PubMed1994
Given its anatomical location the small intestine is the section of the digestive tract most inaccessible to objective clinical and instrumental examination. For this reason, traditional investigation methods provide inadequate data. In the barium meal X-ray, images are superimposed and the barium excessively fragmented due to the tortuosity and length of the intestinal loop. Access problems limit the value of endoscopy. The indications to angiography are fairly restrictive. Ultrasound and CT scans provide no conclusive evidence in this area. The so-called Small Bowel Enema technique based on the direct infusion of an opaque contrast medium after duodenal intubation remains the only way to obtain images with a satisfactory diagnostic value and should be the method of choice in examinations of the small intestine. Introduced in the twenties, the value of the technique was long questioned, mainly because it was difficult to perform correctly and it is only quite recently that several decisive technological innovations have made it highly reliable. The present paper describes its use on a series of patients with suspected pathologies of the small intestine requiring surgical treatment. The aim is to specify the correct indications to this technique as well as its limitations with a view to promoting its appropriate use in routine practice. MATERIALS AND METHODS. The study covers 42 small bowel enemas performed on 29 male and 13 female patients aged 12-85 years. Indications to the enema included chronic abdominal pain in 28.5%, chronic diarrhea in 21.4%, pain+diarrhea in 14%, subocclusion in 16.5%, faecal blood in 11.9%, abdominal pain+diarrhea+intestinal haemorrhage in 4.7%, anaemia in 2.4%. We adopted the Sellink technique involving intubation with a French 14 Bilbao-Dotter probe and the infusion of 200-350 cc barium sulphate in a 90%-70% P/V concentration at a speed of 100 ml/min, followed by the infusion of 1000-1500 cc 0.5-1% methylcellulose in a 50-50 mixture with water for double contrast purposes. Mean duration of procedure 35-40 mins. RESULTS. We found lesions of the small intestine in 18 cases or 45% (true positives) and no alterations in 18 or 42.8% (true negatives). In 3 cases (7%) the examination was inconclusive. One false positive and one false negative complete the series, making a diagnostic accuracy of 89.1%. In 23.8% of the total series the diagnosis of Crohn's disease was confirmed; cancerous lesions were found in 11.9% and adhesions following earlier surgery in 9.7%. Surgery confirmed this diagnosis in 10 cases (5 tumours, 3 stenoses caused by adhesion fragments, 2 Crohn's disease) and disproved it in one case. Biopsy was used, for objective confirmation in 5 cases (2 Crohn's disease, 3 negatives). In the other cases reliance was placed on clinical course and the patients' response to treatment. DISCUSSION AND CONCLUSIONS. Examination of our results reveals that in most clinical cases the small bowel enema was used to confirm suspected Crohn's disease (31 cases out of 42) and with a very high degree of diagnostic accuracy (96.7%). In line with data in the literature we decided to base the indication to this examination on certain primary symptoms such as chronic abdominal pain, diarrhea, blood in the faeces, whether in isolation or in combination. On this rather general basis the diagnosis of Crohn's disease concerned only 23.8% of the cases studied, an incidence that rose dramatically in the few cases in which the indications were made more specific. We therefore conclude that the adoption of more restrictive criteria will improve the cost-benefit ratio for this test. Another major pathology in which small bowel enema possesses a high diagnostic value is partial obstruction of the small intestine.(ABSTRACT TRUNCATED AT 400 WORDS)