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we're gonna talk today about double contrast 

examinations of the gastrointestinal tract 

for the non radiologic people here 

in the audience.

Some of this will probably be review,

some will be new material and I hope 

hopefully it's timely as virtually 

everybody at one time or another does order 

gastrointestinal studies on their 

patients for a variety of reasons.

Obviously this is basically a radiologic 

talk,

but I will orient as much as possible to 

it,

to the clinicians uh when 

appropriate times make themselves 

available.

I have really two themes that go out 

through this entire presentation and that 

is um double contrast techniques 

may be performed by any interested radiology 

department.

They are not difficult to do.

The reason I tell that to you clinically is that if you're ever working 

at other institutions and 

perhaps the radiology department is not perform these 

techniques,

you know,

that they can be performed with these.

There there may be reasons why they don't perform them or differences in 

philosophy,

but they can technically be performed readily.

And the second theme is that uh at least 

in my opinion,

in many instances,

the diagnostic capabilities 

of G.

I tract radiology are extended with these 

techniques.

So,

if we could have the first slide and the lights down,

like 

double contrast examinations of the gastrointestinal 

tract can be performed virtually the entire gastrointestinal 

tract,

the esophagus,

the stomach,

the duodenum and colon colon air contrast 

work has been known about for some time now,

primarily popularized in uh 

europe.

However,

I think in this country it's been generally somewhat under utilized,

but now there are techniques available to study these 

various sites with these techniques.

Next line 

first,

we'll talk about the esophagus and we'll follow the gastrointestinal 

track ab orally.

There are various techniques that may be utilized in the technique that 

we have utilized here with considerable success 

is using the patient upright and 

having the patient hold barium in one hand and a 

cup and water in the other hand,

patient has a mouthful of barium and then 

swallows the barium and quickly thereafter one mouthful of 

water so that you see we do not produce an heir 

contrast effect but rather a double contrast 

effect.

That is the water washes through the 

barium that has previously been swallowed.

Leaves a coating of barium on the esophagus and 

produces the double contrast effect we 

use for the variant preparation 

preparation that is formulated for air 

contrast colon work.

It's a preparation that's a moderate moderately 

viscous and has excellent coding properties and 

spot films are obtained at the appropriate time.

Next slide.

This is a subject holding the barium in one hand and the 

water in the other hand taking a mouthful of 

barium.

Next slide 

patient has the berry um in her mouth,

water is ready and she's going to swallow the barium and 

follow that with a swallow of water as quickly as possible 

so that the water as we said,

can wash the barium through next line.

This is an example then of a normal double contrast to 

Sasha graham.

A good one obtained with this technique.

Next line.

These are the clinical and radiologic uses uh 

for double contrast to soften biography.

I should point out to you when when you're ordering this in your patients,

we don't do this routinely.

We do it if there are so fragile symptoms and 

or if there is a suspicious finding on a 

conventional esophageal examination.

So it is not a routine examination in our department.

As several other of these techniques are.

It's obviously helpful for the detection of small esophageal 

tumors.

I don't know that these small tumors are always early tumors,

but one can detect smaller 

salvageable lesions with reliability.

With this technique,

it's helpful to delineate the morphological features 

of lesions in the esophagus.

That is the surface characteristics.

Is it smooth?

Is it irregular?

Is it also rated?

And finally,

to distinguish between mucosal and sub 

mucosal lesions?

And I'll show you some examples of these things.

And another use for this is to assess 

the total vertical extent of disease that is you have a 

neo plasm.

The total vertical extent of this new plasm can be 

readily assessed with double contrast to soften 

geography.

And this is obviously going to be helpful in treatment planning.

Next line,

this is an example of a lot dilated esophageal 

carcinoma that we had some time ago 

and this lesion would not be missed and was not 

missed on a conventional,

say photography,

but one can see it uh very readily with a 

double contrast technique and can tell the 

gross vertical limits of disease very readily here,

much more readily than on the conventional technique.

Next line.

And this la belated mass in these various projections as an 

example of a carcinoma sarcoma.

Now these several lesions no one is going to miss with 

conventional techniques,

they're obvious.

I think there may be more elegantly displayed here and one can see a little bit more 

about them.

I'm gonna show you some cases now where 

the double contrast technique was of definite value in 

comparison to conventional techniques.

Next slide,

This is a man that was being followed here for a gastric ulcer.

He was referred here because it was felt that the gastric ulcer might be 

malignant and he did have a gastric ulcer,

had a symptomatic patient 

in terms of his esophagus and on his esophagus,

RAM had this obvious uh filling 

defect here.

It's difficult to characterize it,

but a definite filling defect there on multiple swallows.

As you can see next slide 

and here with a double contrast techniques,

we can see this lesion in profile 

and then interestingly we can see it on Fox here.

It's a little unusual to see in esophageal lesion on fox,

but this is analogous to how we see Palepoi defects in the 

colon.

And this is a squamous carcinoma in this patient.

I think that we can see this uh 

lesion considerably better with this technique than with a single 

contrast next live 

here's a very interesting patient and we'll use it to make another 

point to clinicians.

This is a patient who had had a previous head neck tumor several years 

before he had a carcinoma of the tonsils and 

he was having difficulty swallowing and he indeed was 

having difficulty swallowing.

You can see here that he's aspirated a fair amount of 

contrast material.

We could not obtain very many films of his 

thoracic esophagus.

But in this region once he's a little mucosal nodule 

and this proved to be a squamous carcinoma of the 

esophagus and a patient with a previous head and neck 

legion next slide and 

another more recent patient,

another patient with a head and neck lesion a few 

years before.

Again asymptomatic just being studied routinely for 

his head neck problem.

We see this plaque like irregularity along this wall and this has 

been proven now to be a squamous carcinoma of the 

esophagus.

I want to just stop here and make this point to any of 

the clinicians that are here 

who do see patients for head and 

neck problems,

not necessarily head neck surgeons or 

E.

N.

T.

People but anybody who comes in contact with these patients 

at the time they are initially diagnosed and thereafter when 

they're followed up one of the routine things that should be 

done with them at some regular periodicity.

Maybe like every six months after the baseline examination is to 

do in a sofa graham because there is a definite 

increased incidents of esophageal carcinoma in 

patients with any sort of squamous head and neck tumors.

And we have found a large number of them in a several year period 

of time where we've been looking maybe maybe about as many as a 

dozen.

Some of them quite small and others unfortunately,

very large,

bulky tumors.

So this is an association,

I think that it hasn't been entirely recognized here and then we need to look 

for it and maybe just as common as these people later 

developing squamous carcinomas of the lung.

Next slide,

another patient,

this patient on multiple barium swallows had this 

vague area of narrowing in the esophagus.

It was definite but not hard to characterize it.

Next slide,

mucosal pattern through this area was entirely normal.

Next slide,

but on a double contrast study,

we can see some additional findings on the left here,

we can see some shouldering effect that wasn't appreciated 

on the barren field study.

And we see some irregularities on the contour of the 

esophagus on the opposite side.

And this is another squamous carcinoma of the esophagus.

Next live,

here's an interesting patient.

This is a brother of a physician here in this hospital 

who had this vision was examined at another 

hospital and had this filling defect in the 

esophagus.

This filling defect identified.

He was referred here and had some studies done 

here.

Next line on this double 

contrast study,

we see this nice smooth interim euro lesion.

If you look very carefully here and I hope it projects There's another 

thing staring at us on foss.

Next live turning the 

patient into the opposite of liquidy.

We see the other lesion.

Yes,

sir.

Are to lie on my mama's in this patient's esophagus,

only the second one being recognized with double contrast 

study.

Next slide,

here's another interesting patient that has this obvious 

fungal irregular carcinoma with 

some extension seems to be going up into the esophagus as they 

commonly do.

Next slide films of the 

esophagus do show some minor marginally 

regularities.

And one would be suspicious that there is disease there.

But it's a little hard to define next line.

But again,

with double contrast study,

we can readily outline the total vertical extent.

This is not a good study because this patient had relative obstruction 

here.

One can always obtain a beautiful study.

But even in a study here that somewhat compromised by an 

obstruction,

one can still see this Neil players from crawling up the 

esophagus.

This piece of tumor is up here.

So we can see that virtually the distal half the esophagus is 

involved by this gastric nia plasm that's readily 

identified with double contrast examination next lot.

And finally,

just in terms of inflammatory disease.

This is a patient with candid diocese and we see a nice 

cobblestone pattern throughout the assad because in 

this patient next line.

So in summary relating to the esophagus 

double contrast of so photography is simple to perform.

We do the technique of barium and water with successive 

swallows and we find that it is a useful 

adjunct to the morphological examination of the 

esophagus for the detection of small 

esophageal tumors.

Hopefully early in some cases 

defining the morphological features of the tumors 

and finally the vertical extent of disease in 

the esophagus.

Next slide,

we'll go on to the stomach now and talk about 

air contrast or double contrast exams of the 

stomach.

In this case,

the way the technique is performed on your patients.

We use 2-3 ounces of a high density berry.

Um that has certain coding properties for the stomach 

to the barium is added an anti foaming agent that we'll discuss in 

a moment and we use a gas preparation 

effervescent powders to produce the gas in the 

stomach patient ingested the gas 

preparation the effervescent powders and follows this with a 

barium patients turned several times to make sure the 

stomach is coded and to dissipate the bubbles and then 

double contrast views are obtained.

We routinely do four double contrast views 

in our examination and it's readily incorporated into the 

initial part of the examination.

Blue dragon and other anti spasmodic 

agents may or may not be added uh to decrease 

gastric peristalsis uh and decrease 

gastric emptying if that's necessary.

And we use a low killer voltage on 

these radiographs to obtain optimal contrast 

next line these are 

some of the preparations that have been available primarily 

manufactured in japan effervescent 

preparations and many of these had anti 

foam substances in them.

However,

they are generally not available in the United States.

Uh at this time.

Next slide,

this is one of the preparations call unique Zorro.

We see here that when the cap is opened,

there are some japanese script here.

A lot of people think that this is the instructions 

as to how to do the examination,

but others feel that this perhaps represents new plans 

for an attack on Pearl Harbor.

Next line 

we find that just plain old citric carbonate that one 

can obtain from any pharmacy is just as 

good as the other preparations of course here where 

there is no anti foam agent and one has to 

add the anti foam agent.

We use about a teaspoonful of the gas 

powder next line 

and we add Millikan drops.

In other words,

this is signed with a cone to the berry,

um maybe a CC or CC.

And a half of these malecon drops are added to the 2 to 3 

ounces of barium.

Next line,

yes.

So the patient begins the examination 

with citric carbonate powders and bury him in 

hand.

Next line she ingests the powders and 

drinks down the uh the barium 

patients place in a recumbent position and turn from the 

supine to the prone position and back three or 

four times again to achieve as good 

at coding as possible and to uh 

make the bubbles disperse that are formed by the citric 

carbonate.

Next line and then 

three films in the supine and soup.

I know black positions are obtained in rapid succession.

One wants to do this fairly rapidly so that not much 

gastric emptying of either barium or 

uh air takes place.

Next live.

This would be an example of a nice double contrast 

gastro gram in the supine position with 

just a small amount of barium and not much gastric 

emptying.

Haven't taking place.

Next line.

one Old Black View.

Next live the other 

old black view.

Those are three routine views we obtain.

Next lied at this point we stand the patient 

up and obtain an upright view of the fungus.

And at this point then the rest of the examination 

is resumed as in a conventional way.

And most people would at this point do pressure,

mucosal views on the on the rest of the stomach and 

there's just a small amount of barium in the stomach at this time.

And one can readily obtain these views.

Next line,

I'm just gonna digress here for a moment and talk 

about one aspect of the 

stomach anatomy that we've been able to appreciate with 

double contrast studies of the stomach.

Should say that dr Dodd stimulated this work 

in our department.

He has been interested in this for some time.

And for any of you who are further interested in this and 

other aspects of stomach anatomy.

He's going to be talking at jesse jones 

library building on the first floor 

to the Houston Gi Forum this afternoon at three 

o'clock.

The surface of the gastric mucosa,

my gastric mucosa and yours.

Everybody's is subdivided in addition to the Rue Guy that 

everybody knows about into small ovoid or 

political islands by a complex intersecting series 

of shallow grooves.

The islands that will show you in a moment or turned the area 

gas tricky and the surrounding grooves are turned the 

salsa gastric next lot 

this is a stomach that's been opened 

up.

And if you look carefully,

you know,

there are obvious ruby.

I hear that everybody knows about in the stomach of course,

and that we use to make diagnoses with.

But there are other little 

islands here.

In other words,

a fine mucosal relief pattern in and amongst the 

Rue Guy and where the rug I are not in the stomach.

Next line,

this is the same stomach painted with 

barium and one can appreciate this 

network pattern uh in the 

stomach amongst the Rue Guy and in between them and on 

them,

et cetera.

Next line 

here is a close up of one aspect or one portion of the 

body of that stomach.

So like here's a gastric crew guy.

And there's one and then one can see on the Rue Guy and in 

between them these little political islands of 

tissue,

the fine mucosal relief,

the area gastric and then surrounding and 

actually making up these little islands are these 

intersecting grooves called the salsa 

gastric E.

Those salty gastric.

Those little tunnels is where the barium goes to 

make that network pattern.

Next line.

And this is a close up in vitro painted 

view of that portion of the stomach showing 

that appearance.

Next line.

Dr James Anderson in uh the 

laboratory associated with the 

diagnostic radiology department.

Uh did some scanning electron 

microscopy of some stomachs.

And this is an interesting appearance of this 

pattern with a scanning electron 

microscopy.

One of these is an area gastric E.

These are one of these islands blown up.

And here are these tunnels.

These intersecting grooves the salsa gastric E.

And we can notice.

Then each area gastric itself has a 

convoluted patterns like each area gastric has an area 

gastric pattern of itself.

But we see a convoluted pattern on each area.

Gastric Next line 

here's a close up of one of those.

This is one area gas tricky.

Here are these tunnels alongside the salsa gas tricky 

these grooves.

Okay.

And then we see this convoluted pattern.

If you notice amongst the convoluted pattern,

our little pits,

little depressions.

Those are the gastric pits.

Those are the openings on the gastric 

mucosal surface into which gastric 

glands drain so that if you can see here 

each area gastric E.

Each little island maybe has a dozen Of these 

gastric pits into which gastric Glands one or 

more drain next slide.

So this schematic drawing 

summarizes what we've just said.

Then one of these islands is the area gas tricky.

And then one can see these little black dots 

representing the cell site.

Excuse me representing the gastric pits.

And then we can notice here in the cross section.

One or more gastric glands drains into each one of 

these gastric pits.

Thanks line Radio 

graphically we can identify this pattern if we 

do double contrast techniques and have 

good coding variant preparations that are not too viscous so 

that the the barry um 

can enter the shallow sell side gastric.

And we have identified three arbitrary 

patterns.

We've talked about a fine pattern,

a course pattern in a nodule or pattern.

And you will see this in your report sometime where we talk about 

a course fine mucosal relief pattern 

or a coarse or fine area gas tricky 

pattern.

Next lot here are some 

examples.

This fine little network pattern in the distal 

stomach here is an example of a of an average 

fine gastric find relief pattern.

This would be uh not very 

spectacular.

And we see this I guess in about 50% of our cases 

uh using double contrast 

techniques.

Next live this would be a 

coarser pattern where the islands themselves are larger and the 

grooves themselves are denser appear more 

coarsened.

Next line.

Another example of a course area gastric 

pattern.

Next line and finally 

a not very frequent appearance,

the nodule er appearance of the 

fine mucosal relief pattern of the stomach.

Now,

uh anatomically 

this is interesting and I think certainly one 

thing it helps us with is that if we see this 

with regularity,

we know,

then we have an objective criterion to say that we are 

achieving excellent double contrast 

examinations of the stomach.

If one can see this pattern,

one knows he's achieving ah 

good double contrast work of the stomach 

what their functional significance is and if they can 

be used in diagnosis is 

a little more questionable at this time,

we have had some cases where the pattern's been course 

or Nigel er that has been diagnosis gastritis.

We've had one or two cases where it's been helpful in malignant 

disease,

but at this time it would be hard to make a 

definitive statement about its real diagnosable 

value.

Well,

sometimes in our reports say this to the 

clinicians,

you'll see a report that discusses this pattern the fund because of 

relief pattern of the area gastric pattern.

And there will be a statement made that it could suggest 

diagnose of gastritis and you have to correlate that 

clinically with your clinical findings.

But at this time there is no definitive statement that can be 

made regarding its its functional 

significance as diagnostic significance.

Next line,

okay,

now,

back to double contrast gastro graffiti and some 

quick examples of diagnoses that are made very 

readily with double contrast uh studies 

here on the post year.

While the stomach is the evidence of a healed ulcer 

with multiple radiating folds right into a little gastric 

pit.

Next slide 

here's another lesion on the posterior wall of the 

stomach,

a central ulcer crater with radiating folds.

This surprises.

Incidentally,

one can see this network pattern the area gas tricky and the more distal 

stomach.

We thought that this,

you know,

in this projection at least had the appearance of a 

benign ulcer with radiating foals 

dr nelson and his group endoscope this 

patient and took some biopsies and I understand that on this 

one or two of the folds up super early there 

was lymphoma patient did have known 

lymphoma in his liver and this turned out to be a lymphoma.

This involvement of the stomach and this unusual presentation 

of a ulcer with radiating folds.

Next line,

here's a very interesting case.

It's not something that's going to be seen very much probably at 

this hospital but will be seen at other hospitals where this 

technique is performed.

This is a standard right Ontario 

black view of the stomach that's perfectly normal in a patient.

Next line.

This patient,

if you notice on the double contrast study has multiple 

punk Tate and 

linear collections of barium.

Next slide,

I think there's a close up in a different projection.

Multiple punkt eight and linear collections of barium and 

many of the punk take collections are surrounded 

by nuisances.

Can we go back to the other slide out and it seems from here.

It projects a little better.

Many of these little collections are surrounded by licenses and this 

is a pretty classic radiologic example of 

erosive gastritis with multiple fine 

linear and and dot like superficial ulceration surrounded 

by small halos of oedema.

And this is a diagnosis that can be made only with 

this technique and with some frequency according to the 

literature.

Again,

we don't see that kind of patient here.

Very often,

I should comment at this point that 

these techniques were originally evolved in 

Japan primarily.

Certainly they were popularized from Japan 

for the earlier diagnosis of focal,

non invasive carcinomas in that country.

And judging from the literature and from our own experience here,

although it may be a little skewed by the type of institution that this 

is,

we don't find many early malignancies,

certainly not add no carcinomas with this technique 

that may relate to the fact that we don't see early 

patients or that gastric carcinoma is not as common 

a disease here as it is in japan or perhaps 

to some extent the fact that we are not surveying patients in this 

country for this problem as is done in many 

parts of Japan.

So I think that the yield in gastric 

malignant diseases not nearly going to be as high as it 

is in the orient.

However,

there are diagnoses that are made in this country?

Uh that are coming here that can be made really only with this 

technique and that's why I stopped here.

This is such a diagnosis.

The case of a gi bleeder bleeding from erosive 

gastritis.

Uh This is going to be a high yield 

diagnosis with this technique uh in the United 

States and north America in general.

Next line and the next 

a gastric polyp.

Next line and another 

gastric pile up and we can see her again the network 

pattern the area gastric pattern that you'll see discussing the 

reports periodically.

Next line here's a pretty 

obvious case.

Uh I don't think one is going to miss this with any technique 

large sub mucosal mass and other nodule.

A rude guy representing lymphoma in this patient 

but a very elegant example of the entire extent of 

disease in this patient's stomach.

Next line,

another large ulcerated mass.

On the lesser curvature.

This was an adenocarcinoma.

Next slide 

now we were talking about primary malignancies.

We have had a yield in about three or four patients 

of one form of malignant disease in the stomach.

Not diagnosable with conventional techniques.

And here is such a case.

This is a single isolated metastatic melanoma 

deposit on the greater curvature of the stomach that was only diagnosed 

on this film with double contrast techniques.

Next slide and another more 

recent case.

In this upright view of the fund is there is a small sub mucosal 

mass in this patient with melanoma,

isolated lesion.

So we have had yield in this form of malignant 

disease although not primary malignant disease.

Next line 

okay that finishes discussion of the stomach and I 

have a few brief words now on the duodenum.

Hi platonic doing ethnography.

That is the use of a pharmacologic agent to paralyze the 

duodenum and obtain better films of the duodenal 

pancreatic interface has been 

uh pretty popular in this country for about 

10 years or so now.

And uh air contrast portion of that 

exam is is a routine portion of double 

contrast of high platonic doing 

ethnography.

And here is an example of a paralyzed duodenum with a nice 

perry ambulatory or perry vegetarian duodenal 

diverticular one can appreciate the very nice mucosal 

pattern here is the longitudinal fold extending down from the 

area of the ambulance.

Uh So this is certainly a very helpful technique not only 

for the diagnosis of disease and the head of the pancreas,

but for primary duodenal disease as well,

it's gonna be helpful in ulcer disease and occasional 

duodenal tumors as well.

Next line indications for this 

exam or if a conventional upper G.

I.

Series is suspicious for primary duty or 

pancreatic disease.

And if there is a strong clinical suspicion of 

pancreatic disease despite an apparently normal upper 

gastrointestinal uh series 

technique can be done with a tube or without a tube 

and uh we have done them both ways in the 

department.

So this is a technique that you can order on patients 

where you fit these indications.

And very often we will just incorporate it into our 

examination when uh when that 

is necessary to come to a more 

accurate diagnosis.

Next line,

there's an interesting patient we had not long ago.

This is a patient who had a lot of nice spot films of duodenum 

and had an apparent pad effect or mass along the medial 

contour of that duodenum do deny 

graham was performed next slide,

which is perfectly normal and shows us that this 

pseudo mass appearance was formed by this 

longitudinal fold extending down from this 

somewhat prominent and pula.

So sometimes normal anatomical variants in 

the duodenum can be mistaken for 

masses and can be resolved with HIPPA tonic doing 

ethnography.

Next line and this is an 

example of a carcinoma of the 

excuse me of the duodenum with traction 

changes.

I hope you can see that.

I can't see it too well from here,

traction changes on the duodenum in this portion.

So air contrast work is a,

let's say,

a routine part of hip a tonic doing ethnography and 

not infrequently the air contrast films 

uh are the highest yield 

among in the examination performed with a high 

platonic agent of the duodenum.

Excellent.

Yeah.

Next line.

Well all that's been good.

And we've talked about the upper gastrointestinal tract.

But now we really come to the money and that's the colon at 

least the money for neo plastic 

disease.

This is really where I think we can most help 

our patients here is a place 

where when we say a small tumor,

we almost talks anonymously with an early tumor.

Unlike other anatomical parts in the gastrointestinal 

track in other areas of the 

body here.

A small tumor is means 

early tumor.

And we want to be able to make the diagnosis of small uh 

colonic tumors.

And let's talk about the colon preparation.

And let me say to you,

although you know this,

you know,

this is the most important part of the examination.

This is the whole thing.

In fact,

the exam is not very difficult and it 

doesn't require particularly sophisticated equipment,

but you do have to have the colon prepared in 

some ways,

colonoscopy,

which we'll talk about in a few minutes,

which has come in some centers to rival 

uh,

barium studies of the colon really has done us a little 

bit of help there because 

clinicians now at least people are doing colonoscopy 

realized that when we were talking about all the filling 

defects in the colon really can be a problem making a 

diagnosis.

So they colonize space,

appreciate,

appreciate now the value of a clean 

colon,

the entire colon.

Um,

please please please please 

please encourage your patients to take the 

preparation.

Don't tell him our it's okay if you skip something,

you know,

encourage them to take the preparation and we'll discuss what 

we use here.

You know,

the preparation is I'm not saying it's the most pleasant thing to get up 

in the morning and go and have a very minimal,

but you know,

it has to be done,

you know,

it has to be done and we want to do it well and 

help the patient.

So please encourage your patients to 

take the preparation.

Okay,

that's number one.

Number two.

Um four 

patients who are in patients in this hospital,

we are unable to write for routine,

very minimal preparation.

The orders have to be written out.

Well,

there is in every nurse's station at this hospital,

we've checked any number of times,

at least one copy.

If not more of our routine barium enema preparation,

follow it,

sit down with it and write it into the chart.

I don't say it's a pleasant task,

but it has to be done.

So follow it on your impatience.

If there's any question as to why a patient can't take a preparation,

You can call us,

you know,

you can call us the department and we can discuss it and we'll 

modify it if necessary,

but please write for our entire preparation.

So we don't have a compromised exam.

Let me tell you that.

We will not hesitate in the radiology department to 

cancel the patient's examination.

Uh If he has not taken a preparation or it 

hasn't been ordered for him as an inpatient.

We do our best to,

you know,

to accomplish the examination.

We will will go so far,

we'll give multiple enemies in our own department.

But you know,

we need cooperation.

We don't feel we're going to do the patients a favor or you a 

favor if we do an inadequate examination and MS 

a potentially curable colon lesion.

And another point I want to make before we look at some 

cases is that many times you may order a barium 

enema and we'll do an air 

contrast or occasionally vice versa.

Please give us adequate history on the 

requisition so that we can make a reliable judgment as to 

what kind of examination the patient needs.

There are certain indications that we follow that I'm going to show you in a few 

moments.

And uh if we don't have reliable history 

written down there or we can't communicate with the patient,

it's difficult for us to make a good decision about what 

examination is best for that patient.

So uh please give us adequate history 

so that we can make the judgment.

But you will find times when a conventional enemy is ordered 

or just it's written barium enema and we do in air contrast and 

occasionally vice versa.

But we do what we think is most indicated to 

make an accurate diagnosis in that patient 

after we've talked to them and seeing the history 

requisition.

So this is the colon preparation that's used in this hospital.

We do our upper jeez first and we have done that for 

the last several years.

And here is the rationale,

I've had a lot of phone calls on this if a 

patient is going to have both exams that is an 

upper gastrointestinal series and a barium 

enema.

We do the upper gi first,

our scheduling people know to do that.

And the reason we do that examination first is 

so that we use the berry um that they've ingested as a 

marker to tell us if the colon is clean.

That is to say if a patient has an upper gastrointestinal 

series on monday of a given week and 

on Tuesday they begin their colon preparation 

on Wednesday morning.

If there is any significant amount of barium retaining their 

colon,

we have an opaque barium marker to tell us that 

the colon is not clean.

That is the rationale for us doing a upper gastrointestinal 

series first in most routine patents obviously if there 

is a suspicion of colon obstruction,

we don't,

but in the routine patient that's being worked up for 

bleeding or whatever.

Upper gastrointestinal series is done first.

It's basically an 18 hour preparation that begins 

at noon the previous day and it consists of 

hydration.

You got to drink a lot of water juice,

a minimal low residue diet at eight 

p.m. The patient takes magnesium citrate 

at 10 PM.

Doug relax pills and the morning of the examination,

a dull colak suppository.

Probably not the best thing to have to do in life but you know,

it's an important preparation and with this preparation 

we can get most Coghlan's clean.

Occasionally it takes a second day in patients who are particularly not 

ambulatory.

We do have uh facility and we'll have 

further facility I guess in the new department dr 

Dodd as uh designed for a 

uh enema to be given to the patient uh 

if possible and we'll give those in our 

department,

I must say relating to air contrast work.

I personally don't like to do animals prior to air 

contrast work because most patients don't evacuate 

of the water and can affect the coating of the burial.

But others do do this routinely.

But we rely primarily on this preparation.

So please make sure as much as you 

can that the Coghlan's of your patients are 

prepared so that we don't do them injustice and make an inaccurate 

diagnosis.

Excellent 

patients done prone,

we run bury him into part of the colon,

shake the berry um into the rest of the colon,

drained the rectum and put the area.

It's a very simple technique that can be be 

done can be done in any radiology department and then a number of 

radiographs are obtained both spot films taken that 

Flora's copy and what we call overhead 

radiographs taken by the uh technical 

people.

Again,

this idea of low killer voltage,

which means higher contrast on the pictures.

Next line,

these are commercial burying preparations that we are now using for a 

time.

We were mixing several commercial bearing preparations.

But now there are good commercial products available for all of 

these techniques to use.

This comes as a liquid and we just poured into the bag and put that into the 

patient's colon.

Next this is the 

enema tip.

It's a soft plastic enema tip and 

piggybacked into the enema tip is a fairly 

large bore needle,

like a 16 gauge needle that's tips just right in through the enema 

tip into the aluminum,

aluminum,

the enemy tip and stigma nanometer bulb introduces the 

air when we're ready for that.

So the barium goes through here and the air through here.

Very easy setup.

Next line,

so this is about ready to begin the bag of 

barium with large bore tubing so that this moderately viscous 

barium will flow through and patients began prone.

Next line we said that barium does 

have to be squeezed in next line 

and the Baron's run so that the colon is approximately 

halfway field.

Next line and the patients turned on the 

right side and shaking a little bit and usually this will advance the barium into 

the right colon and we'll go ahead and drain the rectum.

Next slide after the rectums 

drain will instill the air we put as much air in as 

the patient can reasonably and comfortably tolerate or 

until reflux into the small bowel occurs and 

then we begin to take spot films at that point 

we'll take spot films of the rectum.

Next line.

Let's take spot films of the fletchers.

These are done in the upright position,

many of them.

Next live 

spot films of the Sikh.

Um There are certain anatomical areas in the colon that we spot in 

various positions.

Next line and then large 

overhead films are obtained by the technician.

Supine films.

Next line,

upright films.

Again,

these are particularly helpful these upright films and to cuBA to 

films that I'm gonna show you particularly helpful because if there is a 

small amount of fecal residue remaining in the colon,

if it's free,

freely moving and not attach the wall with these upright 

films that fecal material will fall into the Bering land.

We can resolve whether an area is normal or 

abnormal.

With these techniques.

Next line and this to cuBA's 

position that is the patient laying on his side and 

the x ray beam directed horizontally at the 

abdomen patient in this case was laying on her patients right 

side.

Next line.

Just a word about colonoscopy.

Uh There's been,

I think in the medical and surgical literature in the 

last few years,

a fair amount of competition between 

radiographic examinations of the colon and 

colonoscopy.

Most of these have been written by uh 

gastro neurologists and surgeons,

particularly one group in new york and they have kind of 

condemned the barium enema examination.

Well,

I think that dr nelson agrees here I 

think and probably this is the appropriate,

the appropriate ah 

point to make on it is that they are complementary exams.

That's kind of almost a trite statement about so many things.

But I think in this case is true.

There are some things that we can do that colonoscopy can 

do.

For example,

colonoscopies can't get to the seek them every time.

And we always can if there's an obstructing lesion of 

colonoscopies can't get by it.

And we usually can to see if there are other lesions in the 

colon.

And there are things that colonoscopy can do 

or detect that we can't detect not 

to mention the therapeutic applications 

of uh colonoscopy.

So I think they are complementary techniques 

and uh should be considered.

So,

certainly from a on a screening basis.

Uh you know,

the time and money involved in doing screening,

colonoscopy is,

you know,

be virtually impossible when in comparison to 

uh barium study.

So,

the barium barium enema examination,

as has been said by a number of 

people.

It's not a bad example,

a very fine examination.

It's just not always done well.

And part of that is our own fault perhaps is the worst 

radiologic examination performed in the United States,

but we take responsibility for that.

And uh but you need to take some responsibility too and 

ensuring as much as you can that your patients 

do take the colon preparation and that their Coghlan's 

are clean next line.

So some examples of uh of the colon here is 

a classic podunk related polyp in this patient's 

descending colon next line.

Yeah.

And here,

seeing this on fox is a cecil polyp.

Next line 

along the right colon here,

I hope you can see them are a 

number of small polyps.

We will routinely find little polyps or 

Palepoi expressions is 123 millimeters in 

size when we have a good clean colon.

And are studying patients very often,

they're not symptomatic in regard to 

bleeding or what one would expect from 

polyps.

And sometimes we don't really know what to do or say about little polyps like 

this,

but we will document them and put them into the patients 

record.

So that's certainly at a later time.

If the patient is re examined or become symptomatic,

one can direct his attention to that area.

But fairly routinely one will follow.

One will discover small 1 to 3 

millimeter polyps in the colon.

Next line,

typical annular apple core carcinoma of 

the distal sigmoid or rectal sigmoid 

colon.

Next line 

here are the indications that we use in this department and are 

generally used by people who advocate um 

Double contrast examination of the colon.

Certainly rectal bleeding is an indication of the classic 

indication for air contrast colon examinations.

Also other symptoms,

ontology or findings,

constipation,

anemia,

weight loss.

Those things that might suggest a colonic 

malignancy pilots having been 

discovered on a practice ka pik examination or any other kind of 

an examination.

Any previous history of polyps or cancer of the 

colon.

Any kind of history like that leads us to do an air contrast 

examination.

Any family history of polyps or cancer.

And I'm not even talking about Paula poses of the colon.

Just a family history of polyps or cancer.

And then certainly previous colon surgery 

For polyps uh 

cancer.

We all know about the increased incidents,

maybe 5% associated 

frequency of synchronous and asynchronous carcinomas of the 

colon.

So we're looking for the second lesion,

the second smaller leading to make sure that the operation 

is complete.

These are the indications we use them for 

many years patients that you send to us for with pelvic mass.

Uh Those don't normally get air contrast in the department unless 

there are other symptoms patients who've had radiation 

uh probably having symptoms from radiation practice 

practice.

Sigmoid itis don't usually get uh air contrast 

examinations.

And also if the patient has an unknown 

primary where there is already known malignant disease to 

deliver to the bone to the notes.

Very common patient in this hospital.

Those patients don't get air contrast.

We feel that we'll find the tumor if the tumor is the 

unknown primary,

we'll find it on a conventional examination.

Next line,

here's an example of a carcinoma of the 

recto sigmoid colon.

We have a nice feature of it in denting the wall from which it 

arises or pulling in the wall from which it arises.

A small carcinoma.

Next line a 

plaque like carcinoma along the posterior wall with the rectum.

Next line,

here's a lobular mass in the ascending colon that 

represented a lie poma.

Next line,

here's a case that was lent to us by dr 

horrible from Hermann Hospital that illustrates 

this.

This was a barium study done on a patient and the sigmoid 

colon in this region does look abnormal,

looks very peculiar,

but it's a little hard to define.

There is kind of a scallop defect here,

but hard to define what's going on there.

And appropriately,

air contrast study was performed the next day or several days 

later.

Next slide and the question 

is resolved.

There is a carcinoma of the colon,

a cecil carcinoma of the colon here and then in addition,

there is a large sentinel polyps 

in this region that arises from the colon wall 

adjacent to the carcinoma.

It's said that as many as 5% we said,

5% of patients have multiple invasive carcinomas of the 

colon.

Another 12% of patients who have won carcinoma 

will have associated polyps or carcinomas 

insight to and as maybe as many as 40% of 

patients that have a carcinoma will have at least one other polyps in the 

colon may not always be adjacent to it in some other place 

in the colon.

So it's very important to do a complete examination 

prior to surgery.

Next line.

Now here makes a point that we're kind of talking about here 

was a patient that was referred in for this obvious annular 

apple core carcinoma of the sigmoid colon.

But as we looked around this colon,

there's all kinds of filling defects in another carcinoma.

Up here and here's a place where colonoscopy will 

be very valuable but wouldn't be able to get past this 

obstructed area.

So,

you know,

this is an example of where a radiology is important and 

where colonoscopy uh 

can't be of much use past this area.

And there are examples to the contrary,

of course.

Next slide,

this same patient also had a third carcinoma 

in the Seattle area,

descending colon,

cervical area.

So this was a patient with three carcinomas and 

multiple other polyps and only one 

identified on an outside study the major 

annular carcinoma.

Obvious one next line,

here's another interesting patient we had not long ago with this 

large villas tumor right here that 

has an obstruction.

But if we look over here in the ascending colon,

there's another lesion.

Next live,

here's a close up of this beautiful villas 

adenocarcinoma of the colon with 

these.

This is has a network pattern to caused by the very um 

being trapped and interspersed among the 

fronds of the villas tumor and this angular component of the 

tumor indicating it's malignant nature.

Next slide and then a close up of this lesion in 

the ascending Siegel region.

Another example of double primary is not 

uncommon and needs to be examined.

For next slide 

example of Paula poses of the colon.

This happened to be a patient with Gardner syndrome.

Next live 

cone down to you to see them.

This is kind of the classic examination.

Everybody knows about air contrast colon examinations for but 

it has obviously many other uses.

Next line,

another case of paul opposes the colon with a 

somewhat different appearance,

more of a carpeting appearance.

Next lie,

here's a gross specimen on that patient.

Next line,

the first patient had no malignant tumors.

This particular patient,

this last one had three areas of Dominant mass 

or carcinomas in his colon.

This was one of them in the rectum.

There were two others.

Next line.

I hope this project again.

I can't see it from up here but this is an entity seen in Children with 

some frequency called lymphoid hyperplasia.

It's common in the terminal ilium and it's also very common in the 

colon.

And these little filling defects can look like pops but 

should not be mistaken for polyps.

These patients are usually asymptomatic and one doesn't want to 

perform a collecting me on these patients 

for benign lymphoid hyperplasia.

Next line and here's 

a most unusual case given to us from texas Children's hospital 

recently of a long juvenile pilot just showed it 

because of its unusual nature usual appearance.

Next line 

now we do uh air contrast work 

occasionally for benign disease.

Uh but not not always.

Here's a patient.

An interesting problem that was resolved.

Benign diseases.

Patient had this filling defect in the cycle 

tip on several outside 

uh conventional studies.

Next slide and with double 

contrast,

we can see this smooth filling defect and this turned out to 

be an intercepted appendix patient had not 

had his appendix out.

It's just that his appendix was intercepted and causing this 

smooth sub mucosal defect in the 

single tip next line.

And here's an example of diverticulitis with multiple 

diverticular here and a sigmoid 

vaginal officially diagnosed by double 

contrast,

this patient had rectal bleeding and was not suspected of having 

diverticulitis and that's why the patient had an air 

contrast.

So one can use this technique to diagnose diseases 

such as diverticulitis,

but this would not normally be an indication 

for uh double contrast work next line 

and inflammatory bowel disease.

Again,

we don't see too much of that at this particular institution,

but some people have advocated for the more accurate and earlier 

diagnosis of inflammatory policies.

Here is one such case.

This is a spot film taken in the distal transverse colon 

and one sees this cobblestone pattern.

Next slide and in the 

ascending colon there were four areas in this 

patient's colon.

You are seeing two of them of this.

Finally,

Nigel er cobblestone appearance in this patient with Crohn's 

disease.

Of the colon.

Next line 

finally,

we're gonna spend a few moments talking about the post 

operative colon.

We said that one of the indications was in the postoperative patient to 

find the asynchronous arm attack Cronus 

carcinoma and one can do this in any 

type of post op patient.

This is a patient that had a primary anastomosis 

and one can visualize the nest emotions very readily with double contrast 

techniques.

Next live and here is a 

patient who had a right hemi collected me and one can see the 

elio transverse colon anastomosis.

Not to mention looking at the rest of the colon.

So we do this in all post op patients where we can 

next line and we've 

also been able to evolve a technique here of examining 

colostomy Coghlan's with air contrast 

techniques.

We do that by asking the patient to insert a soft 

rubber catheter in through their colostomy.

Similar to their irrigation practices.

We tamponade the colostomy stoma with an infant 

feeding nipple.

And do the conventional examination as I showed you with running the 

barium in part of the way and then introducing air.

Next slide.

These are usually these tubes are about 26-30 French and 

they're about the exact same size as um 

as the colostomy 

irrigating tubing is given to patients in 

this hospital.

Next line and this is an 

in vitro picture the patient's introduce this and they always are 

the one to introduce them because they are familiar with the feel of the 

irrigating tube entering their colon,

introduced this into the descending colon patients holding the 

nipple against the stomach to tamponade the 

stomach to prevent leakage and then the barium and air 

will subsequently be introduced.

Next slide.

So this is an upright air 

contrast colostomy enema.

Next live and 

a cubit is view.

All the same views are obtained as much as possible.

Next line an upright spot 

film in the splendid lecture tubes in a little 

farther next line 

and this is the most dramatic case.

We've had to illustrate the value of this technique.

This was a patient who had a carcinoma,

the rectum and a colostomy performed about 

four years before and then for the past two years the 

patient had anemia and this patient had four 

uh colon examinations in our department for 

conventional animals.

I personally did one of them and called it normal.

Uh in retrospective one looks at the system.

There does appear to be a vague filling defect,

but this was a difficult seek them to palpate many times after 

colostomy,

to seek them will occupy the pelvis and they're difficult to palpate and put 

pressure on in that region.

Next line,

the fifth time we examine this patient with their contrast and found 

this obvious lesion in the second.

Um This is the 

best case.

I have to illustrate the value of this technique to this 

point.

Next slide.

So in summary double contrast,

gastrointestinal examinations are simple to 

perform.

Commercial tools and products are available 

and any department therefore is capable of performing them.

The esophagus stomach duodenum and colon,

Both the intact and postoperative colon can be examined with these 

techniques and I hope I've tried to 

show you and convince you that these techniques enable 

diagnostic accuracy not possible with conventional barium 

studies.

I have two more slides.

I wish there were more clinicians here to see these slides.

But this is a message from our department at 

least from most of the members of our department to the clinical 

people.

Next line,

these are past concepts of radiologists and clinicians have 

had ugly do bizarre things in the 

dark,

not too bright,

couldn't really make it in clinical medicine.

That's why they're in radiology.

Need a lot of help from clinicians never can make up 

his mind passive and rich.

Next line these are what present 

concepts and appropriate concept.

We are all good looking,

highly intelligent.

This is the leading medical specialty.

We are indispensable to clinicians.

Many of us have never even seen a pair of red goggles,

let alone warn them were decisive,

aggressive but we are struggling financially.

Thank you.

Yeah.

Okay.

Yeah.