SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 35 CASE SERIES Colorectal cancer (CRC) is a leading cause of death worldwide. 1 Over the past few years colon cancer has been diagnosed in younger adults thus CRC screening in average risk people should now commence at age 45 years and not at the age of 50 years. 2-7 Colonoscopy is used for CRC screening, as well as for therapeutic and diagnostic procedures. A range of reasons for a failed or incomplete colonoscopy is reported in the literature. 8,9 Such cases may be referred by gastroenterologists for a radiological examination of the large bowel. Barium enema (BE) was the only established large bowel examination until the advent of computed tomographic colonography (also called virtual colonoscopy). 10 The focus of this paper is whether there is still a role for BE in failed or incomplete colonoscopy cases since computed tomographic colonography (CTC) is a well-established modality in colorectal imaging. Role of barium enema from early 1920s to early 2000 Barium was reported as being safe to use in 1910. 11 Barium enema examinations started to decline when fibreoptic colonoscopy gained ground. 12,13 Since the 1990s several papers have questioned the role of BE in radiology for large bowel examinations. 14-22 Glick 23 was of the opinion that in order to improve the performance results of double- contrast barium enema (DCBE) radiologists would have to accept the challenge by developing skills to obtain the necessary results. The findings of a 2006 four-year retrospective analysis of DCBE for failed or incomplete colonoscopy were that the examination had a high false- positive rate and would not likely be performed in the future at that institution. 17 Stevenson 20 stated that in terms of clinical practice it was hard to justify offering DCBE and it should be phased out and that CTC should be the required component in training programmes. The sensitivity of DCBE for polyps >10mm was 44% in a national polyp study. 14 The findings were that the level of sensitivity of colonoscopy as the initial diagnostic study for detection of CRC was superior in all segments of the bowel for colonoscopy compared to DCBE: barium enema was approximately six times more likely to miss a CRC than colonoscopy performed by a gastroenterologist. 14 A retrospective study correlated the reports of 244 DCBE reports with colonoscopy reports performed within 12 months before or after a DCBE. 17 The aim of the study was to determine the use and yield of DCBE for colorectal polyp detection. The main indication to perform a DCBE was to complete a failed, incomplete, or inconclusive colonoscopy (109/244 or 45%); only 5.7% of DCBE reports (14/244) gave positive reports for polyps. Furthermore five of the 14 polyps reported were shown to be false-positive at a later colonoscopy. 17 A paper by Chandio et al 24 seems to be an outlier in terms of the performance of DCBE in failed colonoscopy cases. They reported DCBE had a less than 2% failure rate J H Bortz LSG Imaging, Beverly Hills and Santa Monica, California, United States of America Incomplete optical colonoscopy: the importance of choosing CT colonography over barium enema in the completion of the study Correspondence Joel Bortz email: joelbortz23@gmail.com Abstract The role of radiology imaging in incomplete colonoscopy studies is discussed in terms of justification of barium enema and computed tomography colonography in accordance with current guidelines and practice. Keywords: colon-map, fly-through, justification, patient dose