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THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 38 alternative to colonoscopy. 66 The guideline does not list DCBE as an imaging alternative to colonoscopy. The diagnostic performance of CTC in symptomatic and asymptomatic patients for the detection of CRC and large polyps is similar to colonoscopy and superior to BE thus the latter examination should be discouraged. 60 ESGE and ESGAR 66 recommend a same day or next day CTC for incomplete colonoscopy. A same day CTC requires tagging of any residual stool and fluid. A patient is given 250 ml of 2% barium and 50 ml of non-ionic iohexol (Omnipaque) to drink when fully recovered after incomplete colonoscopy. On average it takes three to four hours for the tagging agents to reach the colon. Before insufflation of CO2 commences a pre-procedure low- dose CT scan is performed to exclude the possibility of a colonoscopy caused colonic perforation. 66 Figures 3a and b are examples of colonic perforation in a patient referred for CTC following an incomplete colonoscopy. If free air is visualised a CTC is not performed and the referring gastroenterologist is informed of this complication. If a CTC is to be performed the next day then the patient is kept on fluids only overnight and the tagging agents are taken orally that night. If free air has been excluded on the pre-procedure CT scan then a CTC examination is performed the next day A further consideration is that patients experience more physical discomfort with BE, as well as post-test cramps, soreness, nausea, soiling, and wind. 30, 67 Conclusion The role of DCBE as an alternative to colonoscopy has decreased over the past two decades. Radiologists have to justify the use of selected imaging modalities in terms of informed consent and radiation dose justification. Comparative radiation dose studies of BE (DCBE) and CTC report that the latter is a low-dose examination with a low effective patient dose compared to the former. As discussed in this paper DCBE, due to poor performance as well as a high radiation dose, is no longer listed in current guidelines of imaging alternatives for colonoscopy and incomplete colonoscopy. CTC is recommended in the literature as the imaging alternative in patients with incomplete colonoscopy. Collaboration between radiologists and gastroenterologists is therefore important for optimal management and imaging of incomplete colonoscopy patients. References 1. World Health Organisation. Cancer,2021.[Cited 2022 January 12]. Available from: https://www.who.int/news-room/fact-sheets/detail/cancer 2. Cavestro GM, Zuppardo RA, Mannucci A. Early-onset of colorectal cancer: trends and challenges. The Lancet Gastroenterology & Hepatology. 2019; 4(7):F491-492. https://doi.org/10.1016/S2468- 1253(19)30146-3 3. Exarchakou A, Donaldson LJ, Girardi F,Coleman MP. Colorectal cancer incidence among young adults in England: trends by anatomical sub- site and deprivation. PLoS ONE 14, 2019:(12): e0225547. http://doi. org/10.1371/journal.pone.022554 4. Kim J, Dobson B, Ng Liet Hing C, Cooper M, Lu CT, Nolan G, Von Papen M. Increasing rate of colorectal cancer in younger patients: a review of colonoscopy findings in patients under 50 at a tertiary institution. ANZ Journal of Surgery. 2020; 90: 2484-2489. http://doi. org/10.1111/ans.16060 5. Rajagopalan A, Antoniou E, RajagopalanE, Arachchi A, Chouhan H, Nguyen TC, Teoh W. Is colorectal cancer associated with altered bowel habits in young patients? ANZ Journal of Surgery. 2021; 91:943-946. 6. American Cancer Society. Guidelines for colorectal cancer screening. [Cited 2022 January 12]. 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A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group. NEJM. 2000; 324 (24):1766-1772. 14. Rex DK, Rahmani EY, Haseman JH, Lemmel GT, Kaster S, Buckley JS . Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology. 1997; 112:17-23. 15. Fletcher RH. The end of barium enemas? N Engl J Med. 2000; 342 (24):1823-1824 (Editorial). 16. Martinez F, Kondylis P, Reilly J. Limitations of barium enema performed as an adjunct to incomplete colonoscopy. Dis Colon Rectum 2005; 48(10):1951-4. doi: 10.1007/s10350-005-0140-7 17. Ferrucci JT. Double-contrast barium enema: use in practice and implications for CT colonography. AJR. 2006;187:170-173. http://dx.doi . org/10.2214/ajr.05.0900 18. Campillo-Sota A, Pellicer-Franco E, Parlorio-Andrés E, Soria-Aledo V, Morales-Cuenca G, Aguayo-Albasini JL. Limitations of barium enema performed as an adjunct to incomplete colonoscopy. Med Clin (Barc) 2007; 24;129(19):725-8. doi: 10.1157/13113286. 19. Canon CL. Is there still a role for double-contrast barium enema examination? Clin Gastroent & Hepatology. 2008; 6:389-392. http:// dx.doi.org/10.1016/j.cgh2007.12051 20. Stevenson G. Colon imaging in radiology departments in 2008: goodbye to the routine double contrast barium enema. Can Ass Rad J. 2008;59(4):174-182. 21. Sosna J, Sella T, Sy O, Lavin PT, Eliahou R, Fraifeld S, Lisbon E. Critical analysis of the performance of double-contrast barium for detection colorectal ≥ 6mm in the era of CT colonography. AJR 2008; 190:374-385 22. Shariff MK, Sheikh K, Carroll NR, Whitley S, Greenberg D, Parkes M et al . Colorectal cancer detection: time to abandon barium enema. Frontline Gastroenterology. 2011;2:105–109. http://dx.doi.org/10.1136/ fg.2010.003616 23. Glick S. Double-contrast barium enema for colorectal cancer screening: a review of the issues and a comparison with other screening alternatives. AJR. 2000; 174:1529-1772. 24. Chandio A, Ali A, Javaid A, Mustafa S, Pietrosanu R, Aftab F, Ibrahim M, Naqvi S. The diagnostic yield of double contrast barium enema. Int J Surg Res Pract 2014; 1:010 25. Pickhardt PJ, Choi R, Hwang I, Butler JA, Puckett ML, Hildebrandt A et Figure 3a 2D CTC coronal image shows extensive gas (red arrows) extending along the sigmoid mesentery and superiorly along the rertroperitoneal fascial planes. Incomplete colonoscopy earlier on the same day was difficult and included sigmoid polypectomy. Figure 3b 22D sagittal view of patient in 3a. Red arrows show extraluminal gas extending along the sigmoid mesentery and superiorly along the retroperitoneal fascial planes. CASE SERIES