular mass, two extrinsic sigmoid masses, and multiple Crohn's strictures (in one patient) were found.
In four patients, a suspected colonoscopic abnormality was excluded by DCBE findings and in two patients, colonoscopic abnormalities were further characterized by DCBE findings.
One patient developed a significant complication after incomplete colonoscopy (to the sigmoid level) and enema examination. Both investigations had shown diverticular disease only. The patient returned to the hospital with severe abdominal pain 24 hr after the procedure and was found to have intraperitoneal barium on a radiograph. No endoscopic biopsies had been performed. A sigmoid perforation was found at laparotomy and the patient had a full recovery after sigmoid resection. A review of the DCBE films showed no evidence of a leak at the time of the enema examination.
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Although bowel preparation, coating, distention, and other factors governing the overall diagnostic quality of DCBE were not formally recorded, overall "adequate" diagnostic quality was based on both the provisional and final DCBE reports. In no completed DCBE did the radiologist indicate that the study was nondiagnostic due to poor quality. Multiple factors may cause difficult or incomplete colonoscopy. Redundant colon, previous abdominal or pelvic surgery, and diverticular disease have all been implicated [12, 19,20,21]. Several studies indicate that completion of colonoscopy is inherently more difficult in women than in men and postulate that this may be related to pelvic anatomy and longer colons [12, 22, 23]. In our study group, there was a predominance of women (77%) referred for immediate DCBE. The strongest association of colonoscopic failure was with previous surgery (55%).
The reason for failure to complete the colonoscopy was not necessarily known by the radiologist at the time of examination, and the quality of bowel preparation was frequently not described by the referring endoscopist. These data were later collected from the full colonoscopy report.
The reasons given by the colonoscopist for failure were redundancy or tortuosity of the colon in 52% of the patients. Diverticular disease contributed to difficulty in 12% of the patients, half of those patients in whom it was detected (24% of study population). This difficulty may have been due to a combination of luminal narrowing caused by muscular hypertrophy and an inability to distinguish a diverticular orifice from the true lumen, resulting in reluctance to advance the scope because of the risk of perforation.
The diagnostic accuracy, sources of error, complications, and costs of DCBE and colonoscopy as individual methods of investigation are well described [1]. The complementary nature of the two examinations is confirmed in our study group in which important diagnostic information was provided by the immediate DCBE in 14 patients (14%).
Although the relative ease, completeness, and clinical usefulness of immediate DCBE after incomplete colonoscopy have been verified by this study, no attempt was made to ascertain patient acceptability or cost of this practice. Studies on same-day flexible sigmoidoscopy and DCBE may offer a useful comparison. (This service has been routine at our hospital for more than 10 years for the investigation of suspected large-bowel neoplastic disease.) Flexible sigmoidoscopy (with air or carbon dioxide insufflation) immediately before DCBE does not impair the quality of the subsequent barium enema examination, is well tolerated by patients, and the DCBE is no more difficult to perform (after flexible sigmoidoscopy) than DCBE alone [24,25,26]. The patient benefits from same-day DCBE by avoiding the inconvenience and discomfort associated with repeated bowel preparation and the cost of an additional hospital visit and time away from work. We recognize that in some institutions there may be a potential logistic problem in adding several patients to the barium list at short notice.
The complication rates for DCBE and colonoscopy are well reported. The incidence of perforations is 0.004% for DCBE and 0.2-0.4% for diagnostic colonoscopy, increasing to between 0.3% and 1.0% with polypectomy [1, 27, 28]. The risk of perforation at colonoscopy is greater when the procedure is technically difficult or performed by an inexperienced endoscopist and when there is fixation of sigmoid loops by disease or previous surgery [27, 29].
The development of peritonitis 24 hr after immediate DCBE in one patient in our series is a cause of considerable concern. Review of the images from the DCBE in this patient showed no evidence of leak at the time of the examination. The perforation must therefore have occurred some time later, presumably becuase of progressive changes at a site of colonoscopic abrasion. Patients in whom mucosal laceration is recognized endoscopically should not be referred for immediate DCBE.
Many patients in our series underwent endoscopic biopsy immediately before DCBE. Some authors have recommended a delay of 24 hr after biopsy performed through flexible endoscopes (because these biopsies are shallow) and 5 days after biopsies performed with rigid instruments [30]. The evidence for these recommendations is unclear and in a review of the complications of barium enema, Gelfand [31] found that endoscopic biopsy was responsible for only one of 18 cases of perforation, with that case occurring after rectal biopsy. Animal studies suggest that a barium enema may be safely performed immediately after a superficial biopsy of a nondiseased colon and that barium sulfate has no deleterious effect on healing of colorectal biopsy sites [32, 33]. We do not consider either endoscopic biopsy with a flexible colonoscope or polypectomy of small or pedunculated polyps to be contraindications to immediate DCBE.
In conclusion, immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases and often provides important additional complementary findings, which may hasten diagnostic evaluation and reduce costs. It is technically no more difficult to perform than routine DCBE and is convenient for the patient who may then avoid repeated bowel preparation. The benefits of immediate DCBE justify the logistic difficulties generated by this practice. Because it is technically straightforward to perform DCBE immediately after failed colonoscopy, we recommend that endoscopists should not persevere with technically difficult colonoscopic examinations, with the attendant risks of complications, but instead enlist the help of their radiology colleagues.
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