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GASTROINTESTINAL RADIOLOGY Table of Contents   
Year : 1999  |  Volume : 9  |  Issue : 3  |  Page : 113-117
An improved small bowel meal technique using orally administered methylecellulose


Department of Radiology, Mercy Hospital, Cork, Ireland

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   Abstract 

Objectives: To compare the diagnostic accuracy of conventional barium small bowel meal (BSBM) & methylcellulose mixed barium small bowel meal (MC-BSBM). Materials & Methods: One hundred patients were subjected to MC-BSBM and were compared to a control group of 30 patients who had conventional BSBM studies performed. The MC-BSBM technique involves replacing much of the barium given in the conventional BSBM study with methylcellulose (MC). The transit time, luminal distension, terminal ileal visualization and radiation exposures of the two techniques were compared. Results: Patients found both protocols equally acceptable. The mean transit time for the MC-BSBM group was slightly shorter, resulting in reduced numbers of films and thus radiation exposure. The quality of images was distinctly better in the MC-BSBM group due to optimal mucosal delineation, luminal distension and proper visualization of the deeper small intestine through overlapping bowel loops. Conclusion: The use of oral MC as an adjunct to the BSBM technique results in improved visualization and distension of small bowel loops, without any identified disadvantages.

Keywords: Barium, Methylcellulose,Intestine,Radiography

How to cite this article:
Moghe P K, Brady A P. An improved small bowel meal technique using orally administered methylecellulose. Indian J Radiol Imaging 1999;9:113-7

How to cite this URL:
Moghe P K, Brady A P. An improved small bowel meal technique using orally administered methylecellulose. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Sep 16];9:113-7. Available from: http://www.ijri.org/text.asp?1999/9/3/113/28316
Barium contrast examinations still remain the method of choice for examining the small bowel. Enteroclysis and conventional barium small bowel meal (BSBM) have been the traditional methods of small bowel examination. Conventional BSBM studies are often of limited value due to poor distension of loops and poor visualisation due to overlapping loops. Enteroclysis generally allows better distension and mucosal visualisation, but necessitates small bowel intubation, which can be technically difficult, time consuming and uncomfortable for the patient [1],[2],[3]. Methylcellulose (hydroxypropyl ethylcellulose 1% w/v) is an inert polysaccharide, used in double-contrast enteroclysis to distend the barium-coated small bowel. It is radiolucent, thus allowing visualisation of deeper loops hidden behind other overlying loops. Its water-retaining properties cause an increase in luminal bulk which maintains luminal distension [3]. In this study we evaluated the use of methylcellulose (MC) taken orally as part of a small bowel meal examination, rather than via intubation, to assess whether properties which are valuable during enteroclysis would also apply to direct oral administration [4],[5],[6].


   Materials and Methods Top


A control group of 30 patients had conventional BSBM examinations, as normally performed in our department prior to the introduction of MC [Figure - 1]. After a minimum of nine hours fasting, 700 ml of 72% w/v barium suspension (Sol-O-Pake, E Z EM, Westbury, New York, USA) was administered orally. Abdominal films were obtained at 30-minute intervals till the barium reached the terminal ileum. Spot compression views of the terminal ileum and of other areas of interest were taken.

Hundred consecutive patients had MC-BSBM studies, after a similar fast and using similar filming sequences to the BSBM group [Figure - 2]. One hundred and seventy-five ml of 72% w/v barium suspension (Sol-O-Pake, E Z EM, Westbury, New York, USA) was given orally, followed immediately by 700 ml of 1% aqueous MC solution. Abdominal films were taken following the same protocol as the conventional BSBM group.

Both groups of studies were reviewed independently by both authors, without being aware of the type of preparations used for oral administration. The transit time to the terminal ileum and the number of films taken were measured. Luminal distension and terminal ileal visualisation were graded from one to five, one representing poor distension or visualisation and five representing maximum distension (as would be expected with enteroclysis) or visualisation (as would be expected with pneumocolon-aided ileal distension) [Figure - 3].


   Results Top


No difference was found between the two regimes in terms of patient acceptability. Two patients of the 30 conventional BSBM studies were found to be abnormal, both showing changes typical of celiac disease. Eleven patients of the 100 MC-BSBM studies were found to be abnormal - two with Crohn's disease [Figure - 5], seven with celiac disease [Figure - 4], one with short bowel with ileal mucosal jejunization and one with changes associated with hypoproteinemia [Figure - 6]. The results are summarized in [Table - 1],[Table - 2],[Table - 3]. The use of MC resulted in a slightly shorter transit time relative to barium alone, with a consequent reduction in films taken and radiation exposure to the patients. Luminal distension and loop visualization was significantly better in the MC group. An additional advantage of MC was the greatly improved visualization of the deeper loops through the overlying loops [Figure - 2]. MC did not cause any flocculation of the barium used.


   Discussion Top


The small bowel is poorly visualized with endoscopy and radiographic techniques. Enteroscopy is a little-used and unreliable technique [7] and small bowel studies are mainly radiographic in nature. Unfortunately, the common radiographic small bowel investigations have inherent disadvantages.

Conventional BSBM generally results in reasonable visualization of the jejunal loops and the terminal ileum, but most of the ileum is often poorly seen due to overlapping bowel loops containing dense barium. The relatively slow transit of residual barium results in a significant radiation dose from multiple radiographic exposures. One of the techniques employed to overcome these difficulties is 'watering down' the high-density high-viscosity barium with iced water with or without a gastric stimulant such as metoclopramide. This method is unreliable and produces inconsistent results as the water moves haphazardly along the alimentary tract out of phase with the barium [4].

Enteroclysis is a more sensitive investigation for all parts of the small bowel, but is time consuming, uncomfortable, can be technically difficult and potentially can expose the patient to high radiation doses [1]. The other option available is to perform a peroral pneumocolon maneuver during either BSBM or enteroclysis which greatly improves terminal ileal visualization, but is uncomfortable for the patient, requires intravenous antispasmodics and does nothing to improve the visualisation of proximal small bowel loops [8].

The object of this study was to attempt to achieve loop visualisation approaching that seen at enteroclysis, by the addition of MC taken orally, without the need for intubation. This technique was first described by Ha et al [5],[6]. MC is a non-digestible dietary polysaccharide. It retains water in the bowel lumen, acting as a bulking agent promoting peristalsis and preventing luminal collapse. The barium drunk prior to MC produces mucosal coating in loops distended by the MC. The water retaining property of MC prevents the barium from becoming relatively solid in the terminal ileum and the overall density of the contrast remains uniformly homogeneous throughout the examination with the MC-BSBM technique. MC being radiolucent allows adequate visualization of the deeper small intestine through overlapping bowel loops as seen in double contrast enteroclysis with MC.

Our initial experience has been that by reducing the amount of barium drunk by 75% and replacing the barium volume with 700 ml of MC, we have achieved consistently improved small bowel distension and visualization, coupled with a reduction in the time spent for the study. The additional benefits are less radiation exposure and no adverse effects [9]. This technique has now become our standard approach to small bowel investigation and has replaced conventional BSBM completely in our department.


   Conclusion Top


The quality of small bowel visualization can be markedly improved by the replacement of the conventional dose of barium alone with oral barium and MC. No disadvantages of this technique have been identified in over 500 studies performed to date.

 
   References Top

1.Nolan DJ, Traill ZC. Review: The current role of the barium examination of the small intestine. Clin Radiol 1997; 52: 809-820.   Back to cited text no. 1  [PUBMED]  
2.Herlinger H. Barium examinations. In: Gore RM, Levine MS, Laufer I, eds. Textbook of Gastrointestinal Radiology, 1st ed. Philadelphia: W.B. Saunders, 1994: 766-788.   Back to cited text no. 2  [PUBMED]  
3.Maglinte DDT. Biphasic enteroclysis with methylcellulose. In: Freeney PC, Stevenson GW, eds. Margulis and Burhenne's Alimentary Tract Radiology, 5th ed. St. Louis: Mosby -Year Book, 1994: 533-547.   Back to cited text no. 3    
4.McKean KI. Small bowel follow through using Citrucel solution. Canadian Journal of Medical Radiation Technology, 1992; 23: 61-65.   Back to cited text no. 4    
5.Ha HK, Park KB, Kim YH, Kim PN, Lee M, Auh YH. Use of methylcellulose in small bowel follow through examination: comparison with enteroclysis and conventional series. Radiology 1995; 197 (P): 210 (presentation at RSNA 1995).   Back to cited text no. 5    
6.Park KB, Ha H, Kim PN, Lee M, Auh YH. Modified small bowel follow through with methylcellulose after administration of barium suspension: usefulness in patients with small bowel pathology. Radiology 1996; 210 (P): 380 (presentation at RSNA 1996).   Back to cited text no. 6    
7.Amberg JR. Small bowel examination: Overview. In: Freeney PC, Stevenson GW, eds. Margulis and Burhenne's Alimentary Tract Radiology, 5th ed.St. Louis: Mosby -Year Book, Inc, 1994: 689-691.   Back to cited text no. 7    
8.Brady AP. Use of effervescent agents in small bowel meal examination (letters). Clin Radiol 1994; 49: 434.   Back to cited text no. 8    
9.Moghe PK and Brady AP. The current role of the barium examination of the small intestine (letters). Clin Radiol 1998; 53: 541.  Back to cited text no. 9    

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Correspondence Address:
P K Moghe
Department of Radiology, Mercy Hospital, Cork
Ireland
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

    Tables

[Table - 1], [Table - 2], [Table - 3]

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