Limitations of Barium Enema Performed as an Adjunct to Incomplete Colonoscopy

Colonoscopy is believed to be inadequate in 4 to 24 percent of procedures. Barium enema often is utilized to complete the examination. In radiology literature, a successful barium enema in this setting requires only that the cecum has been reached. In this study, completion barium enema was assessed for both completeness and quality of proximal visualization.

The charts of 16,216 patients undergoing colonoscopy at Saint Vincent Health Center from July 1995 to July 2003 were reviewed to identify patients who underwent barium enema within six months of an incomplete colonoscopy. Incomplete colonoscopies were audited for history of previous abdominal/pelvic surgery, level of colon attained, and apparent reasons for failure. Corresponding barium enema reports were evaluated in a similar fashion.

In 485 patients (2.9 percent), colonoscopy was incomplete. One hundred eighteen patients underwent barium enema after incomplete colonoscopy. In these patients, sharp angulation (42 percent) or redundancy/looping (31 percent) most often limited endoscopy. Among the barium enema studies, 91 (77 percent) were technically adequate. Twenty-seven studies were suboptimal (poor preparation/intolerance = 7, redundancy = 6, poor filling = 6, stricture/narrowing = 6, severe diverticulosis = 2). Two patients demonstrated additional polyps. There was no correlation between reasons for endoscopic failure and inadequacy of barium enema. Completeness of barium enema was not affected by previous pelvic surgery. Immediate barium enema was no less complete than a delayed study.

The reliability of barium enema after incomplete colonoscopy is less than previously reported.