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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 1  |  Page : 35-39

Spectrum of findings on barium enema examination in Benin City


1 St.Bridget X-Ray centre Ltd, Benin City, Nigeria
2 Department of Radiology, School of Medicine, University of Benin, Benin City, Nigeria
3 Department of Radiology, Delta State University Teaching Hospital, Oghara, Nigeria

Date of Web Publication1-Aug-2019

Correspondence Address:
Dr. Festus O Ehigiamusoe
Department of Radiology, School of Medicine, University of Benin, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_11_19

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  Abstract 

Background: In the Western world, barium enema has largely been replaced by computed tomographic (CT) colonography or virtual colonoscopy using the three-dimensional fly-through software. But barium enema remains relevant in our environment because of its availability and affordable cost as compared to cross-sectional imaging. Aim: To document the common pathologies seen on barium enema examinations in Benin City, Nigeria. Materials and Methods: All cases of barium enema performed at St. Bridget X-Ray Centre, a private radio-diagnostic outfit in Benin City, between January 2013 and December 2014, were retrospectively reviewed. The biodata, clinical information, and radiological diagnoses were collated and entered into the Statistical Package for Social Sciences (SPSS) software and then analyzed. Those with inadequate details were excluded from the study. Results: Two hundred and sixteen patients who had barium enema for various indications were reviewed; the males were 135 (62.5%), whereas the females were 81 (37.5%). Constipation (53, 23.0%) was the most common clinical indication, followed by hematochezia (50, 21.7%), abdominal pain (32, 13.9%), colorectal mass (26, 11.3%), and abdominal swelling (12, 5.2%). Colonic carcinoma (39, 20.8%) was the most common diagnosis on barium enema. This was followed by Hirschsprung’s disease (20, 15.4%), ulcerative colitis (15, 11.5%), megacolon (12, 9.2%), and colonic stricture (11, 6.2%). These findings were more in males (88, 67.7%) than that in females (42, 32.3%). Conclusion: This study has enumerated the common indications and common radiological findings on barium enema study in our environment. Furthermore, this study has also buttressed the fact that barium enema is still reliable in making diagnosis in environment where CT scan is either unavailable or costly.

Keywords: Barium enema, fluoroscopy, pathology


How to cite this article:
Enukegwu SU, Ehigiamusoe FO, Ogbeide AO. Spectrum of findings on barium enema examination in Benin City. Int J Med Health Dev 2019;24:35-9

How to cite this URL:
Enukegwu SU, Ehigiamusoe FO, Ogbeide AO. Spectrum of findings on barium enema examination in Benin City. Int J Med Health Dev [serial online] 2019 [cited 2019 Dec 5];24:35-9. Available from: http://www.ijmhdev.com/text.asp?2019/24/1/35/263543




  Introduction Top


Schule[1] pioneered the first contrast examination of the colon in 1904, using oily suspension of bismuth subnitrate with no fluoroscopic guide. It took another 7 years before Haenisch could opacify the colon with a bismuth-based contrast under a primordial fluoroscopy unit.[2],[3]

Since the first reported usage of barium in enema procedure in 1923, a lot of innovations have come up regarding this procedure.[2],[4],[5] Its capability of detecting colonic lesions such as colorectal cancers, polyps, inflammatory bowel diseases, and a host of other colonic disease entities cannot be overemphasized.

Barium enema is a positive contrast examination of the large bowel and it is an age-long radiological investigation that is almost a century old.[2] Since its advent, diagnosis of colonic luminal disease has been simplified but not without its limitations in assessing the colonic wall. It also has the disadvantage of using ionizing radiation and being quite uncomfortable to patients.

On the contrary, ultrasound has been known to be easy to perform, accessible, and inexpensive in evaluating the abdomen. However, there are limitations in using ultrasound for bowel examination. Such limitations are experienced in scenarios such as large body habitus, excessive bowel gas, and postoperative patients in whom the anatomy has been distorted.[3] Nevertheless, when the bowel loops are filled with fluid, visualization with ultrasound becomes excellent.

In the Western world, barium enema has largely been replaced by computed tomographic (CT) colonography or virtual colonoscopy using the three-dimensional fly-through software. This has the advantage of detecting polyps, which are less than 10mm and also has the capability of assessing extra-luminal pathology.[3] Virtual colonoscopy is an expensive modality and not many radiologists are competent in accurately reporting the images. Magnetic resonance imaging and radionuclide imaging are also used in the evaluation of the large bowel. However, the expensive nature of the former and the ionizing radiation nature/lack of detailed anatomy of the latter confer some disadvantages on them.

In many hospitals, barium enema remains the primary investigation for patients referred for lower gastrointestinal symptoms because of equipment availability and staff experience issues.[6] Ours is a developing country with a lot of challenges bedeviling the health sector, ranging from nonavailability of the imaging modalities to expensive nature of the investigation when they are available. Hence, recourse is made to make do with the available modality. So, barium enema under fluoroscopy and sometimes performed under plain X-ray with no fluoroscopy, still finds its prime spot in radiological investigation of the large bowel in our environment.

This study aimed at documenting common findings on barium enema in Benin City, Nigeria.


  Materials and Methods Top


This is a retrospective study carried out at St. Bridget X-Ray Centre, a foremost private radio-diagnostic outfit in Benin City, between January 2013 and December 2014. Approval was obtained from the ethics committee of the center before embarking on this research. All request forms and results of barium enema studies for the aforementioned period were retrieved from the archive of the institution. The age, sex, clinical indication, and radiological diagnoses were collated and entered into an Excel spreadsheet and then analyzed. Those with inadequate details were excluded from the study.

Data were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 18, (IBM, Armonk, NY). Test of significance was carried out with chi-square test. Confidence interval of 95% was used. P value less than or equal to 0.05 was considered statistically significant.


  Results Top


A total of 216 patients who had barium enema for various indications met the inclusion criteria. The males were 135 (62.5%), whereas the females were 81 (37.5%) in number. Twenty patients (9.3%) were below 10 years of age, only 4 patients (1.9%) were between 10 and 17 years, whereas the remaining 192 patients (88.9%) were of 18 years and above [Table 1].
Table 1: Age distribution of patients

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The mean age of the study population was 46.01 ± 2.50 years, ranging between 10 months and 85 years. The mean age for the males and females was 45.13 ± 2.62 and 47.79 ± 2.24 years, respectively.

A total of 230 clinical indications were present in these patients with some having more than one of them. Constipation (53, 23.0%) was the most common indication, followed by hematochezia (50, 21.7%), abdominal pain (32, 13.9%), colorectal mass (26, 11.3%), and abdominal swelling (12, 5.2%). The least common indications were intestinal obstruction, anorectal malformation, fistula, and delayed passage of meconium, which were reported in one patient each [Table 2].
Table 2: Clinical indications for barium enema

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Regarding radiological findings, a total of 130 features were observed on barium enema studies with some patients having more than one feature. In some cases, some patients with different clinical indications were noted to have one radiological feature in common, hence the difference in the number of clinical indications and radiological findings. Colonic carcinoma (39, 20.8%) was the most common diagnosis on barium enema. This was followed by Hirschsprung’s disease (20, 15.4%), ulcerative colitis (15, 11.5%), megacolon (12, 9.2%), and colonic stricture (11, 6.2%). These findings were more in males (88, 67.7%) than that in females (42, 32.3%) [Table 3].
Table 3: Radiological findings

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In terms of age distribution, colonic carcinoma, ulcerative colitis, anorectal carcinoma, colonic stricture, and hemorrhoids were more in adults (above 18 years of age), whereas the diagnoses of Hirschsprung’s disease and megacolon were more in those under 10 years of age [Table 4].
Table 4: Age distribution versus radiological features

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It was observed that in patients, who presented with constipation, Hirschsprung’s disease was the most common radiological diagnosis and this was very significant (P = 0.000). This was followed by megacolon, which was also very significant (P =0.000). In those that presented with hematochezia, colonic carcinoma was the most common radiological diagnosis but was not statistically significant (P = 0.067). This was followed, subsequently, by ulcerative colitis and was statistically significant (P = 0.025) [Table 5] and [Table 6]. Hirschsprung’s disease was also observed in one patient who presented with delayed meconium passage.
Table 5: Constipation versus radiological features

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,
Table 6: Hematochezia versus radiological features

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  Discussion Top


The most common radiological finding in our study was colonic carcinoma. The incidence of this disease in Nigeria was initially thought to be lower compared to the Western world.[7] However, a recent study in Nigeria by Sowunmi et al.[8] in Lagos showed colorectal cancer to be the third most common cancer in both males and females. Furthermore, May and Anandasabapathy[9] in a more recent editorial review documented that colorectal cancer is no longer a disease of the Western world as some studies in sub-Saharan Africa have shown alarming increased incidences. The probable reason given for this rise is the westernization of our diet.[7] Our study showed more males than females being affected by colorectal carcinoma based on radiological findings. This is similar to the study by Ibrahim et al.[10] and Edino et al.[11] The male sex has been documented as a risk factor for colorectal carcinoma. More so, the male indulges more in alcohol consumption and smoking, which are also risk factors for colorectal carcinoma.[12] All cases of colorectal carcinoma observed in our study were in adults above 18 years of age except one seen in the age group of 10–17 years. Studies across different parts of Nigeria put the mean age of occurrence at between 42.9 and 50.7 years of age.[10] However, occurrence at younger age of 9 years has been documented in a Nigerian who had a strong family history of colorectal cancer.[10] Colorectal carcinoma is shown as short segment stricture with irregular margins described as Apple core deformity and overhanging irregular edges described as shouldering.

Furthermore, our study was based on barium enema examination, which has experienced a decline in usage over some decades now, because of the availability of more effective imaging modalities, especially in developed countries.[13] Colonoscopy and CT colonography are presently the recommended investigations for colorectal carcinoma. However, these are not readily available in our environment and are also expensive. Hence, the traditional barium enema examination is still being used as the first-line imaging modality because it is cheap and readily available, though great expertise is required for its performance and interpretation.

Hirschsprung’s disease, first described by Hirschsprung in 1886, was the second most common finding in our study. Its etiology is unknown but the absence of ganglion cells in the myenteric plexus in the affected colon has been postulated.[14] A total of 17 of the 20 patients with radiological diagnosis of Hirschsprung’s disease in this series were males giving a male-to-female ratio of 5:1. This is in tandem with previous documentation in the literature, which puts this ratio at 4:1 in favor of males.[15],[16] The reason for this male dominance is not known. More than half of these patients were in the age group of 0–9 years. Hirschsprung’s disease is documented as the most common cause of intestinal obstruction in the newborn, especially in neonates.[17],[18] In fact, it is regarded as a strong possibility in neonates with failure to pass meconium 24h after birth.[17] Barium enema still plays a pivotal role in the investigative workup of patients with Hirschsprung’s disease [Figure 1], which is shown as narrowing of the aganglionic rectum/colon, megacolon of proximal colon with reversal of the rectosigmoid index.[14] However, definitive diagnosis of this disease entity involves biopsy of the aganglionic colon and subsequent histology.[14]
Figure 1: Post-evacuation lateral view radiograph of a barium enema examination showing a dilated sigmoid colon

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Ulcerative colitis was the third most common radiological diagnosis in our study. It is a type of the inflammatory bowel disease, the other being Crohn’s disease. It is said to be rare in Africa except South Africa, where the incidence approximates to that of the Western nations.[19],[20] It is a disease of the Western culture; nevertheless, the incidence in Nigeria has gradually increased over the years with more cases being reported in the literature now compared to some 20 years ago. This has been adduced to the westernization of our diet.

All age groups are usually affected but two peaks have been documented, 15–40 years in the younger age group and 50–60 years in the older age group.[21],[22] All 15 patients in our study, radiologically diagnosed as ulcerative colitis, were adults above the age of 18 years. Furthermore, our study showed more males than females being affected. Review of literature showed no sex predilection except in the elderly, where the male-to-female ratio was 2:3.[21] This discordant observation may be due to the few cases of ulcerative colitis seen in our study.

Barium enema is the imaging modality of choice used for diagnosing ulcerative colitis.[21] It is initially shown as increased mucosal granularity because of edema and hyperemia, which may progress to developing aphthoid ulcers. Deeper ulcers, which are flask-shaped, are formed later. Other features on barium enema include ahaustration (featurelessness), luminal narrowing of the colon with loss of haustration giving the lead-pipe appearance. The ileocecal valve involvement causes incompetence of the same valve with inflammation of the terminal ileum. Radiologically, this is shown as reduced granularity of the ileum, which is termed backwash ileitis.[21]


  Conclusion Top


In conclusion, a spectrum of the diseases, which can be diagnosed on barium enema studies in our environment, has been presented.

Limitation

A strong limitation of this study was that the diagnoses were not confirmed by histology or by a second confirmatory imaging modality largely because of the fact that most of the patients were referred to this radiological center from private and public hospitals. Hence, follow-up of these patients was impossible.

Acknowledgement

We highly appreciate the staff and management of St. Bridget X Ray Centre for helping in the collation of the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schule A Intubation and radiography of the large intestine. Arch Verdauungskrankheiten 1904;10:111-8.  Back to cited text no. 1
    
2.
Levine MS, Yee J History, evolution, and current status of radiologic imaging tests for colorectal cancer screening. Radiology 2014;273:S160-80.  Back to cited text no. 2
    
3.
Haenisch GF Roentgenologic examination in narrowing of the large intestine: The early roentgenologic diagnosis in carcinoma of the large intestine [in German]. Munch Med Wochenschr 1911;45:2331-75.  Back to cited text no. 3
    
4.
Carman RD, Fineman S The roentgenologic diagnosis of diseases of the colon. Radiology 1923;1:129-42.  Back to cited text no. 4
    
5.
Fischer AW A new roentgenologic method for examination of the large intestine: A combination of the contrast material enema and insufflation of air [in German]. Klin Wochenschr 1923;2:1595-8.  Back to cited text no. 5
    
6.
Tolan DJM, Armstrong EM, Chapman AH Replacing barium enema with CT colonography in patients older than 70 years: The importance of detecting extracolonic abnormalities. Am J Roentgenol 2007;189:1104-11.  Back to cited text no. 6
    
7.
Irabor DO Ethnic differences in colon and rectal cancer incidence in Nigeria: A case of dietary determinants? East Cent Afr J Surg 2012;17:70-3.  Back to cited text no. 7
    
8.
Sowunmi A, Alabi A, Fatiregun O, Olatunji T, Okoro US, Durosinmi Etti AF Trend of cancer incidence in an oncology center in Nigeria. West Afr J Radiol 2018;25:52-6.  Back to cited text no. 8
    
9.
May FP, Anandasabapathy S Colon cancer in Africa: Primetime for screening? Gastrointest Endosc 2019;89:1238-40.  Back to cited text no. 9
    
10.
Ibrahim KO, Anjorin AS, Afolayan AE, Badmos KB Morphology of colorectal carcinoma among Nigerians: A 30-year review. Niger J Clin Pract 2011;14:432-5.  Back to cited text no. 10
    
11.
Edino ST, Mohammed AZ, Ochicha O Characteristics of colorectal carcinoma in Kano, Nigeria: An analysis of 50 cases. Niger J Med 2005;14:161-6.  Back to cited text no. 11
    
12.
Gandomani H, Yousefi S, Aghajani M, Mohammadian-Haf-shejani A, Tarazoj A, Pouyesh V, et al. Colorectal cancer in the world: incidence, mortality and risk factors. Biomedical Research and Therapy 2017;4:1656-1675.  Back to cited text no. 12
    
13.
Mahajan A, Desai S, Sable NP, Thakur MH Status of barium studies in the present era of oncology: Are they a history? Indian J Med Paediatr Oncol 2016;37:223-6.  Back to cited text no. 13
    
14.
Swischuk LE Alimentary tract. In: Swischuk LE, editor. Imaging of the newborn, infant, and young child. 4th ed. Baltimore, MD: Williams & Wilkins. 1997; pp. 353-549.  Back to cited text no. 14
    
15.
Green HL, Rizzolo D, Austin M Surgical management for Hirschsprung disease: A review for primary care providers. JAAPA 2016;29:24-9.  Back to cited text no. 15
    
16.
Christina G, Eero D, Anna B, Einar A, Pernilla S Diagnosis, symptoms, and outcomes of Hirschsprung’s disease from the perspective of gender. Surg Res Pract 2017;2017:9274940.  Back to cited text no. 16
    
17.
Jones PG Causes of neonatal intestinal obstruction. In: Jones PG, editor. Clinical pediatric surgery diagnosis and management. 2nd ed. Oxford, UK; Blackwell Scientific Publications. 7th ed. 2015; pp. 69-86.  Back to cited text no. 17
    
18.
Ameh EA, Chirdan LB Neonatal intestinal obstruction in Zaria, Nigeria. East Afr Med J 2000;9:510-3.  Back to cited text no. 18
    
19.
Alatise OI, Otegbayo JA, Nwosu MN, Lawal OO, Ola SO, Anyanwu SN, et al. Characteristics of inflammatory bowel disease in three tertiary health centers in Southern Nigeria. West Afr J Med 2012;31:28-33.  Back to cited text no. 19
    
20.
Ekwunife CN, Nweke IG, Achusi IB, Ekwunife CU Ulcerative colitis prone to delayed diagnosis in a Nigerian population: Case series. Ann Med Health Sci Res 2015;5:311-3.  Back to cited text no. 20
    
21.
Nwankwo NC, Maduforo CO Radiological features of ulcerative colitis in a Nigerian: A case report. Kanem J Med Sci 2010;4:47-50.  Back to cited text no. 21
    
22.
Obaseki DE, Forae GD Clinicopathological features of inflammatory bowel disease in Benin City, Nigeria. Int J Adv Med Health Res 2014;1:16-9.  Back to cited text no. 22
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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