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Original Research |
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.
Received June 6, 2007;
accepted after revision August 7, 2007.
Address correspondence to M. S. Levine
(marc.levine{at}uphs.upenn.edu).
Abstract
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MATERIALS AND METHODS. Our database contained the records of 35 patients who had undergone retrograde ileostomy examinations from 1999–2005 and fulfilled our inclusion criteria. The images from the examinations were reviewed to determine the frequency and nature of small-bowel abnormalities, whether lateral views were obtained, and whether the catheter tip was withdrawn to the stoma. The accuracy of these examinations was determined by correlating clinical, radiographic, and surgical findings.
RESULTS. Twenty-eight (80%) of the patients had small-bowel abnormalities: adhesions in 14 (40%), adynamic small-bowel ileus in four (11%), strictures in two (6%), Crohn's disease in two (6%), focal perforation in two (6%), fistulas (one enterocutaneous and one enterovaginal) in two (6%), metastasis in one (3%), and parastomal hernia in one (3%) of the patients. The other seven (20%) patients had normal findings. Abnormalities were detected on lateral but not frontal or oblique views in six (75%) of eight patients with distal ileal disease and in three (43%) of seven patients for whom views were obtained only after withdrawal of the catheter to the stoma. Retrograde ileostomy examination had a sensitivity of 96%, specificity of 86%, positive predictive value of 96%, and negative predictive value of 86%.
CONCLUSION. Our experience suggested that retrograde ileostomy examination is an accurate technique for detecting symptomatic small-bowel abnormalities in patients with ileostomies, particularly in the distal-most portion of the ileum abutting the ileostomy stoma.
Keywords: barium study • fluoroscopy • retrograde ileostomy • small bowel • small-bowel abnormality
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Since its original description in the early 1950s [2], retrograde ileostomy examination has been advocated as a useful technique for detecting a variety of small-bowel abnormalities, including adhesions, Crohn's disease, tumors, fistulas, and small-bowel obstruction, in patients with ileostomies and for defining the anatomic features of the intestine before ileostomy closure [3, 4]. The advantages of retrograde ileostomy studies over antegrade small-bowel studies include a more controlled rate of barium infusion and more optimal distention of ileal segments near the ileostomy [3, 4]. To the best of our knowledge, however, no reports in the radiology literature describe assessment of the value of retrograde ileostomy examinations as an alternative to small-bowel follow-through studies for detecting small-bowel disease in this population of patients. The purpose of our investigation was to assess the accuracy of retrograde ileostomy examination for detecting small-bowel abnormalities in patients with ileostomies.
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Thirty-one (89%) of the patients underwent retrograde ileostomy examination because of clinical signs or symptoms of small-bowel disease (distal abnormalities were suspected), and four (11%) underwent the examination as part of a routine preoperative evaluation for ileostomy closure. Eight (23%) of the patients also underwent antegrade small-bowel follow-through studies. The mean interval between the antegrade and retrograde studies was 12 days (range, 1–48 days). The retrograde ileostomy studies were performed before the small-bowel follow-through studies for five (63%) and after small-bowel follow-through for three (37%) of the eight patients.
Nineteen (54%) of the patients were men, and 16 (46%) were women. The patients had a mean age of 52 years (range, 24–74 years). Medical records were reviewed by one investigator to determine the original indications for ileostomy, the nature and duration of symptoms at the time of the retrograde ileostomy examination, and the subsequent treatment and course.
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A 50% weight/volume barium suspension appropriate for the small bowel (Entrobar, Mallinckrodt Imaging) was used for 28 (80%) patients and water-soluble contrast material (diatrizoate meglumine and diatrizoate sodium [Gastroview, Mallinckrodt Imaging] or meglumine diatrizoate [Hypaque, Sanofi Winthrop]) was used for the other seven (20%) because of suspected small-bowel fistula or perforation. As barium was administered, fluoroscopic spot images of the small bowel were obtained periodically with graded compression. Barium was refluxed in a retrograde manner a variable distance into the distal, middle, or even proximal small bowel, depending on whether lesions, particularly obstructing lesions, were found in the distal ileum. In one patient, air also was administered through the catheter.
For the eight patients in whom disease was suspected in the distal-most segment of ileum abutting the ileostomy, lateral spot images were obtained. In seven of these eight patients, additional barium was administered as the catheter was slowly withdrawn to the ileostomy stoma for better visualization of small-bowel abnormalities at or near the stoma. None of the 31 patients had adverse effects due to these retrograde ileostomy examinations.
Antegrade small-bowel follow-through studies were performed by having the patient ingest oral barium sulfate suspension (Entrobar) and periodically obtaining fluoroscopic spot images of the small bowel by graded compression. Spot images at the lowest field of magnification (comparable to a 14 x 14 inch [36 x 36 cm] abdominal radiograph) were obtained to avoid the need for overhead radiographs. Lateral spot images of the distalmost ileal loop abutting the ileostomy stoma were obtained routinely.
All fluoroscopic studies were performed by residents, fellows, or one of three attending gastrointestinal radiologists, and all images were interpreted by one of the attending radiologists. All of the studies were performed with digital fluoroscopic equipment (Diagnost 76, Philips Medical Systems, or Sireskop SD, Siemens Medical Solutions).
Review of Images
All of the images from the 35 retrograde ileostomy studies and eight
antegrade small-bowel follow-through studies were reviewed by consensus of two
gastrointestinal radiologists (25 and 23 years of experience) who at review
had no knowledge of the clinical or surgical findings. The images were
reviewed to characterize the radiographic abnormalities in the small bowel,
including the presence of narrowing, obstruction, neoplastic lesions, Crohn's
disease, parastomal or other hernia, fistulas, and perforation. There were no
major discrepancies between the original radiographic reports and the blinded
review. Images from the retrograde ileostomy examinations were reviewed to
determine whether lateral spot images of the stoma were obtained and whether
the tip of the catheter was withdrawn to or near the stoma during the
examination. The extent of proximal small-bowel filling was noted.
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The indications for retrograde ileostomy examination included clinical signs or symptoms of obstruction (nausea, vomiting, abdominal distention, bloating, decreased ileostomy output) in 21 (60%), abdominal pain in five (14%), suspected enterocutaneous fistulas in four (11%), and bleeding from the ileostomy stoma in one (3%) of the patients. The other four patients (11%) had no symptoms. Retrograde ileostomy examinations were performed on these four patients for routine evaluation of the distal ileum before reversal of the ileostomy. The mean duration of symptoms at barium study was 13 days (range, 1–56 days). Seventeen (49%) of the patients were treated conservatively with nasogastric suction, IV fluids, and close observation; 17 (49%) underwent surgery on the small bowel (including 12 with small-bowel obstruction); and one (3%) underwent percutaneous drainage of an abdominal abscess.
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In 28 (80%) of the patients, abnormalities in the small bowel were found during retrograde ileostomy examinations. These abnormalities included postsurgical adhesions in 14 (40%) (obstructing in eight patients and non-obstructing in six) (Figs. 1A, 1B and 2A, 2B), adynamic small-bowel ileus (dilated small bowel without obstruction) in four (11%), strictures of uncertain causation in two (6%) (obstructing in both) (Fig. 3A, 3B), Crohn's disease in two (6%) (Fig. 4), focal perforation (most likely secondary to ischemia) with extraluminal contrast material in a perienteric collection in two (6%), small-bowel fistula (one enterovaginal and one enterocutaneous) in two (6%) (Fig. 5), metastatic disease with obstruction in one (3%), and obstructing parastomal hernia in one (3%) of the patients. Thirteen (46%) of the 28 patients had luminal narrowing, and 12 (92%) of these 13 patients presented with small-bowel obstruction (one patient with Crohn's disease had ileal narrowing without evidence of obstruction). The other seven (20%) of the patients had normal findings on retrograde ileostomy examinations.
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All eight patients with disease involving the distal-most loop of ileum adjacent to the ileostomy stoma had lateral and frontal or oblique spot images of the stomal region. In six (75%) of these eight patients (three with adhesions, two with strictures, and one with perforation into a contained extraluminal collection), the abnormalities were detected on lateral spot images but not on frontal or oblique spot images of the distal ileum (Figs. 2A, 2B and 3A, 3B). In these six patients, the mean distance from the ileostomy stoma to the distal-most diseased segment was only 2.5 cm (range, 1–5 cm). In the other two patients (one with Crohn's disease and one with adhesions), the abnormalities were detected on both lateral spot images and frontal or oblique spot images. In these two patients, the mean distance from the ileostomy stoma to the distal-most diseased segment was 8.5 cm (range, 7–10 cm).
The tip of the catheter was withdrawn distally to the stoma with additional administration of contrast material after withdrawal of the catheter in seven of the eight patients with disease in the distal-most ileal loop. The abnormalities in the distal ileum were detected only on images obtained after withdrawal of the catheter in three (43%) of these seven patients (two with strictures and one with adhesions) (Figs. 2A, 2B and 3A, 3B). In these three patients, the mean distance from the stoma to the distal-most diseased segment was only 1.7 cm (range, 1–3 cm). In contrast, the mean distance from the stoma to the distal-most diseased segment in the four patients in whom abnormalities were detected before and after withdrawal of the catheter was 5.5 cm (range, 1–10 cm).
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Comparison of retrograde and antegrade studies in eight patients—In five (63%) of the eight patients who underwent both retrograde ileostomy examination and small-bowel follow-through study, the radiographic diagnoses were concordant. In two (25%) of the patients, retrograde ileostomy examination revealed distal ileal obstruction missed on small-bowel follow-through study because of inadequate visualization of the obstructed distal ileum (Fig. 3A, 3B). In the other patient (12%), small-bowel follow-through study revealed proximal jejunal obstruction missed on the retrograde ileostomy examination because of inadequate retrograde filling of the jejunum (Fig. 7A, 7B).
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In our study, 27 of 35 patients with ileostomies who underwent retrograde ileostomy examinations had true-positive findings in the small bowel, for a diagnostic yield of 77% (Figs. 1A, 1B, 2A, 2B, 3A, 3B, 4, 5). This high yield is related to the extremely high prevalence of disease in the study population; most of our patients had clinical signs or symptoms of small-bowel disease after small-bowel or colonic resection with construction of an ileostomy. Retrograde ileostomy examination had a sensitivity of 96%, specificity of 86%, positive predictive value of 96%, and negative predictive value of 86% for detecting abnormalities in the small bowel. Our findings suggest the examination is accurate in the evaluation of symptomatic patients with ileostomies who have small-bowel abnormalities.
At our institution, retrograde ileostomy examination is performed by gentle insertion of a Foley catheter through the ileostomy stoma into the distal ileum abutting the stoma followed by administration of barium or a water-soluble contrast agent through the catheter into the distal portion of the small bowel. The barium can be administered through a syringe or an enema bag. We generally prefer using a syringe for better control of the rate of barium infusion into the distal ileum. The balloon on the Foley catheter is often inflated with 5 cc of air to anchor the catheter and decrease reflux of barium from the stoma. In our study and other previously reported studies of which we are aware, there were no cases of perforation secondary to inflation of the balloon on the Foley catheter. Nevertheless, we recommend that the balloon not be inflated if resistance is encountered when the catheter is advanced through the stoma or when attempting to inflate the balloon. In our study, only one (3%) of the 35 patients who underwent retrograde ileostomy examination had a technically suboptimal study because of stomal leakage of barium that prevented adequate retrograde filling of the small bowel. In most patients, however, this technique enabled enough retrograde filling of small bowel for a technically satisfactory examination.
Retrograde ileostomy examination was particularly useful for showing focal segments of small-bowel narrowing due to adhesions, strictures, and other causes because of the ability to obtain optimal luminal distention with this technique. As on antegrade small-bowel studies, adhesions causing low-grade or partial small-bowel obstruction were characterized by tapered narrowing, angulation, and fixation of the affected loop with preserved but tethered folds [5]. Luminal narrowing was the single most common finding on the retrograde study, occurring in 13 (46%) of 28 patients with small-bowel abnormalities (Figs. 1A, 1B, 2A, 2B, 3A, 3B, 4). All but one of these 13 patients had associated small-bowel obstruction, necessitating surgery with lysis of adhesions or resection of the diseased bowel segment.
The radiographic findings involved the ileum in 27 (96%) of 28 patients with abnormalities in the small bowel on retrograde ileostomy examinations and involved the distal-most ileal loop abutting the ileostomy in eight (32%) of the 25 patients with isolated ileal disease. Our data show that retrograde studies are particularly useful for detecting abnormalities in the distal-most ileum close to the ileal stoma because of the accessibility of these loops and the ability to obtain better distention and visualization of ileal loops closest to the infusing catheter. We rely primarily on fluoroscopic spot images rather than overhead radiographs for this study, so we can use fluoroscopy to monitor infusion of contrast material, manually palpate the small bowel, and optimize positioning of the patient.
We have found it valuable to obtain lateral images of the stomal region for improving detection of abnormalities in the distal-most ileal loop abutting the stoma. In our study, these abnormalities (adhesions, strictures, and focal perforation) were detected on lateral spot images but not on frontal or oblique spot images in six (75%) of the eight patients with disease confined to the distal-most ileal loop within 5 cm from the ileostomy stoma (Figs. 2A, 2B and 3A, 3B). These findings emphasize the importance of lateral views for showing adhesions, strictures, and other abnormalities in the distalmost ileal loop at or near the fascial planes of the anterior abdominal wall abutting the stoma. This loop is often obscured by overlapping loops of small bowel on images obtained in frontal or oblique projections.
Administration of additional contrast material after withdrawal of the catheter to the region of the ileostomy stoma also improves visualization of the distal-most ileal loop abutting the stoma (Fig. 1B) and of focal abnormalities in this region. In our study, strictures and adhesions in the prestomal ileal loop were detected only on images obtained after withdrawal of the catheter in three (43%) of seven patients for whom such images were obtained (Figs. 2A, 2B and 3A, 3B). In all three patients, the diseased segment was 3 cm or less from the ileostomy stoma. Our findings emphasize the value of infusing additional contrast agent after withdrawal of the catheter to the stoma to optimally show abnormalities in the distal-most ileal loop directly abutting the stomal region.
Only eight (23%) of the 35 patients in our study also underwent small-bowel follow-through studies because most patients were treated on the basis of findings at the retrograde ileostomy examination without need for antegrade small-bowel studies. In two (25%) of these eight patients, retrograde ileostomy examination revealed ileal narrowing with associated small-bowel obstruction that was missed on small-bowel follow-through studies because filling of overlapping loops of dilated small bowel proximal to the site of obstruction prevented visualization of the narrowed segment (Fig. 3A, 3B). These data suggest that retrograde ileostomy examination may be better for visualizing abnormalities in distal ileal loops close to the ileostomy stoma because of the proximity of these loops to the infusing catheter.
One (13%) of the eight patients who underwent both procedures had proximal jejunal obstruction missed on the retrograde ileostomy examination because of inadequate retrograde filling of the diseased jejunal segment (Fig. 7A, 7B). This observation reminds us of the potential limitation of retrograde ileostomy studies for detecting proximal small-bowel lesions because of difficulty filling the jejunum in some patients. If no abnormalities are found on retrograde studies, an antegrade small-bowel follow-through study should be performed to rule out the presence of more proximal lesions. Thus, antegrade and retrograde small-bowel studies appear to have complementary roles in evaluating the small bowel in patients with ileostomies, depending on the location of the underlying disease. If the clinical and radiographic findings suggest the presence of disease in the distal ileum, we believe retrograde ileostomy examination should be performed as the initial barium study because of the accessibility of the distal ileum to the ileostomy stoma. If the findings suggest the presence of jejunal disease, however, antegrade barium study should be performed.
Our investigation had the inherent limitations of a retrospective study, including selection bias. Our study was also limited by the lack of pathologic correlation in 17 patients who did not undergo surgery. The high diagnostic yield and positive predictive value of retrograde ileostomy examination were clearly skewed by the extremely high prevalence of small-bowel abnormalities in this select population of patients with ileostomies. It also was not possible to directly compare the diagnostic accuracy of retrograde ileostomy examination with that of antegrade small bowel follow-through because of the small number of patients who underwent both procedures within a reasonable time interval, and selection bias related to the order of these examinations. A prospective study comparing antegrade small-bowel follow-through with retrograde ileostomy examination therefore may be warranted to further elucidate the relative roles of these procedures in the evaluation of patients with ileostomies.
In summary, retrograde ileostomy examination had a sensitivity of 96%, specificity of 86%, positive predictive value of 96%, and negative predictive value of 86% for detecting small-bowel abnormalities in patients with ileostomies. The examination is particularly well suited for showing lesions in the distal-most ileal loops abutting the ileostomy stoma. Both lateral spot images of the stomal region and infusion of contrast material after withdrawal of the catheter to the stoma facilitate detection of abnormalities in this location. Conversely, antegrade small-bowel follow-through studies are more useful for showing abnormalities in the proximal portion of the small bowel that may be more difficult to adequately visualize on retrograde studies. Our experience suggests that the retrograde ileostomy examination is an accurate technique for evaluating symptomatic patients with ileostomies who have small-bowel abnormalities, particularly in the distal-most ileum abutting the ileostomy stoma.
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