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1 Department of Radiology, New York-Presbyterian Hospital, 525 E 68th St., New
York, NY 10021.
2 Department of Radiology, Memorial Sloan-Kettering Cancer Center, Rm. C276F,
1275 York Ave., New York, NY 10021.
Received March 31, 2003;
accepted after revision May 14, 2003.
Presented at the annual meeting of the American Roentgen Ray Society,
Atlanta, 2002.
Abstract
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MATERIALS AND METHODS. Thirty-two patients with known or suspected intraabdominal malignancy and small-bowel obstruction who underwent both CT and subsequent contrast enema were identified. CT and contrast enema reports were reviewed for patients with tumor involvement of the colon to determine whether the contrast enema findings had provided additional information to the data that had been acquired with CT. In cases in which the contrast enema had provided additional information, the patients' medical records were reviewed to determine whether treatment had been modified as a result of the additional information.
RESULTS. In 14 (44%) of 32 patients, the contrast enema provided evidence of synchronous colonic disease not previously detected. The colonic involvement could be classified into two categories: implants (n = 1) and narrowing or complete obstruction (n = 13). Findings of the contrast enema resulted in a change in treatment in 10 (32%) of 32 of our patient population.
CONCLUSION. Patients with known intraabdominal malignancy who present with small-bowel obstruction may have synchronous large-bowel disease that is undetectable on standard CT scans. In these patients, the additional information provided by the contrast enema altered subsequent treatment.
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8.2%) of concurrent small- and
large-bowel obstruction [1].
For those with ovarian carcinoma, the percentage of patients with combined
small- and large-bowel obstructions may be as high as 15–22%
[2]. Malignant obstruction can
be treated with surgical intervention, which has been shown to both offer
relief of symptoms and prolong survival
[3]. However, surgical bypass
in patients presenting with malignant small-bowel obstruction has higher
associated morbidity and mortality than it does in the general population,
including an estimated 20% surgical mortality rate
[4]. Abdominopelvic CT findings have been shown to be highly sensitive and specific in the evaluation of small-bowel obstruction. CT sensitivities as high as 100% and specificities as high as 92% have been reported in the detection of clinically significant obstruction (defined as an obstruction requiring surgical intervention) [5]. The sensitivity of CT in the detection of low-grade obstruction is much lower—48% [6]. CT has also been shown to be helpful in accurately distinguishing malignant from benign large-bowel obstructions in up to 84% of patients with such obstructions [7]. Consequently, CT has become the first and often the definitive examination for the diagnosis and evaluation of suspected bowel obstruction. However, in patients with concurrent small- and large-bowel obstructions, the distal bowel typically is collapsed as a result of the more proximal obstruction.
In clinical practice, it is common for patients to undergo surgery on the basis of the results of CT alone. The purpose of our study was to determine whether contrast enema radiography provides new information that alters subsequent treatment of patients with known intraabdominal malignancy and small-bowel obstruction.
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Thirty-two patients with 32 contrast enema studies met our inclusion criteria. The 22 women and 10 men had a mean age of 59 years (range, 31–89 years). Primary malignancies were ovarian (n = 10), colorectal (n = 10), bladder (n = 5), gallbladder (n = 2), and stomach (n = 1) cancers; pseudomyxoma (n = 2); adenocarcinoma of unknown primary malignancy (n = 1); and Hodgkin's disease (n = 1). The mean time between the CT and contrast enema examinations was 6.5 days (range, 0–30 days).
CT had been performed on HiSpeed and Light-Speed scanners (General Electric Medical Systems, Milwaukee, WI) with 5- to 7.5-mm sections. Both oral (120 mL of MD Gastroview [diatrozoate meglumine and diatrozoate sodium], Mallinkrodt, St. Louis, MO, or 900 mL of Readi-CAT barium sulfate suspension, E-Z-EM, Westbury, NY) and IV contrast (150 mL of 300 mg I/mL Omnipaque [iohexol], Amersham Health, Princeton, NJ) materials had been used. For the contrast enema examinations, either a water-soluble (240 mL of MD Gastroview) or barium (E-Z-paque barium sulfate [95% weight/volume], E-Z-EM) contrast material had been used with a combination of fluoroscopy, spot radiography, and projection imaging. No standardized bowel preparation was used because most of the imaging was performed in urgent or emergency settings. The original reports of all imaging studies were reviewed for notation of large-bowel obstructions or serosal or peritoneal implants. When available, the original imaging studies were reviewed.
We classified patients for whom the contrast enema provided new information as having either serosal implants or colonic narrowing. We then reviewed the patients' charts, including the pre- and postoperative assessments and the surgical notes, to determine whether the new findings had any impact on case management. For the purposes of this study, a change in management was defined as the performance of bypass surgery on another segment of obstructed bowel in addition to the obstructed small-bowel loop initially identified or the creation of an end-ostomy instead of a reanastomosis at initial surgery.
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The contrast enema revealed information that had not be provided in the CT report for 14 (48%) of the 29 patients in whom CT showed no large-bowel obstruction. Of these cases, obstruction was seen in six (100%) of six patients with serosal implants, in one (17%) of six patients with peritoneal carcinomatosis, and in seven (70%) of 10 patients with CT evidence of both diseases. Therefore, in only one (8%) of 13 patients without CT evidence of serosal disease was an obstruction identified. However, an unsuspected obstruction was present in 13 (81%) of 16 patients with documented serosal disease. In the seven patients who had no CT evidence of peritoneal or serosal disease, the contrast enema did not reveal an obstruction and did not provide additional information.
Of the 14 patients for whom the contrast enema provided new information, one patient was found to have unsuspected serosal implants, and 13 patients were found to have narrowing or complete colonic obstruction (Figs. 1A, 1B, 1C and 2A, 2B, 2C). In 12 of these cases, the narrowing was functionally significant, defined as dilatation of the colon proximal to the narrowing (n = 10), or occlusive, defined as the failure to pass contrast material proximal to the lesion during the contrast enema examination (n = 2). In one of these 12 patients, the contrast enema showed a previously unsuspected gastrocolic fistula (Fig. 3). Subsequent treatment was altered in 10 (71%) of the 14 patients in whom new information was obtained, representing 31% (10/32) of our total study population). One patient who was lost to follow-up had a complete obstruction. From our review of the charts, we could not determine the reasons that distal bypass surgery was not performed in the remaining three patients, all of whom had colonic narrowing.
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The contrast enema provided no new information in 18 patients; however, for 14 of these patients, it did confirm the absence of serosal disease (eight patients), the presence of serosal disease and large-bowel narrowing (three patients), or the presence of serosal disease without narrowing (three patients). In these 18 patients, CT findings had revealed concurrent bowel obstruction in three patients, peritoneal disease in 11, and no evidence of either in seven.
Review of the data showed no correlation between the underlying primary malignancy and the likelihood of the contrast enema providing new information or of the new information resulting in a change in treatment.
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In current practice, CT is often the initial and sole imaging technique used to evaluate a patient presenting with small-bowel obstruction. CT has been shown to be highly sensitive and specific for detection of clinically significant small-bowel obstructions; sensitivity has been reported to be as high as 100% and specificity, as high 92% [5]. CT has also been shown to have high accuracy (84%) as a tool in differentiating malignant from benign obstruction [7]. What has not been shown is the sensitivity of CT for revealing a more distal obstruction in patients who have concurrent malignant bowel obstructions.
Our series showed a synchronous distal obstruction in 14 (44%) of 32 patients, much higher than the frequencies reported by Tang et al. [1] and Carter et al. [2]. This result may stem from a selection bias inherent in the patients included in our study. Enemas were ordered only in patients who, in the opinion of the referring physicians, were at high risk for a distal obstruction because of an advanced intraabdominal malignancy. This selection bias may have led to an overstatement of the prevalence of synchronous obstructions, but the referring physicians' requests for contrast enema examinations of these patients also emphasize the inability to document these obstructions using CT despite the high clinical suspicion that they were present. Regardless of the true prevalence of synchronous obstructions, our data confirm that when these obstructions are detected, the surgical treatment for most patients is altered. Consequently, preoperative identification of these more distal obstructions is important.
The lack of luminal distention due to the more proximal obstruction results in an inability to diagnose colonic narrowing or obstruction despite evidence of serosal disease (Figs. 1A, 1B, 1C and 2A, 2B, 2C). However, in a high proportion of these patients (for example, 81% in our study), narrowing or obstruction is present. Our results show that a contrast enema is an effective tool for detecting these conditions. However, for this acutely ill population, a contrast enema examination is often difficult to tolerate. The large bowel can be distended by rectally introducing water-soluble contrast material or air for the CT examination. If the bowel is prepared in this manner, we believe that CT could be as effective in revealing the distal obstruction as it is in revealing the proximal obstruction. CT could then be, in effect, a "one-stop shopping" evaluation. In combination with rectally administered contrast material, recent advances in multidetector CT and multiplanar reformatting may facilitate the detection and depiction of clinically significant distal obstructions and allow radiologists to generate and provide the referring physicians with multiplanar images similar to those from a contrast enema. Indeed, further evaluation of these possibilities may be warranted.
The results of our study confirm that in patients with small-bowel obstruction and advanced intraabdominal malignancy, occult synchronous distal obstructions are present in as many as 44% (14/32) of patients, as found in our select population, and at an even higher rate in the subset of patients with CT evidence of serosal disease. Furthermore, when diagnosed preoperatively, both levels of obstructions can be bypassed at the initial surgery, thereby avoiding the morbidity and mortality associated with a second procedure.
Our data suggest that standard CT examination may be sufficient in patients with small-bowel disease but without current evidence of peritoneal or (especially) serosal implants. However, in those patients in whom CT does reveal advanced intraabdominal malignancy, it is imperative to exclude the presence of an occult synchronous colonic obstruction. The contrast enema has been proven to be an effective tool in the detection of such obstructions.
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