Current status of small bowel radiography

BACKGROUND

In the past, small bowel examinations were usually ordered for the sake of "completeness." As a result, small bowel radiography was performed casually and without attention to detail. This review examines pertinent clinical issues and the recent contribution of small bowel radiography to the evaluation and management of the patient with suspected small bowel disease. Recommendations for the clinical utilization of small bowel radiography are discussed.

METHODS

Analysis of pertinent citations addressing valid indications for, and technique of, small bowel radiography from 1980 to July 1995 through a computerized bibliographic search (Medline and Current Contents).

RESULTS

Accepted clinical indications for small bowel radiography include (1) unexplained gastrointestinal bleeding, (2) possible small bowel tumor, (3) small bowel obstruction, (4) Crohn disease, and (5) malabsorption. The current literature reflects the limitations of the conventional small bowel follow-through, various modifications to improve its clinical yield, the important contribution of enteroclysis in the workup, and subsequent management of patients with possible small bowel disease. A controversy in the radiology literature exists as to whether to use the small bowel follow-through or enteroclysis as the primary method of examining the small bowel.

CONCLUSION

The thoughtful selection of patients by clinicians for small bowel radiography is essential to make radiologic evaluation cost effective. The incidence of disease of the small intestine is low and is associated with nonspecific symptoms. Because of the inherent difficulty of visualizing numerous loops of an actively peristalsing bowel, a reliable imaging method is needed that not only detects small or early structural abnormality but also accurately documents normalcy. The yield of information provided by enteroclysis and its high negative predictive value suggests that it should be the primary method for small bowel examination. The "overhead"-based conventional small bowel follow-through should be abandoned. The "fluoroscopy"-based small bowel follow-through augmented when necessary by the peroral pneumocolon or the gas-enhanced double-contrast follow-through method is an acceptable alternative when enteroclysis is not possible.

Discomfort during double-contrast barium enema examination: a placebo-controlled double-blind evaluation of the effect of glucagon and diazepam

PURPOSE

To evaluate the effectiveness of glucagon and diazepam as compared with placebo in decreasing abdominal discomfort in patients during double-contrast barium enema examination.

MATERIALS AND METHODS

Thirty-six men (n = 9) and women (n = 27) aged 21-62 years with "a lot or terrible discomfort" during double-contrast barium enema examination were randomized into double-blind groups of 12 patients each at the onset of examination. Each group received a placebo, glucagon (1 mg), or diazepam (5 mg) intravenously. Discomfort was scored on a four-point scale by the patients.

RESULTS

Repeated measures analysis of variance findings indicated that those who received an active drug reported significantly (P = .001) greater relief of discomfort. Discomfort scores improved, on average, 2.2 in the glucagon, 2.0 in the diazepam, and 1.2 in the placebo groups. Colonic spasm did not correlate with abdominal discomfort.

CONCLUSION

Discomfort during double-contrast barium enema examination can be statistically significantly diminished with a hypotonic agent or a sedative.

Nasointestinal tube for decompression or enteroclysis: experience with 150 patients

The initial clinical experience with the use of a triple lumen long tube designed for gastrointestinal decompression and enteroclysis is reported in 150 patients. Based on clinical observations, this tube is effective in suctioning retained gastric and intestinal fluid but requires frequent irrigation of the sump port for effective decompression of distended small bowel. In all patients with a preexisting nasogastric tube, the replacement by the decompression/enteroclysis tube was considered more comfortable by the patients. Successful placement of the tube in the jejunum was achieved in 147 of 150 consecutive patients on the initial attempt. The use of this tube obviates dual intubations for decompression and enteroclysis, the attendant discomfort on the patient, and it expedites subsequent performance of enteroclysis if needed. The complications reported with other long intestinal tubes were not observed with this device.

Obstruction of the small intestine: accuracy and role of CT in diagnosis

The reliability of abdominal computed tomography (CT) in the assessment of varying degrees of small bowel obstruction (SBO) was evaluated by using results at enteroclysis and clinical outcome as standards of reference. A blinded retrospective analysis was performed of the studies of 55 patients who underwent both CT and enteroclysis in the course of assessment for suspected SBO. Nine patients had no obstruction, 40 patients had obstruction due to adhesions, and six patients had tumor-related obstruction. CT results were used to identify correctly 63% (29 of 46) of those who had SBO and 78% (seven of nine) of the patients who did not. The overall accuracy of the CT interpretations to help establish diagnosis was 65% (36 of 55). When obstructions were classified into low- and high-grade partial obstruction, CT results could be used to identify correctly 81% (17 of 21) of high-grade SBOs and 48% (12 of 25) of low-grade SBOs. The procedure yielded two false-positive and 13 false-negative results for patients with low-grade obstruction, revealed masses in all six cases with tumor-related obstruction, and helped predict the correct cause in all true-positive cases.

Crohn disease of the small intestine: accuracy and relevance of enteroclysis

The accuracy and clinical relevance of enteroclysis in the evaluation of 138 patients referred for enteroclysis for suspected Crohn disease of the small intestine are reported. The original prospective interpretations of enteroclysis results were assessed after a clinical follow-up period of 2 or more years. With all patients considered, enteroclysis had a sensitivity, specificity, and accuracy of 100%, 98.3%, and 99.3%, respectively, with only one false-positive diagnosis and no false-negative diagnoses. Thirty-one percent (n = 43) of the patients had lesions of early Crohn disease. All patients who required surgery (n = 23) had advanced lesions of the disease, according to enteroclysis criteria. Clinical evidence of Crohn disease did not develop in the 58 patients in whom enteroclysis revealed no abnormality. There were no complications related to the procedure. It is concluded that enteroclysis is an accurate method for diagnosis and exclusion of Crohn disease of the small intestine and provides detailed structural information relevant to appropriate management of the disease.

Evaluation of the small intestine by enteroclysis for Crohn's disease

We reviewed the records of 100 consecutive patients referred for enteroclysis by gastroenterologists because of suspected Crohn's disease of the small bowel to assess the clinical utility of the information obtained by this method. More than one-third of the patients in the study group had subtle lesions of early Crohn's disease, all patients who required surgery had severe disease by radiologic criteria, and none of the 34 patients clinically suspected of having Crohn's disease of the small bowel in whom the enteroclysis was normal developed Crohn's disease in two or more years of clinical follow-up. Enteroclysis provides gastroenterologists with accurate and detailed structural information relevant to the appropriate management of the disease and in our hands is a reliable test for excluding Crohn's disease of the small bowel.

Factors in the diagnostic delays of small bowel malignancy

The overall survival from primary malignancies of the small intestine has not changed over more than four decades. This generally is ascribed to delays in establishing the diagnosis and the advanced stage of the disease when treatment is begun. There has been no critical analysis of these delays. To answer these questions, we reviewed the records of all patients diagnosed with small bowel malignancy from 1967 to 1988 at the Methodist Hospital of Indiana. The onset and duration of symptoms, first medical consultation, time of performance of diagnostic procedures and surgery were verified in 77 patients with histologically confirmed small bowel malignancies. The longest delay occurs from the time medical help is sought to the time the diagnosis is made, not from the onset of symptoms to the first medical consultation. The small bowel should always be considered as a source of unexplained, persistent subtle abdominal symptoms.

The role of the physician in the late diagnosis of primary malignant tumors of the small intestine

Survival from primary malignancies of the small intestine has not improved during the last four decades. One reason for this is the advanced stage of disease at the time of surgery. In order to determine why diagnosis is made late, we reviewed the records of all patients with small bowel malignancy diagnosed between 1967 and 1988. The time from the onset of symptoms to the first medical contact and the time from medical contact until diagnosis were evaluated in 77 patients. The average delay in diagnosis attributable 1) to the patient failing to report symptoms was less than 2 months, 2) to the physician not ordering the appropriate diagnostic test was 8.2 months, and 3) to the radiologist failing to make the diagnosis was 12 months. Thus, the major delay in diagnosis was after medical help was sought and not from the onset of symptoms to first medical consultation. Physicians must increase their sensitivity to the subtle but persistent symptoms that necessitate a small bowel evaluation.

Primary malignant tumors in the small bowel: a comparison of the small-bowel enema and conventional follow-through examination

Of 71 patients diagnosed with primary mesenteric malignant tumors in the small bowel over a 21-year period in a community/teaching hospital, 14 underwent small-bowel follow-through, 16 underwent small-bowel enema (enteroclysis), and four patients underwent both studies preoperatively. In a retrospective study, the sensitivity of both the small-bowel enema and the conventional small-bowel follow-through examination were compared on the basis of the original radiologic interpretation. The studies were ordered by clinicians in a clinical setting. Results of the small-bowel follow-through were abnormal in 11 of 18 patients for a sensitivity of 61%, and small-bowel enema showed abnormalities in 19 of 20 patients for a sensitivity of 95% (p = .0165). The actual tumor was shown in six (33%) of 18 small-bowel follow-through studies and in 18 (90%) of 20 small-bowel enemas (p = .0005). In four patients, normal findings on conventional small-bowel follow-through were followed by abnormal findings on small-bowel enema done for the same reason. This experience suggests that the small-bowel enema is more sensitive than the conventional follow-through examination for the detection of small-bowel cancers.

Healing and recurrence of active duodenal ulcer with nizatidine

Nizatidine, a new H2-receptor antagonist for treatment of duodenal ulcer disease, was evaluated in a unique two-phase, placebo-controlled, randomized, double-blind, multicenter clinical trial. Patients received either 150 mg nizatidine twice daily or placebo for 4 weeks (phase I). If ulcer healing did not occur during phase I, patients were randomly reallocated to receive either 150 mg nizatidine twice daily or placebo for an additional 4 weeks (phase II). Patients with a healed ulcer continued on the same therapy. All patients were endoscoped at week 8. Healing rates at week 2 were 93 of 265 (35%) nizatidine-treated patients and 55 of 260 (21%) placebo-treated patients (p less than 0.001); at week 4, healing rates were 198 of 259 (76%) nizatidine-treated patients and 95 of 243 (39%) placebo-treated patients (p less than 0.001). In phase II, ulcer healing occurred in 46 of 86 (53%) nizatidine-treated patients and in 23 of 90 (26%) placebo-treated patients (p = 0.002). In patients who had a healed ulcer at previous endoscopies, 18 of 178 (10%) nizatidine-treated patients and 10 of 81 (12%) placebo-treated patients had a recurrence of duodenal ulcer. Smokers who had histories of previous ulcers were more likely to have an early recurrence.

The laboratory response to glucagon dosages used in gastrointestinal examinations

Laboratory studies occasionally are necessary for patients who have undergone hypotonic gastrointestinal examinations. To ascertain the effects of glucagon on these patients, we determined the biochemical and hematologic responses to doses of 0.25-2 mg of glucagon in a double-blind crossover study. When glucagon was given intravenously or intramuscularly in increasing doses, serum values for glucose and insulin increased linearly up to 1 mg with a slight decrease at 2 mg. After intravenous and intramuscular administration of glucagon, the white blood cell count and the percentage of neutrophiles and bands increased, and the percentage of lymphocytes decreased. Reports of side effects included one each of nausea and mouth dryness after intravenous glucagon and four reports of nausea and one of mouth dryness after intramuscular glucagon. No changes in the pulse and blood pressure could be attributed to glucagon administration.

Small bowel radiography: how, when, and why?

Since the advent of endoscopy for evaluating the upper and lower gastrointestinal (GI) tracts, it has become clear that only in the small bowel does barium radiography remain unchallenged. Regrettably, barium examination of the small bowel has traditionally been regarded by many radiologists as a study of minor importance. Small bowel follow-through techniques and enteroclysis methods differ in their diagnostic purpose, potential, and methods of performance. This review examines in detail the spectrum of barium examination techniques currently available for evaluating the small bowel. The benefits of enteroclysis in the majority of clinical situations requiring contrast examination of the small bowel are stressed. Radiologists play the crucial role in the diagnostic evaluation of the small bowel and should strive to refine and advance the accuracy of small bowel radiography.

Nizatidine as maintenance therapy of duodenal ulcer disease in remission

A new H2-receptor antagonist, nizatidine (150 mg h.s.), was compared with placebo as maintenance therapy in a randomized, parallel, double-blind, one-year study of 513 patients with recently healed duodenal ulcer. Endoscopies were performed at 0, 3, 6, and 12 months and at unscheduled times if symptoms of active peptic ulcer disease were present. Cumulative ulcer recurrence rates for nizatidine and placebo were 13 versus 40% at 3 months, 24 versus 57% at 6 months, and 34 versus 64% at 12 months. The differences were significant (p less than 0.001) at each treatment period. Smokers in both treatment groups had significantly greater recurrence rates than non-smokers. Symptoms of peptic ulcer disease were significantly less in nizatidine-treated patients in the first 3 months of treatment. Adverse events, including those related to peptic ulcer disease, occurred more frequently in placebo-treated patients. Nizatidine proved to be safe and effective in preventing recurrences of duodenal ulcer.

Treatment of duodenal ulceration in the United States

Nizatidine, a new H2-receptor antagonist for the treatment of duodenal ulcer disease, was compared with placebo in a dose-response, double-blind, parallel, multicenter clinical trial. Patients were randomly allocated to receive either nizatidine (25 mg b.i.d., 150 mg b.i.d., or 300 mg at bedtime) or placebo. At the end of 4 weeks, patients whose ulcer had not healed were randomly reallocated to receive either the nizatidine 150 mg b.i.d. dosage regime or placebo for an additional 4 weeks. Nizatidine doses of 300 mg at bedtime and 150 mg b.i.d. demonstrated similar healing frequencies. Both of these doses were statistically significantly superior in ulcer healing to the nizatidine 25 mg b.i.d. dose and to placebo at the end of 4 weeks. Patients randomly reallocated to receive nizatidine had significantly greater healing rates than patients randomly reallocated to receive placebo. In summary, nizatidine given as a single evening dose of 300 mg or as 150 mg b.i.d. proved to be equally safe and effective in the healing of active duodenal ulcers.

State-of-the-art barium examination in opportunistic esophagitis

This report presents a comparison of state-of-the-art esophagography and endoscopy in the diagnosis of pathologically proven esophagitis. The modern multiphasic esophagogram is shown to have a sensitivity of 92% for the detection of opportunistic esophagitis in the immunocompromised patient. State-of-the-art esophagography provides a sensitive and inexpensive method for investigating patients in whom opportunistic esophagitis is suspected and for monitoring their response to therapy.

Acquired jejunoileal diverticular disease: subject review

Of 519 consecutive patients examined by enteroclysis, 12 (2.3%) were found to have acquired diverticula of the jejunum and ileum. All except one patient had multiple diverticula, most occurring in the jejunum. In only one patient could symptoms be ascribed to the abnormality. The combination of intraluminal distention and extrinsic abdominal compression provided by the enteroclysis technique appears to be the most reliable method for the demonstration of small-bowel diverticula. A discussion of the complications that may result from acquired jejunoileal diverticulosis and a review of the literature are presented.

Intubation routes for enteroclysis

The transnasal and peroral intubation routes for enteroclysis examination are described. A survey of 22 patients who underwent enteroclysis by both approaches revealed an overwhelming preference for the transnasal route. Transnasal intubation for enteroclysis is rapidly performed with adequate catheter control and in most patients is associated with less discomfort compared with the peroral route.

Flow artifacts in double-contrast esophagography

Artifacts related to barium flow during double-contrast esophagography may obscure mucosal surface details. Double-contrast esophagograms with flow artifacts of 35 patients were evaluated to determine the effect on radiographic interpretation and to assess the method of examination. Initial radiographs obtained during swallowing of barium were compared with those obtained after a slight delay while patients repeatedly dry swallowed. When severe surface flow artifacts were present, the extent of mucosal disease was underestimated in all cases. Mild surface flow artifacts interfered with the demonstration of the reticular pattern of Barrett esophagus, and luminal flow artifacts caused misinterpretation. The demonstration of strictures was unaffected by flow artifacts. This study suggests that the dry swallowing maneuver and some delay improve depiction of esophageal surface details on double-contrast radiographs and obviate interpretive error from barium flow artifacts.

Enteroclysis in the diagnosis of chronic unexplained gastrointestinal bleeding

In a six-year period (1977-83), lesions were identified by enteroclysis in 26 patients with melena or recurrent gastrointestinal bleeding undiagnosed by other modalities. These included nine Meckel's diverticula, three metastatic lesions, three primary carcinomas, one lipoma, four leiomyomas, five surgically created blind pouches, one carcinoid, and one idiopathic dilatation of the ileum. Our experience suggests that, when the standard diagnostic procedures used to investigate chronic gastrointestinal blood loss are unrevealing, enteroclysis should be performed. The method is fast, accurate, is done in one sitting, and can be productive in the diagnostically difficult patient.

Early rectal tube removal for improved patient tolerance during double-contrast barium enema examination

During a five year period, 62 patients each underwent two barium enema examinations. The length of time that the rectal tube remained in place varied in each subject. Early rectal-tube removal resulted in better patient acceptance of the double-contrast barium enema examination.

Gastric emptying of enteric-coated tablets

To evaluate the gastric emptying time of pharmaceutical dosage forms in a clinical setting, a relatively simple dual-radionuclide technique was developed. Placebo tablets of six different combinations of shape and size were labeled with indium-111 DTPA and enteric coated. Six volunteers participated in a single-blind and crossover study. Tablets were given in the morning of a fasting stomach with 6 oz of water containing 99mTc pertechnetate and continuously observed with a gamma camera. A scintigraph was obtained each minute. The results suggested that the size, shape, or volume of the tablet used in this study had no significant effect in the rate of gastric emptying. The tablets emptied erratically and unpredictably, depending upon their time of arrival in the stomach in relation to the occurrence of interdigestive myoelectric contractions. The method described is a relatively simple and accurate technique to allow one to follow the gastric emptying of tablets.

Enteroclysis in partial small bowel obstruction

In a 5 year period, 56 patients with suspected partial small bowel obstruction were evaluated by enteroclysis or the antegrade small bowel enema. Mechanical partial obstruction was diagnosed by enteroclysis in 38 of the patients, 24 of whom required surgery. The diagnosis by enteroclysis was confirmed in 23 of the patients. In the single patient with "false-positive" enteroclysis, the obstruction had been interpreted as minimal. The thirteen remaining patients were managed conservatively. The possibility of significant mechanical obstruction was excluded by enteroclysis in 19 patients. There were no complications associated with the procedure. Enteroclysis is a safe, rapid, and accurate method for the evaluation of patients with partial small bowel obstruction.

Detection of surgical lesions of the small bowel by enteroclysis

Enteroclysis is an examination in which barium is infused directly into the small intestine, and compression radiographs are taken on each segment. This method eliminates many of the inherent limitations of the conventional small bowel follow-through examination. This report concerns 45 patients with 48 small bowel lesions. They were missed on the conventional examination but detected within 3 months by subsequent enteroclysis and confirmed surgically. There were 15 patients with Meckel's diverticula, 7 with obstructive adhesive bands, 5 with Crohn's disease, 5 with blind pouch syndrome (1 with a leiomyoma inside the blind pouch), 2 with other leiomyomas, 3 with metastatic carcinoma, two with primary carcinoma 3 with radiation stricture, two with sinus tract lesions and fistulas, and 1 with another lesion. Improved intubation techniques and better barium mixtures make enteroclysis possible in most hospitals. As surgeons appreciate the value of enteroclysis, they can request this examination for appropriate patients to sooner find many surgical lesions of the small bowel which frequently go undiagnosed.

Esophageal food impaction: treatment with glucagon

Nineteen patients who had foreign bodies in the distal esophagus were examined prospectively to determine the efficacy of intravenous glucagon in relieving the obstruction. The administration of glucagon resulted in clearance of the impacted food in seven patients. Although the success rate is relatively low, the risk is minimal and justifiable. Use of intravenous glucagon is a safe, worthwhile initial step in the treatment of distal esophageal foreign bodies.

The effect of barium enemas and barium sulfate on healing of colorectal biopsy sites

Twelve mongrel dogs had superficial and deep colon biopsies above and below the peritoneal reflection. Six of the animals were given a barium enema; two had a barium enema immediately, two in three days, and two in six days. The animals were sacrificed 48 hours after the barium enema; the sigmoid was removed and tissue was examined macroscopically and microscopically. When healing rates of the biopsy sites were compared with those of control animals, there was no difference. The results suggest that barium has no deleterious effect on the healing of superficial or deep colorectal biopsies.

Colon and rectal carcinoma: spatial distribution and detection

Recent studies have challenged the concept that 50% of colon cancers are detectable by digital examination and two-thirds are within reach of the rigid sigmoidoscope. This is an important consideration because of the potential for failure of an otherwise appropriate screening method when evaluating a patient for carcinoma of the colon. An analysis of 2,298 cases of colorectal carcinoma diagnosed over 20 years showed that the most common sites were the rectum (34%) and sigmoid (25%). Over the 20 years, the incidence of cancer in the cecum increased and that in the rectum decreased. Cecal, ascending, and transverse colon cancers accounted for 34% of lesions - all beyond the range of the flexible sigmoidoscope. The changing site distribution emphasizes the need for an accurate and inexpensive technique to evaluate the entire colon. These data suggest that the barium pneumocolon examination should be included in the screening of high-risk patients.

Survey of the esophagus during the upper gastrointestinal examination in 500 patients

Of 500 patients referred for an examination of the upper gastrointestinal tract, 15% were found to have radiographic evidence of esophageal disease. A cursory esophageal survey appears to be insufficient. Thorough evaluation should consist of a minimal multiphasic approach involving double- and single-contrast radiography, fluoroscopic studies of motility, and a mucosal relief study.

The use of glucagon in hydrostatic reduction of intussusception: a double-blind study of 30 patients

Thirty patients were referred for hydrostatic reduction of ileocolic intussusception. Children with suspected gangrenous bowel or sensitivity to glucagon were excluded from the investigation. A standard protocol for the procedure was used in all patients, including the intravenous administration of glucagon or placebo (0.05 mg/kg) when the intussusception was encountered. Successful reduction was achieved in 53% of both control and glucagon-treated patients. Analysis of the length of the procedure and the ease of reduction of the intussusception indicated no difference in the two groups. This multicenter double-blind study failed to show any therapeutic value of glucagon in hydrostatic reduction of intussusception.

The minimum effective dose of glucagon in upper gastrointestinal radiography

The effect of small intravenous doses (0.025 and 0.05 mg) of glucagon was evaluated in 22 patients. All 12 patients given 0.05 mg demonstrated by hypotonicity of the stomach and duodenum at 1 min and beginning return of peristalsis at 2 1/2 min. Subsequently, 100 patients with radiographically normal upper gastrointestinal examinations who received 0.05 mg of glucagon intravenously were compared to 100 patients with normal examinations without it. Comparison was made to determine the effect of glucagon on gastric mucosal coating and distention of the stomach and duodenum. In all areas of the stomach, mucosal coating was significantly improved in the glucagon group. There was also increased distention of the distal antrum, duodenal bulb, and duodenal loop. No adverse effects were reported. Because of the short duration of action of glucagon, the examination needs to be coordinated and done rapidly. The routine use of a small dose of glucagon increased the performance time slightly with small additional cost but was compensated for by the increased diagnostic quality of the examination.

Barium enema after colorectal biopsies: experimental data

The appropriate interval between a colorectal biopsy and a barium enema is controversial. Superficial and deep biopsies, above and below the peritoneal reflection, were performed on 12 dogs. Six control dogs did not have a barium enema. Six study dogs had a barium enema at different postbiopsy time intervals: immediately, 3 days, and 6 days. After superficial biopsies, there was no barium extravasation in any study animal. Histological examination, 48 hr after enema, showed complete epithelialization of all superficial sites on both study and control dogs. When the barium enema was done after a deep biopsy, there was intramural extravasation of barium immediately after biopsy but not after 3 or 6 days. Focal ulcerations were seen microscopically at sites of deep biopsies when the barium enema was performed immediately and 3 days after the diagnostic procedure. All deep biopsy sites were reepithelialized in 6 days. There was no evidence of intraperitoneal or retroperitoneal perforation and no difference in healing of biopsy sites in subjects and control animals. This study in dogs suggests that a barium enema may be performed without hazard immediately after a superficial biopsy of nondiseased colon and 6 days after a deep biopsy.

Gastrointestinal response to minute doses of glucagon

Small doses of glucagon are effective when performing a biphasic gastrointestinal (GI) examination. The authors conducted a controlled double-blind crossover study to determine the optimum and smallest effective doses and the onset and duration of drug action. Fifteen men received a placebo and 0.025, 0.05, 0.1, and 0.2 mg of glucagon intravenously. Hypotonicity of the stomach, duodenum, and small bowel was adequate with 0.1 mg of glucagon. Low-dose glucagon makes the biphasic upper GI examination short and practical. There is no need to delay the second phase of the examination or the small-bowel follow-through.

Effect of D-Val1, D-Trp8-somatostatin on the motility of the stomach, duodenum and jejunum

D-Val1, D-Trp8-somatostatin was given to seven volunteers to relax the gastrointestinal tract. Doses of drug ranging from 1-250 mcg. were given intravenously, single blind, as one bolus. The seven subjects had a total of 23 studies. The stomach never became hypotonic in any subject. The onset of drug effect on the duodenum and jejunum of moderate hypotonicity after 10-100 mcg. was 4.8 minutes and at 150-250 mcg., was 10.1 minutes. Onset of atonicity after 10-100 mcg. wa 5.7 minutes and at 150-2509 mcg., was 13.0 minutes. Duration of moderate hypotonicity after 10-100 mcg. was 20.9 minutes and at 150-250 mcg., was 22.4 minutes. Duration of atonicity at 10-100 mcg. was 11.5 minutes and at 50-250 mcg., was 14.1 minutes. Preliminary results suggest that the onset and duration of effect, relative to dose, were so variable that the drug appeared to be an unsatisfactory hypotonic agent for upper gastrointestinal radiography.

Comparison of gastrointestinal effects of aspirin and fenoprofen. A double blind crossover study

Sixteen men received 3904 mg of aspirin, 2400 mg of fenoprofen, or placebo daily for 1 week in a double blind and crossover trial. Fecal blood loss was measured by 51Cr labeled red cells; gastric and duodenal pathology were observed endoscopically. There was more (P less than 0.05) blood loss (4.96 ml) after aspirin than after fenoprofen (2.46 ml) or placebo (0.79 ml). By endoscopic examination, aspirin induced more (P less than 0.05) gastrointestinal pathology than fenoprofen or placebo, and there was a correlation of 0.70 between the two methods used in this study.

Gastrointestinal radiography with glucagon

This report summarizes the results of nine diagnostic radiographic studies done double blind crossover comparing glucagon to placebo and to anticholinergic drugs in volunteers. In seven studies the subjects were administered drug intramuscularly and in two studies intravenously. There were five diagnostic studies of the upper gastrointestinal tract, one for esophageal varices and three of the colon. The results indicate that glucagon can be given intramuscularly and intravenously. When given intravenously it has a rapid onset and predictable length of action depending on the dose given. Reports of side effects were few consisting primarily of nausea and or vomiting. These results indicate that glucagon is the drug of choice for hypotonic diagnostic examinations.

Comparison of the effects of glucagon and atropine sulfate on gastric emptying

Six asymptomatic adult males cooperated in a study of gastric emptying. Each subject was given a test meal of 500 ml. of 3.5% glucose on a fasting stomach. Ten minutes prior to the meal each was given either 1 mg atropine sulfate, placebo, or 2 mg. glucagon, double-blind and crossover. Each drug was given twice, intravenously, in a random order. The meal was removed by a Salem sump tube half an hour after ingestion. When compared to placebo, the active drugs significantly (P less than 0.05) slowed gastric emptying; atropine sulfate was more effective (P less than 0.05) than glucagon. The active drugs significantly (P 0.05) decreased total gastric acid secretion and total gastric chloride as compared to placebo. Glucagon significantly (P 0.05) increased the blood glucose concentration as compared to placebo. These results indicate that both glucagon and atropine sulfate slow the gastric emptying of a liquid sugar meal from the stomach.

Double-blind radiographic study of dose response to intravenous glucagon for hypotonic duodenography

This study was undertaken to determine a dose response to glucagon during hypotonic duodenography. Fifteen male and female volunteers received placebo and 0.25 mg, 0.5 mg, 1 mg, and 2 mg of glucagon intravenously, double-blind, and crossover. Onset of drug effect occurred in approximately 45 seconds, regardless of the dose of glucagon given. There was a significant (p less than 0.01) decrease in gastrointestinal tonicity with all doses. The larger the dose, the greater the duration of drug action. Satisfactory stomach, duodenal, and small bowel hypotonicity for radiography were obtained with 0.25 to 0.5 mg of glucagon given intravenously with few side effects.

Dose response to intramuscular glucagon during hypotonic radiography

In a study to determine a dose response to glucagon during hypotonic duodenography, 15 male and female volunteers received placebo and 0.25 mg 1 mg and 2 mg glucagon intramuscularly, double-blind and cross-over. When 0.25 mg glucagon was given, the onset of drug effect was approximately 13--18 min: the mean duration of moderate hypotonicity was approximately 4--7 min. The larger the dose, the greater the duration of drug action. When 2 mg glucagon was given, the onset of drug effect occurred in approximately 4--7 min; the mean duration of moderate hypotonicity was 22--32 min. There were no changes in pulse or blood pressure attributable to the drug with these doses, and reports of nausea and diarrhea did not increase significantly until a dose above 1 mg was given. One mg glucagon given IM is useful in hypotonic upper Gl radiographic examinations. The onset of hypotonicity was 8--10 min with a duration of 12--27 min when this dose was given. Few reports of side effects were attributable to this dose.

A comparative double-blind study of esophageal barium pastes

To demonstrate esophageal varices barium sulfate suspensions must coat the lower esophagus for as long as 5 to 10 minutes. This study compared the ability of five barium sulfate preparations to resist disappearance by inadvertent swallowing. Three of the special preparations for esophageal examination, Esophatrast, Barosperse Esophageal Paste, and HD-5000 performed satisfactorily. Examiner skill, persistence, and careful technique are the most important factors in examining the lower esophagus. The authors' procedure for examination of the esophagus for varices is described. It takes into account position, time, phase of respiration, occasional use of drugs, and procedures to insure good coating and relaxation of the lower esophagus.

GLC determination of ethinamate and its hydroxy derivative in biological fluids

A sensitive, specific GLC assay was developed for the determination of ethinamate in plasma and its major metabolite, trans-4-hydroxyethinamate, in urine. The assay uses a mass internal standard of dimethylethinamate. Ethinamate is extracted from alkalinized plasma with dichloromethane. Urine samples require beta-glucuronidase hydrolysis prior to extraction of hydroxyethinamate. The dichloromethane is removed by evaporation, and the compounds are measured by GLC using a flame-ionization detector. By using GLC-chemical-ionization mass spectrometry, the compounds measured were identified as the intact ethinamates. Plasma and urine data are presented from a bioavailability study to demonstrate the utility of this method. From these data, the ethinamate plasma half-life was calculated as 1.9 +/- 0.3 hr.

Optimal visualization of esophageal varices

Twelve patients with known esophageal varices and willingness to cooperate were included in the study. Medications administered were placebo, 2 mg of glucagon, and 30 mg of propantheline bromide. All medications were given double-blind and crossover. On the basis of this study the authors believe that for optimal visualization of esophageal varices the following is the procedure of choice: (1) the patient should remain horizontal (this is best done in the left lateral position for comfort and ease of expectoration) for ten minutes after swallowing high density barium; (2) the patient should "clear his throat" frequently and expectorate all saliva (barium sticks to the pharynx and makes the patient want to swallow and "clearing his throat" by forced expiration helps the patient to expectorate this coating and prevents swallowing); (3) filming should be done in expiration in the supine (left posterior oblique to table top) position; and (4) in equivocal cases the examination can be repeated with an anticholinergic drug if the patient has no contraindications to its use. The patient should empty his bladder just before administration of the drug. The intelligent use of these factors should result in a saving of both fluoroscopic time and film, and give the radiologist a safe optimal diagnostic yield.

Response of normal subjects to a single 2-milligram dose of glucagon administered intramuscularly

Recently there has been increased interest in glucagon because in human radiographic and endoscopic studies it has been reported to relax the gallbladder, stomach, small bowel and colon. These results suggest it may be preferable as a diagnostic aid for these procedures. Therefore, we believed it important to assess the safety, and clinical laboratory responses after glucagon is given to normal subjects. Twenty normal subjects received 2 mg of glucagon and placebo intramuscularly at daily intervals, double-blind and crossover. After glucagon there was an increase in the WBC, bands, neutrophiles, fasting blood sugar, glucagon and insulin, and a decrease in the lymphocytes. There was no change in the pulse rate or blood pressure with minimal reports of side effects. These results tend to confirm other reports that glucagon is one of the stress hormones. Glucagon is remarkably safe and produces few, mild and transient side effects, not much greater than placebo.