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Barium enema interpretation
Challenging cases:How not to sit on the fence!
Gary CulpanGary CulpanLecturer in Radiography, University of BradfordLecturer in Radiography, University of Bradford
ADVANCED PRACTICEIN GASTROINTESTINAL IMAGING Principles of reporting
MedicolegalMedicolegal basisbasisPractical skillsPractical skillsStructure of a reportStructure of a reportMake a decisionMake a decisionAnswer the clinical questionAnswer the clinical questionInfluence patient managementInfluence patient management
Medicolegal basisScheme of workScheme of work
Outline what is undertakenOutline what is undertaken
Reporting policy / protocolReporting policy / protocolTrust boardTrust boardRadiology managerRadiology managerStaff providing serviceStaff providing service
Professional body guidanceProfessional body guidanceSCoRSCoRHPCHPCRCRRCRGMCGMC
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Practical skillsRadiographic anatomyRadiographic anatomy
Normal and variantNormal and variantPattern recognitionPattern recognition
Range of pathologyRange of pathologyFull range of pathologies which can affect the large bowelFull range of pathologies which can affect the large bowel
Radiographic appearances of pathologyRadiographic appearances of pathologyDiagnostic featuresDiagnostic featuresClarity of margins of abnormalityClarity of margins of abnormalityAssessment of mucosaAssessment of mucosa
Terminology / CommunicationTerminology / CommunicationRangeRangeDescriptive Descriptive TechnicalTechnicalUnderstandableUnderstandable
Post Graduate courses
Structure of a report
Guidelines from RCRGuidelines from RCR11 and ACRand ACR22
1. Board of the Faculty of Clinical Radiology, The Royal College of Radiologists (2006), Standards for the reporting and interpretation of imaging investigations. Royal College of Radiologists, London.
2. American College of Radiologists:–Standard for Communication in General Diagnostic Radiology (2005)
Practical example
Patient / examination / institution detailsPatient / examination / institution detailsClinical history / questionClinical history / questionDescription / discussion of findingsDescription / discussion of findingsDiagnostic featuresDiagnostic featuresDifferential diagnosisDifferential diagnosis
Most likely to least likelyMost likely to least likely
Recommendation for further imagingRecommendation for further imagingConclusionConclusion
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Make a decisionReport without a decision may render the Report without a decision may render the examination worthlessexamination worthless
Technical inadequacy of the examinationTechnical inadequacy of the examination
Patient is subjected to further invasive testsPatient is subjected to further invasive testsColonoscopy, Computed Tomography, follow up Barium Colonoscopy, Computed Tomography, follow up Barium EnemaEnema
Degree of certainty clearly indicatedDegree of certainty clearly indicatedDonDon’’t know is sometimes the right answert know is sometimes the right answer
What is needed to ascertain the diagnosis?What is needed to ascertain the diagnosis?Clinical examination Clinical examination –– laboratory tests laboratory tests –– imaging imaging –– invasive invasive teststests
Errors in decision makingIrrationalityIrrationalityAvailability errorAvailability errorPrimacy errorPrimacy error
Halo effectHalo effectObedienceObedienceConformityConformityConsistencyConsistency
Ignoring / distorting the evidenceIgnoring / distorting the evidenceWrong judgementsWrong judgementsMisinterpretation of the evidenceMisinterpretation of the evidenceOverconfidenceOverconfidenceFalse inferencesFalse inferences
Sutherland S. (1992) Irrationality: The Enemy Within Constable & Co. London
Errors in decision makingAvailability errorAvailability error
This is judging an issue by the first thing that comes to mindThis is judging an issue by the first thing that comes to mindExample 1Example 1
Are there more words in the dictionary beginning with R or Are there more words in the dictionary beginning with R or with R as the third letter?with R as the third letter?
Our perception is coloured by the fact that dictionaries are Our perception is coloured by the fact that dictionaries are sorted in alphabetical order so we immediately think that sorted in alphabetical order so we immediately think that there are more starting with R when in fact there are more there are more starting with R when in fact there are more with R as a third letterwith R as a third letter
Example 2Example 2The film JAWS caused a sharp drop in the number of people The film JAWS caused a sharp drop in the number of people prepared to swim off the coast of California where the prepared to swim off the coast of California where the occasional shark is seen. However, in reality the risk of being occasional shark is seen. However, in reality the risk of being killed in an accident on the way to the beach is much greater killed in an accident on the way to the beach is much greater than the chance of being attacked by a shark!than the chance of being attacked by a shark!
More examplesIf you are driving along the road and pass an If you are driving along the road and pass an accident do you:accident do you:
Slow down because you think that you might also be Slow down because you think that you might also be involved in an accident? involved in an accident? Carry on regardless?Carry on regardless?Can you explain your answerCan you explain your answer
What if you are speeding and see a police car What if you are speeding and see a police car travelling in the opposite direction?travelling in the opposite direction?
Do you slow down?Do you slow down?Can you explain your answer?Can you explain your answer?
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More examples
Which is more probable?Which is more probable?1.1. A girl with blue eyes has a mother with blue A girl with blue eyes has a mother with blue
eyeseyes2.2. A mother with blue eyes has a daughter with A mother with blue eyes has a daughter with
blue eyesblue eyes
Over 75% of people asked this question Over 75% of people asked this question instinctively think that cause produces instinctively think that cause produces effect and so answer 2effect and so answer 2
More examples
In medicine it is well recognised that In medicine it is well recognised that doctors who have recently seen a number doctors who have recently seen a number of cases of a specific disease are more of cases of a specific disease are more prone to diagnose it in patients who do not prone to diagnose it in patients who do not have the diseasehave the diseaseRadiographers also fall into such traps. Radiographers also fall into such traps. ““I saw one like that last week and it was I saw one like that last week and it was ……..”” without rationalising the imageswithout rationalising the images
Answer the clinical question
If your findings are unrelated to the clinical If your findings are unrelated to the clinical question are they relevant?question are they relevant?
The unexpected findingThe unexpected findingHow urgent?How urgent?Document verbal communicationsDocument verbal communicationsHave specific protocols in placeHave specific protocols in place
Influence patient management
Need to have a good idea what the Need to have a good idea what the management will be in order to influence itmanagement will be in order to influence itIf you are unable to distinguish faecal If you are unable to distinguish faecal remnant from true pathology remnant from true pathology –– what what happens next?happens next?Limited exclusion valueLimited exclusion value
What does it mean?What does it mean?
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Practical experience
Review of specific images from real casesReview of specific images from real cases
How easy is it to make the decision?How easy is it to make the decision?
What are the limitations?What are the limitations?
Anatomical variant
72 year old male with alternating constipation and diarrhoea with excessive flatus.Iron deficiency anaemia, upper GI endoscopy arranged. FOS limited by diverticulosis.
Analyse the image
Exclude significant pathology
No mass lesion or stricture
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Analyse the pattern in the ascending colon
Obstruction to retrograde flow of
barium and air
N o evidence of appendix,
terminal ileum, ileo-caecal
valve
Abnormal mucosal contour This shows the distal
edge of an obstructing carcinoma
51 year old male with rectal bleeding. Flexible sigmoidoscopy NAD
Multiple filling defects Polypoid
On non-dependent surface
Endoscopy missed them
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79 year old male with change in
bowel habit and weight
loss
Long stricture
in sigmoid
Mucosa is destroyed at distal end of
strictureMucosa is
preserved at proximal end of
stricture
Diverticular necks visible
Both ends of stricture are
tapered
Rationalise the findings
Is this a benign or a malignant stricture?Is this a benign or a malignant stricture?Features of bothFeatures of both
Perforated tumour may produce this image Perforated tumour may produce this image patternpatternClinical history influences decision that Clinical history influences decision that tumour likelytumour likelyConfirmation requiredConfirmation required
CT will reveal extra luminal pathologyCT will reveal extra luminal pathologyEndoscopy and biopsy determine tissue typeEndoscopy and biopsy determine tissue type
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Comparison inflammatory stricture
Stretched diverticular
necks
Complicated mucosal pattern No mass effect
Malignant stricture
Relatively short and tight
Destroyed mucosa
“Shouldering”
76 year old female with
change in bowel habit to
constipation. Iron deficiency anaemia noted
Loss of haustral folds
at hepatic flexure
Trace edge of lesion
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Profile view hepatic flexure
Destroyed mucosa
Trace outline of lesion
88 year old male with
iron deficiency anaemia
Review caecum
“Target” signIrregular filling
defect
Pedunculated polyp
Villous tumour
69 year old female with
iron deficiency anaemia
Other views clear the hepatic flexure
Unexplained soft tissue density
sigmoid descending colon
junction
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Close up of suspicious
area
Diverticula are evident
Analyse soft tissue density
Analysis Overlap lateral margin
transverse colon
Must lie in descending
colon Associated smaller polyp?
56 year old
male with
blood and
mucus noticed on toilet paper
Filling defects noted
Bubbles can be ignored
Faecal?
Trace the outline of the
bowel
Mucosal coating stops
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Rectal lesion
Poor coating
Irregular surface
Villous tumour
85 year old female with change in bowel habit.
DiverticulosisGas filled viscus
Stretched diverticular
neck
Mass effect
Giant sigmoid diverticulum
58 year old male with change in bowel habit
Does the rectum look odd?
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Oblique images – helpful? Review the lateral rectum
Review findings
Rectum is elongated and stretched
Mucosa is intact
There is some “pleating” of the rectal mucosa
This is extrinsic compression
What pathology can we relate this to?
Review the clinical historyThis man was an overweight AfroThis man was an overweight Afro--Caribbean Caribbean malemaleHe was also under investigation by urologists for He was also under investigation by urologists for ““urinary retentionurinary retention”” and had previously had a and had previously had a TURPTURPDoesnDoesn’’t fit with enlarged bladder impressiont fit with enlarged bladder impression
Review of the case makes pelvic Review of the case makes pelvic lipomatosislipomatosis the the most plausible diagnosismost plausible diagnosis
Levine, Rubesin & Laufer (2000) p 515
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Discussion The The ““expertexpert”” reporting practitioner homes in on a reporting practitioner homes in on a relatively few but highly specific features of the relatively few but highly specific features of the image to determine normal from abnormalimage to determine normal from abnormal
This process occurs subconsciously but the final diagnosis is This process occurs subconsciously but the final diagnosis is tempered by conscious deliberation tempered by conscious deliberation This allows the differential diagnosis list to be shortThis allows the differential diagnosis list to be short
The The ““expertexpert”” reporting practitioner also is able to reporting practitioner also is able to remember key features of individual cases and remember key features of individual cases and associated diagnosesassociated diagnoses
““Aunt Aunt MinniesMinnies””
Specific features of the clinical history will guide Specific features of the clinical history will guide the conscious reasoningthe conscious reasoning
The Novice reporting practitioner
Build upon early pattern recognition skillsBuild upon early pattern recognition skillsEnhance knowledge of normal and Enhance knowledge of normal and abnormal patternsabnormal patternsApply a directed search patternApply a directed search patternUtilise deductive reasoning to determine Utilise deductive reasoning to determine the differential diagnosis listthe differential diagnosis listRelate clinical history to imaging findingsRelate clinical history to imaging findingsPositively influence patient managementPositively influence patient management
Use of “stock” phrases – help or hindrance?
““Barium flowed to the caecum Barium flowed to the caecum …………..””““The whole of the large bowel is shown in The whole of the large bowel is shown in double contrastdouble contrast””““Barium refluxed into a normal terminal ileumBarium refluxed into a normal terminal ileum””““The caecum is adversely affected by poor The caecum is adversely affected by poor coating due to retained colonic fluidcoating due to retained colonic fluid””““There is faecal residue within the caecum and There is faecal residue within the caecum and ascending colonascending colon””““Due to sigmoid diverticulosis, polypoid lesions Due to sigmoid diverticulosis, polypoid lesions cannot be excluded in this segmentcannot be excluded in this segment””
Thank you for listening
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60 year old male with 2
year history of intermittent diarrhoea. Recently
mucus and small amount
of blood
Classic appearances
of UC
36 year old male with
intermittent diarrhoea.
Acute episode with associated
severe pain.
Rectosigmoid shows apthous
ulceration
“Cobblestone”pattern
“Collar stud”ulcers in
descending colon
Discontinuous and
asymmetrical