(Radiology. 1999;211:197-201.)
© RSNA, 1999
Modified Small-Bowel Follow-through: Use of Methylcellulose to Improve Bowel Transradiance and Prepare Barium Suspension1
Hyun K. Ha, MD,
Ji H. Shin, MD,
Sung E. Rha, MD,
Yang S. Lee, RT,
Kwang B. Park, MD,
Moon-G Lee, MD,
Pyo N. Kim, MD and
Yong H. Auh, MD
1 From the Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poognap-Dong, Songpa-Ku, Seoul 138-040, Korea. From the 1997 RSNA scientific assembly. Received May 13, 1998; revision requested July 10; revision received August 1; accepted October 6. Address reprint requests to H.K.H.
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Abstract
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PURPOSE: To evaluate the efficacy of barium suspension prepared in methylcellulose (MC) in modified small-bowel follow-through (SBFT).
MATERIALS AND METHODS: The authors evaluated 155 patients who underwent modified SBFT with oral administration of MC after ingesting barium suspension. Of these patients, 52 received 40% suspension in MC, 46 received 40% suspension in water, and 57 received 70% suspension in water. Patients were divided into normal (n = 74) and abnormal (n = 81) groups according to the final results. The image quality, transit time to the cecum, and time to and frequency of flocculation were compared for both groups.
RESULTS: In the normal group, the quality of the images in patients receiving 40% suspension in MC or 70% suspension in water was superior to that of images in patients receiving 40% suspension in water. In the abnormal group, the best image quality was achieved for the patients who received 40% suspension in MC. In the normal group, the difference in transit time between the three preparations was not substantial. In the abnormal group, however, the 40% suspension in MC showed the fastest transit time. Use of the 40% suspension in MC helped lower the frequency of flocculation in the normal group.
CONCLUSION: Use of 40% barium suspension in MC is effective for improving the image quality in modified SBFT.
Index terms: Intestines, diseases • Intestines, radiography, 74.1273
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Introduction
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Various techniques have been used to improve the quality of peroral small-bowel follow-through (SBFT) (1–5); these techniques include the addition of 10-mL meglumine diatrizoate to the barium suspension, the use of effervescent agents, or changes to the barium composition, volume, or temperature. Recently, we (6) reported on the usefulness of SBFT with peroral administration of methylcellulose (MC) directly after administration of the barium suspension. With that method, the bowel transradiance and transit time were much improved compared to that with conventional SBFT. This improvement appears to be associated with the functions of MC, which include propelling the barium into the distal small bowel, improving the distensibility of the small intestine, and having low diffusivity with compatible barium suspensions (7). Although a barium suspension of 40%–45% wt/vol is recommended for SBFT, we previously tested 70% and 120% wt/vol barium suspensions (6). Therefore, further investigation of the 40%–45% wt/vol barium suspension is warranted.
MC and its esters have been widely used both in industry and in medicine to stabilize and increase the viscosity of suspensions (8). It is unabsorbable, nonirritating to the intestinal mucosa, and has no toxic effect (8). In fact, the addition of MC and some of its esters to barium suspension has been described in the past for the study of the small intestine (9) and colon (10). Its practicability, however, has not been emphasized. We presume that improved stability of barium suspension with this method would be one way to improve the quality of modified SBFT performed with oral administration of MC.
Thus, the purpose of this study was to evaluate the efficacy of 40% wt/vol barium suspension prepared in MC in modified SBFT.
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MATERIALS AND METHODS
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Between October 1995 and January 1997, 155 patients who were suspected of having small-bowel abnormality underwent modified SBFT with oral administration of 600 mL of 0.5% MC after receiving three different preparations of barium suspension. Of these 155 patients, 52 received 250 mL of 40% wt/vol barium suspension prepared by mixing barium powder with MC, 46 received 250 mL of 40% wt/vol suspension in water, and 57 received 150 mL of 70% wt/vol suspension in water. The study group consisted of 60 female and 95 male patients aged 16–80 years (mean, 47 years). These patients were divided into two groups according to the final results: Seventy-four patients had normal findings ("normal group"), and 81 had abnormal findings ("abnormal group"). The final diagnosis in these patients was made with surgery (n = 15), colonoscopic biopsy (n = 11), or clinical data and radiologic findings (n = 129) (Table 1).
Barium suspension was prepared with the following method: A mixture of both MC (Carboxymethylcellulose sodium; Kukjeon Pharmacal, Seoul, Korea) and barium sulfate powder (Solotop powder; Taejoon Pharmacal, Seoul, Korea) in the proportion of approximately 1:100 by weight was stirred in water with use of an electric barium mixer (model VPM-10; Thermal Chemical Industry, Tokyo, Japan). We used 2,022 g of the dry mixture in 4,300 mL of water. Modified SBFT was performed by using the following technique. Patients fasted for at least 12 hours. After taking the barium suspension by mouth, patients reclined on their right side for 5–10 minutes and were given 600 mL of 0.5% MC. Patients remained in the decubitus position, right side down, until the stomach emptied. If the barium column did not reach the cecum, 150–200 mL of additional barium suspension was given intermittently to the patients at the times when the stomach was seen to empty on the overhead radiographs, according to the radiologists' decision. Serial overhead radiographs were routinely obtained with the patients in a prone position at 15-minute intervals during the 1st hour, at 30-minute intervals for the next 2 hours, and then hourly until barium reached the cecum. Multiple spot radiographs of the small intestine were obtained with frequent compression. None of the patients received an accelerating agent (eg, metoclopramide or cholecystokinin) or a hypotonic agent (eg, glucagon).
Before analyzing the efficacy of modified SBFT, we assessed the frequency of additionally administered barium suspension in both groups. In addition, in order to assess patient tolerance of orally administered MC, specific inquiry was made to the 61 patients who underwent modified SBFT between August 1996 and October 1996 as to whether the taste of the administrated MC was "well tolerable," "tolerable," or "not tolerable." Thereafter, we compared the normal and abnormal groups with regard to the image quality, time to and frequency of flocculation, and transit time to the cecum. The image quality was graded independently by three radiologists (H.K.H., S.E.R., K.B.P.) as excellent, good, fair, or poor. Because patients received an additional volume of barium suspension if the barium column did not reach the cecum, the image quality differed at the early and late periods of the examination. Therefore, image quality was graded on the basis of bowel transradiance demonstrated mainly on the overhead radiographs. An image was graded as excellent when the quality was much better than that of a conventional series at both the early and late periods, good when it was better than that of a conventional series at either the early or late period, fair when it was nearly equal to that of a conventional series, and poor when the image failed to depict the small intestine. If the interpretations of the three radiologists differed, the majority opinion was used for the final decision.
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RESULTS
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The frequency of additionally administered barium suspension (150–200 mL at one time) in both groups was as follows: In the normal group, 44 (59%) of the 74 patients did not receive an additional dose of barium suspension, 27 (36%) received one additional dose, and three (4%) received two additional doses. In the abnormal group, 38 (47%) of the 81 patients did not receive an additional dose of barium suspension, 31 (38%) received one additional dose, eight (10%) received two additional doses, and four (5%) received three additional doses. The maximum amount of the additional suspension was 700 mL. Of the 61 patients who rated the taste of the MC, eight (13%) rated the taste as well tolerable, 44 (72%) as tolerable, and nine (15%) as not tolerable.
Table 2 shows the image quality of modified SBFT performed with use of different barium preparations in normal and abnormal groups. In the normal group, use of 40% wt/vol barium suspension in MC or 70% wt/vol barium suspension in water provided better image quality than did use of 40% wt/vol barium suspension in water (Figs 1, 2). The former two groups had nearly equal image quality: Image quality was rated as excellent or good in 31 (97%) of the 32 patients receiving 40% wt/vol suspension in MC and 21 (95%) of the 22 patients receiving 70% wt/vol suspension in water. In the abnormal group, the best image quality was achieved with the use of 40% wt/vol barium suspension in MC, with images rated as excellent or good in 19 (95%) of the 20 patients; 17 (65%) of the 26 patients receiving 40% barium suspension in water and 25 (71%) of the 35 patients receiving 70% barium suspension in water had images rated as excellent or good (Fig 3).
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Figure 1. Image in a 36-year-old man from the normal group who underwent modified SBFT with 250 mL of 40% wt/vol barium suspension in MC. Overhead radiograph obtained 30 minutes after ingestion shows excellent bowel transradiance with favorable demonstration of small-bowel fold patterns.
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Figure 2a. Images in a 54-year-old woman from the normal group who underwent modified SBFT with 250 mL of 40% wt/vol barium suspension in MC. (a) Overhead radiograph obtained 30 minutes after ingestion shows excellent transradiance and adequate distention of the small-bowel loops. (b) Overhead radiograph obtained 1 hour after ingestion, after the patient received an additional volume of 200 mL of barium suspension, shows that the bowel transradiance becomes poorer than that seen in a.
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Figure 2b. Images in a 54-year-old woman from the normal group who underwent modified SBFT with 250 mL of 40% wt/vol barium suspension in MC. (a) Overhead radiograph obtained 30 minutes after ingestion shows excellent transradiance and adequate distention of the small-bowel loops. (b) Overhead radiograph obtained 1 hour after ingestion, after the patient received an additional volume of 200 mL of barium suspension, shows that the bowel transradiance becomes poorer than that seen in a.
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Figure 3a. Images in a 35-year-old man with intestinal Behçet disease involving the terminal ileum, after ingestion of 250 mL of 40% wt/vol barium suspension in MC. (a) Overhead radiograph obtained 15 minutes after ingestion shows early transit to the colon and favorable demonstration of jejunal fold patterns. A geographic type of ulceration (arrow) is suspected at the terminal ileum. (b) Spot radiograph obtained 15 minutes after the patient received an additional volume of 150 mL of barium suspension shows excellent demonstration of ulceration (*) due to Behçet disease along with thickened and converging folds at the terminal ileum.
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Figure 3b. Images in a 35-year-old man with intestinal Behçet disease involving the terminal ileum, after ingestion of 250 mL of 40% wt/vol barium suspension in MC. (a) Overhead radiograph obtained 15 minutes after ingestion shows early transit to the colon and favorable demonstration of jejunal fold patterns. A geographic type of ulceration (arrow) is suspected at the terminal ileum. (b) Spot radiograph obtained 15 minutes after the patient received an additional volume of 150 mL of barium suspension shows excellent demonstration of ulceration (*) due to Behçet disease along with thickened and converging folds at the terminal ileum.
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Table 3 shows the time to and frequency of flocculation in each group. The frequency of flocculation in the normal group was 0% with 40% wt/vol suspension in MC, 15% with 40% wt/vol suspension in water, and 5% with 70% wt/vol suspension in water. In the abnormal group, the mean time to and frequency of flocculation was 138 minutes and 30% in 40% wt/vol suspension in MC, 77 minutes and 35% in 40% wt/vol suspension in water, and 107 minutes and 26% in 70% wt/vol suspension in water.
In transit time to the cecum, the normal group did not show a substantial difference between modified SBFT examinations performed with different barium preparations; the transit time was within 2 hours in 90%–100% of patients, with mean transit times ranging from 37 to 48 minutes. In contrast, the abnormal group showed substantially delayed transit time, with mean times of 101 minutes in 40% wt/vol barium suspension in MC, 113 minutes in 40% wt/vol suspension in water, and 140 minutes in 70% wt/vol suspension in water.
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DISCUSSION
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Although 40%–45% wt/vol barium suspension is most commonly used for the peroral small-bowel examination (11,12), our study showed that, with modified SBFT performed with use of oral administration of MC, only the lower-concentration (40% wt/vol) barium suspension prepared in water did not substantially improve the image quality compared to a modified series with a higher-concentration (70% wt/vol) suspension. Because the radiopacity of the film is closely linked to the amount of barium present in the suspension and, thus, depends on the specific gravity, use of a lower-concentration barium suspension is expected to improve bowel transradiance. The viscosity of the suspension decreases under such circumstances, however, and, therefore, flocculation develops earlier and the frequency is increased. Thus, image quality does not appear to be proportionately improved, especially in patients with delayed transit time. Therefore, to maintain the effect of transradiance of a lower-concentration suspension, it is considered that the stability of the suspension should be improved.
The stability of barium suspension is the capacity of a contrast material to remain unchanged during transit in the gastrointestinal tract and depends, to a great extent, on the characteristics of the environment into which it is introduced. Because MC is one kind of viscosizing agent, the viscosity of the barium suspension is increased when it is prepared in MC instead of water. In our study, there was no substantial difference in image quality with a 40% wt/vol suspension in MC and a 70% wt/vol suspension in water in patients in the normal group whose mean transit time was within 1 hour. In those patients in the abnormal group who had varying degrees of passage disturbance and delayed mean transit times of more than 100 minutes, improved stability with use of the barium suspension in MC resulted in considerable improvement in image quality. To prepare the barium suspension, we mixed both dry barium sulfate and MC powder and then diluted it with water. Most radiologists in the United States use a liquid barium suspension prepared by the manufacturers. Therefore, the results of this study would not be applicable directly. Moreover, further tests may be necessary to determine whether similar results can be reached by using another manufacturer's barium product.
In addition to improved image quality, acceleration of the transit time is another advantage of using barium suspension in MC, especially for patients with small-bowel abnormality. In our previous study (6), in which only healthy subjects were analyzed, the transit time for the barium to reach the cecum was within 1 hour in 86% of subjects who underwent modified SBFT and 65% of subjects who underwent conventional SBFT. In our study, in which modified SBFTs with different preparations of barium suspension were compared for both normal and abnormal groups, no substantial difference was noted in the transit time between the suspensions used in the normal group. The transit time in the abnormal group, however, was fastest (mean, 101 minutes) when a 40% wt/vol barium suspension in MC was used. To accelerate the transit time, we have shown, in this study and our previous study (6), that intermittent administration of an additional volume of suspension is absolutely necessary until the barium column reaches the cecum. Likewise, further acceleration of transit time in our study appears to result from the administration of a larger volume of barium suspension than that used in our previous study (6). Although we gave an additional 100 mL of barium suspension hourly (6), a larger volume of additional barium suspension (150–200 mL) was administered more frequently. Indeed, MC is known to have hydrophilic properties and the ability to activate peristalsis (13). It is questionable at this time, however, whether MC still exerts an accelerating influence at this low concentration. The optimal timing for administration of an additional volume of suspension is when the stomach is emptied. We have recently started to give additional barium suspension when the small-bowel loops in the regions of interest are not satisfactorily distended, even if the distal barium column has already reached the cecum. Such frequent administration was also helpful in preventing or decreasing the development of flocculation. As a result, however, the image quality in the modified series nearly equaled that of conventional SBFT when the study was delayed. In addition, we have noted that a large amount of fecal material in the colon also causes delayed transit time. In such patients, frequent administration of additional barium suspension is also considered necessary. The use of a larger volume of oral contrast material in modified SBFT may be uncomfortable to the patients; however, in addition to accelerating the transit time, such small-bowel overload may improve the sensitivity of peroral small-bowel examination for detecting small-bowel abnormality. It is attributable to the fact that the radiographic finding of bowel loop dilatation proximal to the focal stricture in the small intestine will have a higher chance to be overlooked if only a small volume of oral contrast material is administered slowly.
The results of our study demonstrate that MC provided a better-quality peroral examination. The patient tolerance to this technique, however, is a concern. Of the 61 patients asked to rate the taste of orally administered MC, 52 (85%) rated it as well tolerable or tolerable, whereas nine (15%) rated it as not tolerable. Although these results may change according to differences of food habits between countries, further investigation will be necessary to make MC tolerable to every patient. The addition of a flavoring agent to the MC solution may increase the tolerance by improving its taste.
In conclusion, we have found that the use of 40% wt/vol barium suspension in MC is effective for improving image quality in modified SBFT performed with oral administration of MC.
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Acknowledgments
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We thank Bonnie Hami, Department of Radiology, University Hospitals Health System, Cleveland, Ohio, for editorial assistance in preparing the manuscript.
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Footnotes
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Abbreviations: MC = methylcellulose
SBFT = small-bowel follow-through
Author contributions: Guarantor of integrity of entire study, H.K.H.; study concepts and design, H.K.H.; definition of intellectual content, Y.H.A.; literature research, J.H.S.; clinical studies, J.H.S., K.B.P.; experimental studies, Y.S.L.; data acquisition, J.H.S., S.E.R.; data analysis, H.K.H., J.H.S.; manuscript preparation, H.K.H.; manuscript editing, Y.H.A.; manuscript review, M.G.L., P.N.K.
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Abstract
Introduction
