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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