(Radiology. 2000;214:908-911.)
© RSNA, 2000
Balloon-occluded Endoscopic Retrograde Ileography1
Masaki Taruishi, MD,
Yusuke Saitoh, MD,
Jiro Watari, MD,
Toshifumi Ashida, MD,
Tokiyoshi Ayabe, MD,
Kiyokazu Takemura, MD,
Kinichi Yokota, MD,
Takeshi Obara, MD and
Yutaka Kohgo, MD
1 From the Third Department of Internal Medicine, Asahikawa Medical College, 4-5-3-11 Nishikagura, Asahikawa 078-8510, Japan. Received March 3, 1998; revision requested May 6; final revision received June 21, 1999; accepted July 21. Address reprint requests to Y.S. (e-mail: y52015@asahikawa-med.ac.jp).
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Abstract
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For diagnostic ileography, the authors developed balloon-occluded endoscopic retrograde ileography and performed 77 studies in 36 consecutive patients with Crohn disease. Balloon-occluded endoscopic retrograde ileography proved to be useful in visualization of minute mucosal lesions such as aphthous ulcers and lymphoid hyperplasia in the distal ileum, and satisfactory ileographic images of Crohn disease were obtained in 54 (70%) studies.
Index terms: Colon, radiography, 75.125 • Crohn disease, 74.262, 75.262 • Ileum, 742.262 • Intestines, diseases, 74.262, 742.262, 75.262 • Intestines, radiography, 74.125, 742.125, 75.125
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Introduction
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For the study of the small intestine, barium studies such as small-bowel follow-through examination and small-bowel enteroclysis are mainly used, but these techniques are time-consuming, and little information is sometimes available in the pelvic area and the distal ileum owing to overlapping loops (1–3). Frimberger (4) and others (5,6) developed ileography with the use of colonoscopy (endoscopic retrograde ileography), which is a combination of colonoscopy and radiographic ileal examination. This technique may be more useful for visualization of the distal ileum than are the conventional radiographic techniques such as small-bowel follow-through examination and small-bowel enteroclysis, but it can demonstrate only 20–30 cm of imaging length in the distal ileum and provides mainly single-contrast radiographs. It is well known that Crohn disease affects preferentially the small intestine (3,7,8), especially the distal ileum (2), and is associated with minute mucosal lesions. Among various findings, aphthous ulcers are reported as one of the important initial minute lesions of Crohn disease (9–13). To delineate those lesions radiographically, it is necessary to obtain high-quality radiographs of the distal ileum. We developed a technique for balloon-occluded endoscopic retrograde ileography with use of a guide wire that results in air-barium double-contrast ileographic images.
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Materials and Methods
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Between April 1990 and July 1997, we encountered 46 consecutive patients with endoscopically and histologically proved Crohn disease. Among these patients were some in whom the colonoscope could not pass into the ileum owing to stenosis of the ileocecal valve (n = 1) or prior ileocolectomy (n = 9), and they were excluded from this study. Consequently, 36 patients with Crohn disease were enrolled, and 77 balloon-occluded endoscopic retrograde ileographic studies were performed. Written informed consent was obtained from each patient.
Our procedure is schematically illustrated in Figure 1. Patients underwent preparation with polyethylene glycol solution according to the same method used for conventional colonoscopy. After observation of the entire colon, the colonoscope was inserted into the terminal ileum and advanced 20–30 cm forward from the ileocecal valve, and intraintestinal fluid was withdrawn. The terminal ileum was also observed endoscopically and sampled at biopsy if necessary. After a Teflon-coated guide wire (diameter, 0.052 inch; length, 300 cm) (Create Medic, Yokohama, Japan) was introduced through the working channel with fluoroscopic guidance, the colonoscope itself was carefully removed with the guide wire left in place. Then, a double-lumen silicone balloon tube (diameter, 16 F; length, 120 cm) (Create Medic) was advanced over the guide wire into the ileum, and the balloon was inflated with 20 mL of air. After an anticholinergic agent was administered intravenously, about 100 mL of 70% wt/vol barium sulfate (Baroject Sol 100; Horii Pharm, Osaka, Japan) was injected, followed by an adequate amount of air into the ileum through the balloon tube. After several changes in position by the patient, an air-barium double-contrast radiograph was obtained. To separate the overlapping loops, the compression method was occasionally used. If the patient experienced severe discomfort or pain, the procedure was discontinued.
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Figure 1. Schematic of procedure. A, The colonoscope is inserted into the terminal ileum, and a Teflon-coated guide wire is introduced through the forceps channel. B, The colonoscope is removed, and the guide wire is left in place in the ileum. C, A double-lumen silicone balloon tube is advanced over a guide wire into the ileum. D, The balloon is inflated with 20 mL of air in the ileum, and the guide wire is removed. E, About 100 mL of 70% wt/vol barium is injected through the balloon tube, followed by an adequate amount of air into the ileum. After several changes in position by the patient, an air-barium double-contrast ileographic image is obtained.
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The quality of balloon-occluded endoscopic retrograde ileographic images was reviewed and evaluated in consensus by two gastroenterologists (M.T., Y.S.) and divided into two categories: satisfactory and unsatisfactory. Satisfactory double-contrast ileographic images demonstrated not only typical lesions such as narrowing, cobblestone pattern, or linear ulcer but also minute lesions such as aphthous ulcer or lymphoid hyperplasia with little overlapping ileum. Unsatisfactory images demonstrated only typical lesions but not the minute lesions.
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Results
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Representative balloon-occluded endoscopic retrograde ileographic images are shown in Figures 2 and 3. Figure 2 shows a satisfactory air-barium double-contrast ileographic image. Multiple areas of narrowing, linear ulcers, and small aphthous ulcers are demonstrated with little overlapping ileum. Figure 3 demonstrates another satisfactory image. Minute lesions of shallow aphthous ulcers in addition to linear ulcers are clearly depicted.
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Figure 2. Balloon-occluded endoscopic retrograde ileographic image obtained in a 32-year-old man with Crohn disease. Multiple narrowing and linear ulcers (arrowheads) and aphthous erosions (arrows) are clearly demonstrated with little overlapping ileum.
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Figure 3a. Balloon-occluded endoscopic retrograde ileographic images obtained in a 17-year-old adolescent boy with Crohn disease. (a) Air-barium double-contrast ileographic image depicts little overlapping ileum. (b) Minute shallow aphthous ulcers (arrows), lymphoid hyperplasia, and short linear ulcers (arrowheads) are evident.
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Figure 3b. Balloon-occluded endoscopic retrograde ileographic images obtained in a 17-year-old adolescent boy with Crohn disease. (a) Air-barium double-contrast ileographic image depicts little overlapping ileum. (b) Minute shallow aphthous ulcers (arrows), lymphoid hyperplasia, and short linear ulcers (arrowheads) are evident.
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All the procedures were easily performed without severe complaints from patients, and no complications occurred during the procedures. The examination time for balloon-occluded endoscopic retrograde ileography excluding colonoscopy was about 15 minutes, and x-ray exposure time was 7–8 minutes. Total examination time including colonoscopy was about 30 minutes.
The Table shows the results of balloon-occluded endoscopic retrograde ileography. Fifty-four (70%) of the 77 ileographic images were evaluated as satisfactory. In 70 (91%) of the 77 studies, all the procedures were completed such as removal of a colonoscope, insertion of a balloon tube over a guide wire into the ileum, and injection of barium sulfate and air into the ileum without the displacement of a balloon tube to the colon. Among these complete procedures, a satisfactory ileographic image was obtained in 52 studies (74%), and an unsatisfactory image in 24. On the other hand, seven studies (10%) resulted in incomplete procedures due to the dislodging of the balloon tube back to the colon during the injection of air in five studies and the displacement of the guide wire to the colon during insertion of the balloon tube into the ileum in two studies. In these seven incomplete procedures, a satisfactory ileographic image was obtained in two and an unsatisfactory image in five.
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Results of Balloon-occluded Endoscopic Retrograde Ileography according to Complete and Incomplete Procedure Groups
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Discussion
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The basis of balloon-occluded endoscopic retrograde ileography lies in the use of a guide wire and a balloon tube to withdraw the colonoscope and to obtain clear air-barium double-contrast ileographic images. Removal of the colonoscope decreases discomfort and facilitates the multiple changes in position required for the patients; thus, diagnostic air-barium double-contrast ileographic images could be obtained easily. Balloon-occluded endoscopic retrograde ileography proved to be useful in the visualization of minute mucosal lesions such as aphthous ulcers and lymphoid hyperplasia, as well as typical findings of Crohn disease including narrowing, cobblestone pattern, and linear ulcers in the distal ileum. Satisfactory ileographic images of Crohn disease were obtained in 54 (70%) procedures.
Unlike in other small-bowel radiographic techniques, balloon-occluded endoscopic retrograde ileography allows examination of the colon and the terminal ileum with endoscopy and of the distal ileum with air-barium double-contrast ileography in the same examination. In endoscopic retrograde ileography as reported by Frimberger (4) and with other related methods (5,6), there are no descriptions of the mucosal findings (ie, aphthous ulcers or lymphoid hyperplasia). These findings are important as they are some of the earliest minute lesions in Crohn disease (1,9–12). Compared with conventional endoscopic retrograde ileography, balloon-occluded endoscopic retrograde ileography appears more useful for the demonstration and evaluation of the early minute ileal involvement in Crohn disease because balloon-occluded endoscopic retrograde ileography provides air-barium double-contrast ileographic images with high quality and depicting long segments. In endoscopic retrograde ileography, the patient might experience difficulty when changing positions on the fluoroscopic table because of the presence of a colonoscope. Miller (14) reported "complete reflux small-bowel examination," which requires use of a large amount of barium suspension (1,500–2,000 mL) administered from the rectum to visualize the colon and also the small intestine. However, this method does not seem to be comfortable or suitable to delineate the faint mucosal lesions on air-barium double-contrast ileographic images. Compared with this method, balloon-occluded endoscopic retrograde ileography provides excellent air-barium double-contrast ileographic images.
One of the disadvantages of balloon-occluded endoscopic retrograde ileography is, however, the rather complicated procedure of exchange of the colonoscope for a balloon tube. In our series of 77 studies, seven (9%) resulted in an incomplete procedure due to displacement of a balloon tube from the ileum to the colon during the injection of air. Furthermore, 23 studies resulted in unsatisfactory ileographic images, which were single-contrast images that could not help delineate the minute mucosal lesions in Crohn disease. Most of the unsatisfactory ileographic images were caused by a large amount of residual intraintestinal fluid as a result of the preparation with polyethylene glycol solution. Thus, unsatisfactory ileographic images might be prevented by withdrawing intraintestinal fluid more extensively with an endoscope before visualization. Further improvements in techniques and preparation are necessary to overcome these problems.
This balloon-occluded endoscopic retrograde ileographic technique was developed for the delineation of fine mucosal lesions in the distal ileum and thus may be used in combination with small-bowel enteroclysis or small-bowel follow-through examination. Balloon-occluded endoscopic retrograde ileography enabled us to obtain precise diagnostic ileographic images and helped ensure an accurate diagnosis, especially in patients with ileal involvement and initial minute mucosal findings of Crohn disease.
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Footnotes
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Author contributions: Guarantors of integrity of entire study, all authors; study concepts, M.T., Y.S.; study design, all authors; definition of intellectual content, all authors; literature research, M.T., Y.S.; clinical studies, all authors; data acquisition and analysis, M.T., Y.S.; manuscript preparation, M.T., Y.S., J.W., T.O.; manuscript editing and review, all authors.
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References
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Abstract
Introduction
