1976, British Journal of Radiology, 49, 658-659
Radiology now Upper digestive tract radiology today* The approach to the diagnosis of lesions in the upper digestive tract has changed since fibre-endoscopy hit the headlines, because a true assessment of the limitations of the standard barium meal became apparent for the first time since it was introduced over half a century ago. Before this there was insufficient criticism since surgery and autopsy were the only methods of judging our performance. Reliance on the standard barium meal, and by that is meant a technique frequently using the normal fundal gas bubble to achieve some degree of double contrast, but without the deliberate addition of distending gas, has been called in question in numerous papers throughout the Western world. Classen in Germany, Cotton and others in Britain, Calenoff and Sparberg in the United States have independently stressed the disturbing level of inaccuracy inherent in this technique. The result was a swing heavily in favour of endoscopic diagnosis; a swing so far as to encourage some overenthusiastic endoscopists to suggest that the patient actually preferred endoscopy to the barium meal! What is our alternative? In 1958 Welin had shown the merit of double-contrast radiology of the colon, and Japanese radiologists, in close co-operation with their endoscopy colleagues and stimulated by the unenviable incidence of their particular form of gastric cancer, had turned to double contrast upper gastro-intestinal tract radiology in the early 1960s. In this country independent endoscopic assessments of double-contrast techniques are now coming into the picture and show a high degree of accuracy, well into the 90% level and rising as experience of the method grows. In short, false X-ray negative dyspepsia is rapidly becoming a thing of the past. If we accept the situation as it now stands, and surely nobody can continue to swim against this tide for very long, the immediate effect is close co-operation between radiologist and endoscopist in place of the unfortunate separatism which tends to continue so long as the standard barium meal is practised. In my experience, up and down the country, endoscopists are only too pleased to be rid of the workload and boredom from an excessive number of false X-ray negative dyspeptics, allowing them to concentrate on their proper role as sophisticated trouble-shooters; a role in which the biopsy forceps *Reprints from: Dr. W. G. Scott-Harden, Department of Radiology, Cumberland Infirmary, Carlisle CA2 7HY.
makes a prior claim. Certainly the clinician in receipt of the routine double-contrast report shows his enthusiasm for this service and would not tolerate a return to the outmoded technique. For the sake of argument, therefore, let us accept the undoubted value of double-contrast techniques. Some would then argue that this method should be reserved for the difficult diagnostic problem, and that the standard barium meal should continue as the initial routine survey. Surely this is inherently defeatist because the prime need is to get rid of false X-ray negative dyspepsia. The only sensible approach is to institute routine double-contrast radiology of the upper digestive tract in all departments. Having said this, we must look at the implications of this decision. About one in every hundred of the population requires investigation for dyspepsia each year. This means a workload of 2000 examinations per 200 000 of the population, the average served by a district hospital. Here is the rub; super sophistication in each and every case, aimed at the demonstration of areae gastricae (the criteria laid down by Kreel and others (1973) as a "must" and necessitating drug-induced gastric atony) is not for the radiologist shouldering this sort of workload in normal hospital practice. The technique adopted must therefore be simple, straightforward and easily learned by junior members of the department. It must be no more time-consuming than the conventional barium meal. I know a number of colleagues scattered over the country who practise simple double-contrast methods, using gas tablets or effervescent drinks according to their own choice and by their own experiment and initiative. These techniques, once standardized to individual choice, are easily turned to routine performance. Because there is no requirement to attempt a diagnosis whilst screening, with the detailed concentration and strain involved, the time taken to obtain the films for an overall contrast survey is certainly no longer than the time required for a conventional barium meal. Our own consultant and registrar experience is that this technique actually allows a more rapid turnover without risking loss of accuracy because of observer error. Surely the double-contrast method has a very real departmental advantage also. The diagnosis is made entirely from the films so that realistic consultation within the
658
AUGUST 1976
Radiology now department is practical, and a library of lesions can be collected from which to teach the young radiologist, the clinician and the medical student. What of the medical student? In this department we are conscious that the students attached to our clinical colleagues actively seek a demonstration of gastro-intestinal contrast methods and the definition of lesions stemming from these. They express a significant interest. May this not be a recruiting potential for the future ? What of the young radiologist? Gastro-enterology has not generally been a favoured subject with the radiologist in training who tends to prefer the quasi-surgical activities embodied in the various forms of vascular radiology. Is this possibly because he is depressed by clinical criticism of the results of the conventional techniques and sees no dividend from his effort? This is a pity because clinical response to double-contrast accuracy is enthusiastic, and the dividend is very well worth while. Double-contrast radiology and endoscopy are complementary, and when practised together in harmony, the diagnostic yield is lifted to 98%. It is also true that radiologists in training, who practise double-contrast methods, gain much by regular attendance at endoscopy sessions. Relating endoscopic appearances to radiological detail helps to unravel the mysteries of the "funny folds" which cause difficulty for those of us learning the trade. Finally, the concept of the combined gastro-
enterological clinic should be encouraged to the advantage of all concerned. This certainly enables the radiologist member to have a realistic clinical backcloth to his diagnostic problem and an influence in decisions regarding the choice and sequence of investigation. Inevitably his interest grows and his performance is enhanced. Gastro-enterology practised in this way should then be a fascinating clinico-radiological subject. It is up to our teachers, both radiological and clinical, to encourage this approach to mutual advantage. W. G. SCOTT-HARDEN
REFERENCES CALENOFF, L., and SPARBERG, M., 1971. Gastric pseudo
lesions: roentgenographic-gastrophotographic correlation. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 113,139-149. CLASSEN, M., 1973. Endoscopy in benign peptic ulcer. Clinics in Gastroenterology, 2, 315. COTTON, P. B., 1973. Fibreoptic endoscopy and the barium meal-results and implications. British Medical Journal, 2, 161-164. KREEL, L., HERLINGER, H., and GLANVILLE, J., 1973.
Technique of the double contrast barium meal with examples of correlation with endoscopy. Clinical Radiology, 24, 307-314. SALTER, R. H., 1975. Upper-gastrointestinal endoscopy in
perspective. Lancet, 2, 863-864. SCOTT-HARDEN, W. G., 1973a. Evaluation of double contrast gastro-duodenal radiology. British Journal of Radiologv, 46,153. 1973b. Radiological investigation of peptic ulcer. British Journal of Hospital Medicine, 10, 149-153. WELIN, S., 1958. Modern trends in diagnostic roentgenology of the colon. British Journal of Radiology, 31, 453-464.
Book reviews Atlas of Enteroscopy. By L. Demling, M. Classen, and P. Ultrasonics in Medicine. Proceedings of the Second European Friihmorgen, pp. 246, 1975 (Berlin, Springer-Verlag), Congress of Ultrasonics in Medicine, Munich, May 12—16, 1975. Edited by E. Kazner, M. de Vleiger, H. R. Muller, $93.50. Although entitled an Atlas, the first 69 pages of this book V. R. McCready, pp. 360, 1975 (Amsterdam, Excerpta are devoted to a review of fibre optic instruments and Medica), $46.50. The Second European Congress consisted of 230 profferaccessories and descriptions of duodenoscopy, retrograde cholangio-pancreatography, jejuno-ileoscopy and colon- ed papers on all aspects of ultrasound. The proceedings oscopy. The text is clearly a translation from the original were compiled before the congress on the basis of abstracts German, but suffers little for this. The remainder of the submitted and consists of 51 papers, often in slightly book has beautifully illustrated examples of normal and modified form, which represents a fair cross section of abnormal findings in the duodenum, small bowel and colon. papers presented. The difficulties of judging a paper on the It is lavishly illustrated with endoscopic photographs, basis of a short abstract is reflected by the absence from the proceedings of several excellent presentations, but the book pathological speciments and X-rays. Although it is undoubtedly a useful reference work for is nevertheless a valuable reference work and the 'subject practising endoscopists, the cost will unfortunately prohibit index' is particularly useful. A list of papers read at the most gastroenterological departments from obtaining a copy congress, but not included in the proceedings, would have increased the value of the book still further. of Professor Demling and colleagues' work. R. ZEEGEN.
659
H. B. MEIRE.
Radiology now Upper digestive tract radiology today* The approach to the diagnosis of lesions in the upper digestive tract has changed since fibre-endoscopy hit the headlines, because a true assessment of the limitations of the standard barium meal became apparent for the first time since it was introduced over half a century ago. Before this there was insufficient criticism since surgery and autopsy were the only methods of judging our performance. Reliance on the standard barium meal, and by that is meant a technique frequently using the normal fundal gas bubble to achieve some degree of double contrast, but without the deliberate addition of distending gas, has been called in question in numerous papers throughout the Western world. Classen in Germany, Cotton and others in Britain, Calenoff and Sparberg in the United States have independently stressed the disturbing level of inaccuracy inherent in this technique. The result was a swing heavily in favour of endoscopic diagnosis; a swing so far as to encourage some overenthusiastic endoscopists to suggest that the patient actually preferred endoscopy to the barium meal! What is our alternative? In 1958 Welin had shown the merit of double-contrast radiology of the colon, and Japanese radiologists, in close co-operation with their endoscopy colleagues and stimulated by the unenviable incidence of their particular form of gastric cancer, had turned to double contrast upper gastro-intestinal tract radiology in the early 1960s. In this country independent endoscopic assessments of double-contrast techniques are now coming into the picture and show a high degree of accuracy, well into the 90% level and rising as experience of the method grows. In short, false X-ray negative dyspepsia is rapidly becoming a thing of the past. If we accept the situation as it now stands, and surely nobody can continue to swim against this tide for very long, the immediate effect is close co-operation between radiologist and endoscopist in place of the unfortunate separatism which tends to continue so long as the standard barium meal is practised. In my experience, up and down the country, endoscopists are only too pleased to be rid of the workload and boredom from an excessive number of false X-ray negative dyspeptics, allowing them to concentrate on their proper role as sophisticated trouble-shooters; a role in which the biopsy forceps *Reprints from: Dr. W. G. Scott-Harden, Department of Radiology, Cumberland Infirmary, Carlisle CA2 7HY.
makes a prior claim. Certainly the clinician in receipt of the routine double-contrast report shows his enthusiasm for this service and would not tolerate a return to the outmoded technique. For the sake of argument, therefore, let us accept the undoubted value of double-contrast techniques. Some would then argue that this method should be reserved for the difficult diagnostic problem, and that the standard barium meal should continue as the initial routine survey. Surely this is inherently defeatist because the prime need is to get rid of false X-ray negative dyspepsia. The only sensible approach is to institute routine double-contrast radiology of the upper digestive tract in all departments. Having said this, we must look at the implications of this decision. About one in every hundred of the population requires investigation for dyspepsia each year. This means a workload of 2000 examinations per 200 000 of the population, the average served by a district hospital. Here is the rub; super sophistication in each and every case, aimed at the demonstration of areae gastricae (the criteria laid down by Kreel and others (1973) as a "must" and necessitating drug-induced gastric atony) is not for the radiologist shouldering this sort of workload in normal hospital practice. The technique adopted must therefore be simple, straightforward and easily learned by junior members of the department. It must be no more time-consuming than the conventional barium meal. I know a number of colleagues scattered over the country who practise simple double-contrast methods, using gas tablets or effervescent drinks according to their own choice and by their own experiment and initiative. These techniques, once standardized to individual choice, are easily turned to routine performance. Because there is no requirement to attempt a diagnosis whilst screening, with the detailed concentration and strain involved, the time taken to obtain the films for an overall contrast survey is certainly no longer than the time required for a conventional barium meal. Our own consultant and registrar experience is that this technique actually allows a more rapid turnover without risking loss of accuracy because of observer error. Surely the double-contrast method has a very real departmental advantage also. The diagnosis is made entirely from the films so that realistic consultation within the
658
AUGUST 1976
Radiology now department is practical, and a library of lesions can be collected from which to teach the young radiologist, the clinician and the medical student. What of the medical student? In this department we are conscious that the students attached to our clinical colleagues actively seek a demonstration of gastro-intestinal contrast methods and the definition of lesions stemming from these. They express a significant interest. May this not be a recruiting potential for the future ? What of the young radiologist? Gastro-enterology has not generally been a favoured subject with the radiologist in training who tends to prefer the quasi-surgical activities embodied in the various forms of vascular radiology. Is this possibly because he is depressed by clinical criticism of the results of the conventional techniques and sees no dividend from his effort? This is a pity because clinical response to double-contrast accuracy is enthusiastic, and the dividend is very well worth while. Double-contrast radiology and endoscopy are complementary, and when practised together in harmony, the diagnostic yield is lifted to 98%. It is also true that radiologists in training, who practise double-contrast methods, gain much by regular attendance at endoscopy sessions. Relating endoscopic appearances to radiological detail helps to unravel the mysteries of the "funny folds" which cause difficulty for those of us learning the trade. Finally, the concept of the combined gastro-
enterological clinic should be encouraged to the advantage of all concerned. This certainly enables the radiologist member to have a realistic clinical backcloth to his diagnostic problem and an influence in decisions regarding the choice and sequence of investigation. Inevitably his interest grows and his performance is enhanced. Gastro-enterology practised in this way should then be a fascinating clinico-radiological subject. It is up to our teachers, both radiological and clinical, to encourage this approach to mutual advantage. W. G. SCOTT-HARDEN
REFERENCES CALENOFF, L., and SPARBERG, M., 1971. Gastric pseudo
lesions: roentgenographic-gastrophotographic correlation. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 113,139-149. CLASSEN, M., 1973. Endoscopy in benign peptic ulcer. Clinics in Gastroenterology, 2, 315. COTTON, P. B., 1973. Fibreoptic endoscopy and the barium meal-results and implications. British Medical Journal, 2, 161-164. KREEL, L., HERLINGER, H., and GLANVILLE, J., 1973.
Technique of the double contrast barium meal with examples of correlation with endoscopy. Clinical Radiology, 24, 307-314. SALTER, R. H., 1975. Upper-gastrointestinal endoscopy in
perspective. Lancet, 2, 863-864. SCOTT-HARDEN, W. G., 1973a. Evaluation of double contrast gastro-duodenal radiology. British Journal of Radiologv, 46,153. 1973b. Radiological investigation of peptic ulcer. British Journal of Hospital Medicine, 10, 149-153. WELIN, S., 1958. Modern trends in diagnostic roentgenology of the colon. British Journal of Radiology, 31, 453-464.
Book reviews Atlas of Enteroscopy. By L. Demling, M. Classen, and P. Ultrasonics in Medicine. Proceedings of the Second European Friihmorgen, pp. 246, 1975 (Berlin, Springer-Verlag), Congress of Ultrasonics in Medicine, Munich, May 12—16, 1975. Edited by E. Kazner, M. de Vleiger, H. R. Muller, $93.50. Although entitled an Atlas, the first 69 pages of this book V. R. McCready, pp. 360, 1975 (Amsterdam, Excerpta are devoted to a review of fibre optic instruments and Medica), $46.50. The Second European Congress consisted of 230 profferaccessories and descriptions of duodenoscopy, retrograde cholangio-pancreatography, jejuno-ileoscopy and colon- ed papers on all aspects of ultrasound. The proceedings oscopy. The text is clearly a translation from the original were compiled before the congress on the basis of abstracts German, but suffers little for this. The remainder of the submitted and consists of 51 papers, often in slightly book has beautifully illustrated examples of normal and modified form, which represents a fair cross section of abnormal findings in the duodenum, small bowel and colon. papers presented. The difficulties of judging a paper on the It is lavishly illustrated with endoscopic photographs, basis of a short abstract is reflected by the absence from the proceedings of several excellent presentations, but the book pathological speciments and X-rays. Although it is undoubtedly a useful reference work for is nevertheless a valuable reference work and the 'subject practising endoscopists, the cost will unfortunately prohibit index' is particularly useful. A list of papers read at the most gastroenterological departments from obtaining a copy congress, but not included in the proceedings, would have increased the value of the book still further. of Professor Demling and colleagues' work. R. ZEEGEN.
659
H. B. MEIRE.
