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Diagnosis of Colorectal Neoplasms at Double-Contrast Barium Enema Examination¹

¹ From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received June 22, 1999; revision requested August 9; revision received August 18; accepted August 25. Address correspondence to M.S.L.

View larger version (111K): [in a new window]   Figure 1. Double-contrast barium enema spot image obtained with the patient in a supine position shows a lobulated polyp. The lobulated contour (arrow) of this adenomatous polyp in the descending colon increases the risk that it harbors adenocarcinoma.

View larger version (110K): [in a new window]   Figure 2. Left posterior oblique double-contrast barium enema spot image shows a sessile polyp with the bowler hat sign. Note that the dome of the hat (arrowhead) points (arrow notes the direction) toward the center of the lumen of the sigmoid colon.

View larger version (132K): [in a new window]   Figure 3. Supine double-contrast barium enema spot image shows a diverticulum with the bowler hat sign. In this case, note that the dome of the hat (arrowhead) points (arrow notes the direction) away from the center of the lumen, which indicates a diverticulum. (Reprinted from reference 26.)

View larger version (103K): [in a new window]   Figure 4. Upright double-contrast barium enema spot image shows a pedunculated polyp. The head (straight arrow) and stalk (curved arrow) of this polyp are readily visible in the descending colon despite the presence of multiple diverticula. By using optimal technique, polypoid lesions can be detected even in patients with severe diverticulosis.

View larger version (95K): [in a new window]   Figure 5. Supine double-contrast barium enema spot image shows villous adenoma in the rectum. The lesion is seen as a polypoid mass (arrows) with a granular or reticular surface.

View larger version (116K): [in a new window]   Figure 6. Right posterior oblique double-contrast barium enema spot image shows a carpet lesion. Note the finely nodular or reticular surface pattern of the lesion (arrows) in the cecum due to barium filling the interstices of this tubulovillous adenoma.

View larger version (94K): [in a new window]   Figure 7. Upright right posterior oblique double-contrast barium enema spot image shows a plaquelike carcinoma. A subtle plaquelike lesion (arrow) is seen in the splenic flexure. This lesion could be missed easily without meticulous scrutiny of the images.

View larger version (118K): [in a new window]   Figure 8a. Double-contrast barium enema spot images show a polypoid carcinoma on the anterior wall of the bowel. (a) Supine spot image shows a polypoid mass etched with barium (arrows) near the lateral border of the ascending colon. (b) On the prone image, however, the lesion is seen as a filling defect (arrows) in the barium pool. The lesion therefore must be located on the anterior wall.

View larger version (85K): [in a new window]   Figure 8b. Double-contrast barium enema spot images show a polypoid carcinoma on the anterior wall of the bowel. (a) Supine spot image shows a polypoid mass etched with barium (arrows) near the lateral border of the ascending colon. (b) On the prone image, however, the lesion is seen as a filling defect (arrows) in the barium pool. The lesion therefore must be located on the anterior wall.

View larger version (119K): [in a new window]   Figure 9a. Double-contrast barium enema spot images show a polypoid carcinoma and the importance of distention. (a) Initial supine spot image of the distal descending colon shows no definite lesion. (b) Repeat supine spot image with better distention of the bowel shows a polypoid mass (arrows) that was not visible in a.

View larger version (131K): [in a new window]   Figure 9b. Double-contrast barium enema spot images show a polypoid carcinoma and the importance of distention. (a) Initial supine spot image of the distal descending colon shows no definite lesion. (b) Repeat supine spot image with better distention of the bowel shows a polypoid mass (arrows) that was not visible in a.

View larger version (107K): [in a new window]   Figure 10a. Double-contrast barium enema spot images show a polypoid carcinoma obscured by the barium pool. (a) Initial supine image shows no definite lesion, but too much barium is present in the proximal sigmoid colon. (b) Repeat supine image obtained after the barium was cleared from this region shows a polypoid mass (arrows) that was obscured by the barium pool.

View larger version (132K): [in a new window]   Figure 10b. Double-contrast barium enema spot images show a polypoid carcinoma obscured by the barium pool. (a) Initial supine image shows no definite lesion, but too much barium is present in the proximal sigmoid colon. (b) Repeat supine image obtained after the barium was cleared from this region shows a polypoid mass (arrows) that was obscured by the barium pool.

View larger version (128K): [in a new window]   Figure 11. Upright right posterior oblique double-contrast barium enema spot image shows a polypoid carcinoma. A barium-etched polypoid lesion (arrows) is seen in the splenic flexure.

View larger version (111K): [in a new window]   Figure 12. Left posterior oblique double-contrast barium enema spot image shows a small polypoid carcinoma. This relatively subtle polypoid lesion in the hepatic flexure causes focal enlargement of a haustral fold (arrows).

View larger version (122K): [in a new window]   Figure 13. Supine double-contrast barium enema spot image shows a semiannular "saddle" carcinoma. This lesion in the transverse colon manifests as two convex, barium-etched lines (arrows) that represent the edges of the lesion, which straddles one-half of the circumference of the bowel.

View larger version (112K): [in a new window]   Figure 14. Supine double-contrast barium enema spot image shows synchronous carcinomas. An annular carcinoma in the distal transverse colon is characterized by mucosal destruction and by shelflike, overhanging borders (straight white arrows). A second polypoid carcinoma (black arrow) is seen more proximally in the transverse colon. This patient also has an adenomatous polyp (curved white arrow) adjacent to the distal aspect of the annular lesion.

View larger version (146K): [in a new window]   Figure 15a. Double-contrast barium enema digital spot images show an annular carcinoma and the importance of projection. (a) Initial supine image of the hepatic flexure shows diverticulosis without other definite abnormalities in this region. However, the hepatic flexure has not been displayed adequately in profile. (b) Repeat left posterior oblique image obtained after the hepatic flexure was displayed in profile reveals an annular carcinoma (arrow) of the hepatic flexure that was not visible in a.

View larger version (147K): [in a new window]   Figure 15b. Double-contrast barium enema digital spot images show an annular carcinoma and the importance of projection. (a) Initial supine image of the hepatic flexure shows diverticulosis without other definite abnormalities in this region. However, the hepatic flexure has not been displayed adequately in profile. (b) Repeat left posterior oblique image obtained after the hepatic flexure was displayed in profile reveals an annular carcinoma (arrow) of the hepatic flexure that was not visible in a.

View larger version (115K): [in a new window]   Figure 16. Left lateral decubitus double-contrast barium enema overhead radiograph shows internal hemorrhoids. Thickened, undulating folds (arrows) are seen extending less than 3 cm from both sides of the anorectal verge.

View larger version (140K): [in a new window]   Figure 17. Supine double-contrast barium enema spot image shows rectal carcinoma, which mimics internal hemorrhoids. Thickened, lobulated folds (arrows) are seen along the left lateral wall of the distal rectum because of submucosal spread of the tumor. Although this appearance could be mistaken for internal hemorrhoids, the possibility of tumor should be considered because these lesions extend further than 3 cm from the anorectal verge and are confined to one side of the rectum. (Reprinted, with permission, from reference 39.)