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Healthsouth Tulsa, OK
Is it acceptable to perform solid-column single-contrast barium enemas on patients who have just undergone a failed colonoscopy? Most of these patients have Hemoccult-positive stools. Would it be better to wait and perform an air-contrast barium enema?
McMaster University Medical Centre Hamilton, Ont. L8N 3Z5, Canada
There is obviously a concern that there may be serious risks attached to performing an enema shortly after a failed colonoscopy. To date, we have performed more than 300 double-contrast barium enemas on patients who have had a failed colonoscopy. These have been done the same day as the colonoscopy. Of those 300, only one patient had a complication that can be considered serious. Twenty-four hours after having a double-contrast enema, the patient returned with abdominal pain, and there was evidence of a perforation. Review of the barium enema films showed no evidence of perforation at the time of the examination, but films done on the day the patient returned with symptoms showed extravasation of contrast material. The patient was treated conservatively and did well.
It is extremely important that patients who have a failed colonoscopy, especially those who test positive for occult blood in the stool, be given a barium enema as soon as possible. There is no doubt that the barium enema has to be done in double contrast, as it is far superior to a single-contrast examination. We have had significant lesions shown on the barium enema that would have been missed if we had used a single-contrast, solid-column method. These were flat, plaque-type, early malignancies. Therefore, I would advocate that these patients have only double-contrast examinations. It is also important to persist and get a complete examination, because it is not unusual to find a small cecal carcinoma, just when you thought that this was another examination with normal findings.
There are certain precautions that one must take to ensure success. Because these patients have just undergone a failed colonoscopy, they are sometimes more heavily sedated than the patients who have undergone successful colonoscopy. Therefore, most of them will require time to recover from the sedation before proceeding. One has to use clinical judgment to ensure that the patient can understand instructions and is not so sedated that he or she is likely to fall off the table. Most of the patients will have recovered sufficiently in about an hour, some in less time.
These patients often have redundant bowel, especially in the sigmoid and transverse colons. Therefore, it is important to introduce sufficient contrast material to coat the right colon. Usually, contrast material is introduced until it pours just over the splenic flexure. In these patients, it is safer to introduce the contrast material until it reaches the mid transverse colon, or at least until you are assured that there is enough barium that can be pushed by carbon dioxide or air to the right colon. It is not unusual to use more barium than normal in these failed-colonoscopy patients. The colon is often filled with air, so it is easy to determine its extent and use the appropriate volume of barium.
The patients who have undergone failed colonoscopy are likely to have more water in the bowel than the patients coming for barium enemas. This is because their colonoscopies are often done earlier in the day, or because their preparation has been modified to account for their afternoon appointments. As a result, their bowel is not as dry, and judgment has to be used as to how much barium is introduced to overcome the diminished quality of coating as a result of the retained water. Again, introducing enough barium to reach at least the mid transverse colon is good practice in this group of patients. More barium is necessary if there is lots of retained water and redundancy present. The excess barium in the distal colon is drained once there is enough to adequately coat the right colon. This results in good coating of the mucosa and a complete examination without excessive barium.
The use of carbon dioxide instead of air reduces recovery time from the discomfort associated with gaseous distention. Even if the colon is full of air from the colonoscopy, "air lock" impeding the flow of barium is not a problem. In these patients, carbon dioxide may still be introduced but mostly to push the barium to the right colon. Also, a reduced volume of gas is used, because most of the air from the colonos-copy is used for distention of the colon.
The only disadvantage of performing sameday double-contrast barium enemas for failed colonoscopies is the increased volume of non-elective examinations you will be asked to perform, once the colonoscopists have realized how safely it can be done.
In summary, a failed colonoscopy can be safely followed with a double-contrast barium enema almost immediately after the colonoscopy and a single-contrast examination is not necessary. A more detailed discussion of this topic may be found in the April issue of this journal [1].
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  M. Goldshein and S. Somers Single-Contrast Versus Double-Contrast Barium Enema Examinations Am. J. Roentgenol., November 1, 2001; 177 (5): 1217 - 1218. [Full Text] [PDF]
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