Adequacy of preparation for barium enema among elderly outpatients Roland M. Grad, MD, CM, CCFP; A. Mark Clarfield, MD, CCFP, FRCPC; Marvin Rosenbloom, MD, FRCPC; Maria Perrone, MD, CM, CCFP Objective: To determine whether outpatients 75 years of age or older have a higher rate of inadequate bowel preparation for barium enema and of complications associated with the preparation and the test than patients aged 55 to 74 years. Design: Cross-sectional survey. Setting: Radiology department in a teaching hospital. Patients: Patients 55 years or older referred for a barium enema from March to August 1988. Outcome measures: All films were reviewed independently by a study radiologist blind to the staff radiologist's report. Patients were interviewed by telephone within several days after the test to assess the occurrence of problems during the preparation or the test. Main results: Of the 213 patients assessed 72 were excluded: 43 refused to participate or could not be contacted, 16 had previously undergone colonic surgery, and 13 were excluded for other reasons. The remaining 141 patients were separated into three age groups: those 55 to 64 years (46 patients), those 65 to 74 (47) and those 75 or older (48). In 104 cases (74%) the bowel had been prepared adequately; there was no significant difference between the three groups with regard to the adequacy of preparation. The incidence of problems reported by the patients did not differ significantly between the groups. Conclusions: Outpatients aged 75 years or more are no more likely than those aged 55 to 74 to have problems with bowel preparation or the barium enema itself. Age should not be a criterion for exclusion from barium enema. To try to lower the rate of poor bowel preparation clinicians and radiologists should consider counselling patients more carefully about the importance of proper preparation. Also, the current method of preparation could be examined to determine whether simple changes would significantly improve colon cleanliness.
Objectif: Determiner si le taux de preparation insuffisante des intestins en vue d'un lavement baryte et de complications liees a la preparation et a l'examen est plus eleve chez les malades consultants de 75 ans ou plus que chez les malades de 55 a 74 ans. Conception: Enquete transversale. Contexte: Service de radiologie d'un h6pital d'enseignement. Patients: Malades de 55 ans ou plus devant subir un lavement baryte de mars a aouit 1988. Mesures des resultats: Toutes les radiographies ont ete examinees independamment par un radiologue du groupe d'etude qui n'etait pas au courant du rapport du radiologue de l'h6pital. On a interviewe les malades par telephone quelques jours apres l'examen pour determiner s'ils avaient eu des problemes au cours de la preparation ou de l'examen. Principaux resultats: Parmi les 213 patients examines, on en a rejete 72: 43 ont refuse de participer ou n'ont pu etre contactes, 16 avaient deja subi une intervention Drs. Grad and Perrone are staffphysicians, Herzl Family Practice Centre, Sir Mortimer B. Davis-Jewish General Hospital, and assistant professors, Department ofFamily Medicine, McGill University, Montreal, Que. Dr. Clarfield is chief, Division of Geriatrics, Sir Mortimer B. Davis-Jewish General Hospital, and professor, departments ofFamily Medicine and Medicine and the McGill Centre for Studies on Aging, McGill University, Montreal, Que. Dr. Rosenbloom is senior radiologist, Sir Mortimer B. Davis-Jewish General Hospital, and assistant professor, Department of Radiology, McGill University, Montreal, Que.
Presented May 16, 1990, at the 18th annual meeting of the North American Primary Care Research Group, held in Denver. Reprint requests to: Dr. Roland M. Grad, Herzl Family Practice Centre, Sir Mortimer B. Davis-Jewish General Hospital, 3755 Cote St. Catherine Rd, Montreal, PQ H3T IE2 MAY 15, 1991
CAN MED ASSOC J 1991; 144 (10)
1257
chirurgicale au colon et 13 ont ete exclus pour d'autres raisons. Les 141 patients restants ont ete separes en trois groupes d'age: les 55 a 64 ans (46 patients), les 65 a 74 ans (47) et les 75 ans ou plus (48). Dans 104 cas (74 %), les intestins avaient ete bien prepares. I1 n'y avait aucune difference importante entre les trois groupes pour ce qui etait de la suffisance de la preparation. L'incidence de problemes signales par les patients ne differait pas beaucoup entre les groupes. Conclusions: Les malades consultants de 75 ans ou plus ne risquent pas plus que les 55 a 74 ans de connaitre des problemes lies a la preparation des intestins ou au lavement baryte. L'age ne devrait pas etre un critere de rejet du lavement baryte. Afin d'essayer de reduire le taux de preparation insuffisante des intestins, les cliniciens et radiologistes devraient considerer de conseiller leurs patients plus attentivement au sujet de l'importance d'une bonne preparation. De plus, il faudrait revoir la methode de preparation actuelle afin de determiner si des changements simples pourraient ameliorer considerablement la proprete du colon.
espite the advent of fibreoptic colonoscopy barium enema continues to be a common and cost-effective method for diagnosing diseases of the colon."2 However, one of the main problems associated with barium enema has been inadequate preparation of the colon, which prevents proper radiologic assessment.3'4 To circumvent this problem patients who might have difficulty with the preparation, such as elderly people, are sometimes admitted to hospital, where diet and the administration of cathartics and enemas can be supervised. Because of a scarcity of beds this practice is not usually possible at our institution. Thus, most members of the large elderly population served by our hospital who require a barium enema undergo the procedure on an outpatient basis. However, the inability of elderly outpatients to prepare their bowel adequately for barium enema results in significant costs to the physician, the patient and the health care system. We conducted this study to verify our clinical impression that elderly outpatients (those aged 75 years or more) have (a) a higher failure rate in adequately preparing their colon for barium enema and (b) a greater incidence of problems with the bowel preparation and the test itself than people aged 55 to 64 years and those aged 65 to 74 ("young old"). D
Methods This study involved the departments of Radiology and Family Medicine and the Division of Geriatrics at the Sir Mortimer B. Davis-Jewish General Hospital (a 620-bed teaching hospital in Montreal). From March to August 1988 we assessed 213 consecutive outpatients who had undergone barium enema.
The bowel preparation most often recommended involved a clear fluid diet for 24 hours, oral hydration, and ingestion of 300 mL of magnesium citrate after lunch the day before and 15 mg of 1258
CAN MED ASSOC J 1991; 144 (10)
bisacodyl at 10 pm the night before the procedure. In 96% of the cases a single-contrast technique was used. After the test patients were advised to take 30 mL of milk of magnesia to help eliminate the barium. A data sheet and questionnaire were used to help in the data collection, which included reviewing and recording of information in the staff radiologist's report. Within several days after the barium enema the patients were sent a letter explaining the reasons for the study and a consent form. They were then contacted by one of us (R.M.G.) by telephone to assess whether any problems had occurred during the bowel preparation or the test. Mental status was not objectively assessed, but help from a caregiver was sought if confusion or language problems were encountered. For purposes of analysis patients were divided into three groups: those aged 55 to 64 years, those aged 65 to 74 and those aged 75 or more. Because interpretation of the results of barium enema is subject to interobserver variation5 all films were assessed by one of us (M.R.) using the fivepoint scoring system developed by Dodds and associates.6 The evaluator was blind to the staff radiologist's interpretation. The results were analysed with the use of standard x2 and Student's t-tests.
Results Of the 213 outpatients assessed 43 refused to participate or could not be contacted; the remainder were excluded because of previous colonic surgery (16 patients), bowel obstruction (1) and other (5) or unknown (7) reasons. We excluded those who had undergone colonic surgery or had bowel obstruction because this might influence the adequacy of colon cleanliness. This left 141 patients. There was no statistically significant difference between the enrolled patients and the excluded ones with respect to age, sex and adequacy of preparation. In addition, enrolled patients were just as likely as excluded ones LE 15 MAI 1991
m
to have had their tests ordered by a consultant as observed in 59 (42%) (Table 3). The patients 75 opposed to their family physician (70% and 80% years of age or older had significantly more diverrespectively). ticulosis and significantly fewer "normal" test results Two-thirds of the study patients were 65 years than those in the other two age groups (p < 0.01). of age or older (Table 1). As in most studies There were no major complications. However, involving elderly people the proportion of women minor problems were reported frequently (Table 4). exceeded that of men. There was no significant The patients 75 years of age or older were less likely difference between the three age groups with regard than the other patients to complain of abdominal to adequacy of bowel preparation. The study radi- pain either during the bowel preparation or immediologist (M.R.) found that 104 (74%) of the patients ately after the test (p = 0.04); there was no signifihad an adequately prepared colon and that 22 (16%) cant difference between the three groups in the did not; in 15 cases (11%) the study radiologist could incidence of other problems. not assess the adequacy of bowel preparation because no clinical question or relevant clinical data Discussion appeared on the requisition. Of the 22 patients Although we expected that the outpatients aged whose bowel preparation was judged to be inade75 years or more would be less able than the younger quate 16 (73%) had no follow-up tests of any kind. The three most common indications for barium patients to prepare their colons adequately for barienema were gastrointestinal (occult, melenic or um enema our data did not support this hypothesis. One explanation is selection bias. Only patients bright red) bleeding (in 42 [30%] patients), abdominal pain (in 26 [18%]) and change in bowel habit (in felt to be capable of withstanding the rigors of the 24 [17%]) (Table 2). There was no significant differ- preparation are selected to undergo barium enema; thus, frail or housebound elderly people would not ence between the three groups in these indications. Lesions suggestive of polyp or carcinoma were likely be selected on an outpatient basis. In addition, noted in 16 (11%) of the patients, and diverticulosis, in some patients selected to undergo barium enema, alone or in association with other disease, was problems might develop during bowel preparation Table 1: Characteristics of elderly outpatients who underwent barium enema
Characteristic Mean age (and standard deviation), yr
Sex, no. (and %) of patients Female Male Bowel preparation, no. (and %) of patients Adequate Inadequate Indeterminate*
55-64 (n = 46)
Age group, yr > 75 65-74 (n = 48) (n = 47)
(n
59.8 (2.9)
68.7 (3.1)
80.3 (4.0)
69.7 (9.1)
27 (59) 19 (41)
24 (51) 23 (49)
28 (58) 20 (42)
79 (56) 62 (44)
33 (72) 7 (15) 6 (13)
32 (68) 9 (19) 6 (13)
39 (81) 6 (13) 3 (6)
104 (74) 22 (16) 15 (11)
Total =
141)
*No clinical question or relevant clinical data were on the test requisition.
Table 2: Indications for barium enema by age group
Indication* Gastrointestinal bleeding Abdominal pain Change in bowel habit
Age group, yr; no. (and %) of patients > 75 Total 65-74 55-64 42 (30) 12 (26) 14 (29) 16 (35)
6(13) 5 (11)
Follow-up because of previous condition (e.g., history 7 (15) of polyps) Other (e.g., anemia or weight 16 (35) loss or unknown 'There was more than one indication for some patients.
MAY 15, 1991
12(26) 6 (13)
13 (27)
8(17)
26(18) 24 (17)
6 (13)
5 (10)
18 (13)
19 (40)
13 (27)
48 (34)
CAN MED ASSOC J 1991; 144 (10)
1259
and prevent the test from going ahead as planned. Because patients were entered in our study only after completion of the test we did not determine the proportion of those who failed to present for the procedure. In retrospect, it would have been useful to include these people because they are part of the population referred by clinicians for testing. This exclusion and the use in 96% of the cases of a single-contrast technique (with which the need for a clean colon is perhaps less pressing than with a double-contrast technique) suggest that our findings underestimated the magnitude of the problem of inadequate preparation. Nevertheless, an outpatient aged 75 years or more who presents for single-contrast barium enema is not more likely than younger patients to have inadequate results because of poor bowel preparation. Another form of selection bias may have occurred when patients found to have a serious condition on barium enema were quickly admitted to hospital for surgery, which would have prevented contact with us for the telephone interview. One of us (R.M.G.) knew of at least two patients excluded from the study who were admitted to hospital shortly after the test revealed carcinoma. One died immediately after surgery, and the other was un-
available because he was transferred to a convalescent hospital. Finally, the lack of difference between the three age groups in adequacy of bowel preparation may have been attributable to a 3 error. Information about the risks of diagnostic tests is often incomplete.7 A computer search identified only a few relevant articles, none of which specifically addressed the ability of elderly outpatients to prepare themselves adequately for barium enema. In one study8 age was not a factor in the successful preparation of patients; however, only 42 patients were involved, and just 8 (19%) were elderly. In another study9 the double-contrast barium enema was found to be feasible in the elderly; however, all patients whose colons were found to be poorly prepared by means of plain film examination just before the barium enema were excluded, but the number of exclusions was not reported. DiPalma, Brady and Pierson'0 reported that "the adequacy of barium enema cleansing . . . does not appear to be influenced by age"; however, the articles they cited6"'l did not address this issue. Although they examined 176 "older" patients the mean age was 66.5 (standard deviation 4.3) years; this suggested that few of the subjects were 75 years or older. In
Table 3: Findings of barium enema by age group
Finding* Normal bowel Diverticulosis Possible polyp or carcinoma Inadequate bowel preparation. as determined by Staff radiologist Study radiologist Other (e.g., calcified hilar nodes)
Age group, yr; no. (and %) of patients ?> 75 Total 55-64 65-74 22 (47) 14 (29) 28 (61) 64 (45) 15 (32) 17 (37) 27 (56) 59 (42) 7 (15) 5 (11) 16 (11) 4 (9) 1 (2) 7 (15)
4 (9)
9 (19)
0 6 (13)
5 (4) 22 (16)
2 (4)
4 (9)
3 (6)
9 (6)
'Some patients had more than one finding.
Table 4: Problems associated with barium enema reported by patients Problem* None Trouble with bowel
Age group, yr; no. (and %) of patients > 75 55-64 65-74 Total 23(50) 23(49) 21 (44) 67 (48)
preparationt
20 (44)
14 (30)
constipation
5 (11) 8(17) 4 (9)
6 (13) 7(15) 6 (13)
10 (22)
8 (17)
New or exacerbated Abdominal pain Weakness Other (e.g., insomnia or dizziness)
10((21) 7 (15) 1 (2)t 4 (8)
12 25)
44 (31)
18 (13) 16 (11) 14(10) 30 (21)
'Some patients reported more than one problem.
tProblems included difficulty swallowing laxatives or inserting suppositories. tp 0.04, as compared with the other two age groups. =
1260
CAN MED ASSOC J 1991; 144 (10)
LE 1 5 MAI 1991
addition, they did not state what proportion of their subjects were outpatients. A recent study involving elderly inpatients'2 revealed that 31% had an inadequately prepared colon; this compares closely with the rate of 26% among the outpatients in our study. One question that arises from our findings is whether any measures can be implemented to reduce the high rate of poor bowel preparation. Perhaps the rate could be reduced if clinicians and radiologists counselled their patients more carefully about the importance of proper preparation. A second measure would be to re-examine the current method of preparation to determine whether simple changes could significantly improve colon cleanliness. The likelihood of serious complications during barium enema such as bowel perforation has been reported to be quite low (1 in 2250 tests);'4 there were none in our study, but minor problems occurred in about 50% of the patients. These data have not been previously reported and should help clinicians to counsel their patients better on potential problems associated with bowel preparation for barium enema and the test itself. Of the 22 cases in which the preparation was judged to be inadequate by the study radiologist the staff radiologist's judgement was similar in only 5. In 15 of the remaining 17 cases the test had been ordered because of either a previous condition (e.g., polyps) or gastrointestinal bleeding. As such, good bowel preparation was mandatory in order to detect small polyps. Yet in none of the 17 cases did the staff radiologist report to the clinician that bowel preparation was inadequate to rule out polyps; the report often read "fecal residue" or "feces" in addition to the usual comment of "no gross abnormality demonstrated." It is not surprising, then, that no follow-up testing was ordered in any of these cases, because the referring clinician likely was unaware of the test's inadequacy for polyp detection. Although there was substantial disagreement between the study and staff radiologists the former did not have the benefit of viewing the colon under fluoroscopy and thus may have been more likely to label the bowel preparation as inadequate. Nevertheless, it is the responsibility of the radiologist4 to inform the clinician of whether the findings are positive or negative or whether the test must be
MAY 15, 1991
repeated. Therefore, in our hospital, and perhaps in others,'5 there was clearly room for improvement in the communication of information between radiologist and clinician. This study prompted our hospital's Department of Radiology to change its reporting practice significantly. In conclusion, age alone should not be a criterion for excluding outpatients from barium enema. Our results cannot be generalized to elderly inpatients or frail housebound people, among whom greater difficulty in bowel preparation and a higher complication rate may be encountered. In addition, our study shows that it is relatively simple for several hospital departments to cooperate on one audit to the benefit of all.
References 1. Knoepf LF, Suits GS: A comparison of barium enema and colonoscopy in the diagnosis of colon and rectal cancer. J SC MedAssoc 1984; 80: 7-9 2. Eddy DM: Screening for colorectal cancer. Ann Intern Med 1990; 113: 373-384 3. Miller RE: Detection of colon carcinoma and the barium enema. JAMA 1974; 230: 1195-1198 4. Idem: The clean colon [EJ. Gastroenterology 1976; 70: 289290 5. Sackett DL, Haynes RB, Tugwell P: Clinical Epidemiology: a Basic Science for Clinical Medicine, Little, Toronto, 1985: 28-31 6. Dodds WJ, Scanlon GT, Shaw DK et al: An evaluation of colon cleansing regimens. Am JRoentgenol 1977; 128: 57-59 7. Flegel K, Oseasohn R: Adverse effects of diagnostic tests. Arch Intern Med 1982; 142: 583-587 8. Gutwein I, Baer J, Holt PR: The effect of a formula diet on preparation of the colon for barium enema examination. Impact on health care and costs. Arch Intern Med 1981; 141: 993-996 9. Wolf EL, Frager D, Beneventano TC: Feasibility of double contrast barium enema in the elderly. AJR 1985; 145: 47-48 10. DiPalma JA, Brady CE, Pierson WP: Colon cleansing: acceptance by older patients. Am J Gastroenterol 1986; 81: 652655 11. Fork F, Ekberg 0, Nilsson G et al: Colon cleansing regimens. GastrointestRadiol 1982; 7: 383-389 12. Tinetti ME, Stone L, Cooney L et al: Inadequate barium enemas in hospitalized elderly patients: incidence and risk factors. Arch Intern Med 1989; 149: 2014-2016 13. Tinetti ME, Speechley M: Prevention of falls among the elderly. NEnglJMed 1989; 320: 1055-1059 14. Gelfand DW: Complications of gastrointestinal radiologic procedures: 1. Complications of routine fluoroscopic studies. GastrointestRadiol 1980; 5: 293-298 15. Heilman RS: What's wrong with radiology? N Engl J Med 1982; 306: 477-479
CAN MED ASSOC J 1991; 144 (10)
1261
Objectif: Determiner si le taux de preparation insuffisante des intestins en vue d'un lavement baryte et de complications liees a la preparation et a l'examen est plus eleve chez les malades consultants de 75 ans ou plus que chez les malades de 55 a 74 ans. Conception: Enquete transversale. Contexte: Service de radiologie d'un h6pital d'enseignement. Patients: Malades de 55 ans ou plus devant subir un lavement baryte de mars a aouit 1988. Mesures des resultats: Toutes les radiographies ont ete examinees independamment par un radiologue du groupe d'etude qui n'etait pas au courant du rapport du radiologue de l'h6pital. On a interviewe les malades par telephone quelques jours apres l'examen pour determiner s'ils avaient eu des problemes au cours de la preparation ou de l'examen. Principaux resultats: Parmi les 213 patients examines, on en a rejete 72: 43 ont refuse de participer ou n'ont pu etre contactes, 16 avaient deja subi une intervention Drs. Grad and Perrone are staffphysicians, Herzl Family Practice Centre, Sir Mortimer B. Davis-Jewish General Hospital, and assistant professors, Department ofFamily Medicine, McGill University, Montreal, Que. Dr. Clarfield is chief, Division of Geriatrics, Sir Mortimer B. Davis-Jewish General Hospital, and professor, departments ofFamily Medicine and Medicine and the McGill Centre for Studies on Aging, McGill University, Montreal, Que. Dr. Rosenbloom is senior radiologist, Sir Mortimer B. Davis-Jewish General Hospital, and assistant professor, Department of Radiology, McGill University, Montreal, Que.
Presented May 16, 1990, at the 18th annual meeting of the North American Primary Care Research Group, held in Denver. Reprint requests to: Dr. Roland M. Grad, Herzl Family Practice Centre, Sir Mortimer B. Davis-Jewish General Hospital, 3755 Cote St. Catherine Rd, Montreal, PQ H3T IE2 MAY 15, 1991
CAN MED ASSOC J 1991; 144 (10)
1257
chirurgicale au colon et 13 ont ete exclus pour d'autres raisons. Les 141 patients restants ont ete separes en trois groupes d'age: les 55 a 64 ans (46 patients), les 65 a 74 ans (47) et les 75 ans ou plus (48). Dans 104 cas (74 %), les intestins avaient ete bien prepares. I1 n'y avait aucune difference importante entre les trois groupes pour ce qui etait de la suffisance de la preparation. L'incidence de problemes signales par les patients ne differait pas beaucoup entre les groupes. Conclusions: Les malades consultants de 75 ans ou plus ne risquent pas plus que les 55 a 74 ans de connaitre des problemes lies a la preparation des intestins ou au lavement baryte. L'age ne devrait pas etre un critere de rejet du lavement baryte. Afin d'essayer de reduire le taux de preparation insuffisante des intestins, les cliniciens et radiologistes devraient considerer de conseiller leurs patients plus attentivement au sujet de l'importance d'une bonne preparation. De plus, il faudrait revoir la methode de preparation actuelle afin de determiner si des changements simples pourraient ameliorer considerablement la proprete du colon.
espite the advent of fibreoptic colonoscopy barium enema continues to be a common and cost-effective method for diagnosing diseases of the colon."2 However, one of the main problems associated with barium enema has been inadequate preparation of the colon, which prevents proper radiologic assessment.3'4 To circumvent this problem patients who might have difficulty with the preparation, such as elderly people, are sometimes admitted to hospital, where diet and the administration of cathartics and enemas can be supervised. Because of a scarcity of beds this practice is not usually possible at our institution. Thus, most members of the large elderly population served by our hospital who require a barium enema undergo the procedure on an outpatient basis. However, the inability of elderly outpatients to prepare their bowel adequately for barium enema results in significant costs to the physician, the patient and the health care system. We conducted this study to verify our clinical impression that elderly outpatients (those aged 75 years or more) have (a) a higher failure rate in adequately preparing their colon for barium enema and (b) a greater incidence of problems with the bowel preparation and the test itself than people aged 55 to 64 years and those aged 65 to 74 ("young old"). D
Methods This study involved the departments of Radiology and Family Medicine and the Division of Geriatrics at the Sir Mortimer B. Davis-Jewish General Hospital (a 620-bed teaching hospital in Montreal). From March to August 1988 we assessed 213 consecutive outpatients who had undergone barium enema.
The bowel preparation most often recommended involved a clear fluid diet for 24 hours, oral hydration, and ingestion of 300 mL of magnesium citrate after lunch the day before and 15 mg of 1258
CAN MED ASSOC J 1991; 144 (10)
bisacodyl at 10 pm the night before the procedure. In 96% of the cases a single-contrast technique was used. After the test patients were advised to take 30 mL of milk of magnesia to help eliminate the barium. A data sheet and questionnaire were used to help in the data collection, which included reviewing and recording of information in the staff radiologist's report. Within several days after the barium enema the patients were sent a letter explaining the reasons for the study and a consent form. They were then contacted by one of us (R.M.G.) by telephone to assess whether any problems had occurred during the bowel preparation or the test. Mental status was not objectively assessed, but help from a caregiver was sought if confusion or language problems were encountered. For purposes of analysis patients were divided into three groups: those aged 55 to 64 years, those aged 65 to 74 and those aged 75 or more. Because interpretation of the results of barium enema is subject to interobserver variation5 all films were assessed by one of us (M.R.) using the fivepoint scoring system developed by Dodds and associates.6 The evaluator was blind to the staff radiologist's interpretation. The results were analysed with the use of standard x2 and Student's t-tests.
Results Of the 213 outpatients assessed 43 refused to participate or could not be contacted; the remainder were excluded because of previous colonic surgery (16 patients), bowel obstruction (1) and other (5) or unknown (7) reasons. We excluded those who had undergone colonic surgery or had bowel obstruction because this might influence the adequacy of colon cleanliness. This left 141 patients. There was no statistically significant difference between the enrolled patients and the excluded ones with respect to age, sex and adequacy of preparation. In addition, enrolled patients were just as likely as excluded ones LE 15 MAI 1991
m
to have had their tests ordered by a consultant as observed in 59 (42%) (Table 3). The patients 75 opposed to their family physician (70% and 80% years of age or older had significantly more diverrespectively). ticulosis and significantly fewer "normal" test results Two-thirds of the study patients were 65 years than those in the other two age groups (p < 0.01). of age or older (Table 1). As in most studies There were no major complications. However, involving elderly people the proportion of women minor problems were reported frequently (Table 4). exceeded that of men. There was no significant The patients 75 years of age or older were less likely difference between the three age groups with regard than the other patients to complain of abdominal to adequacy of bowel preparation. The study radi- pain either during the bowel preparation or immediologist (M.R.) found that 104 (74%) of the patients ately after the test (p = 0.04); there was no signifihad an adequately prepared colon and that 22 (16%) cant difference between the three groups in the did not; in 15 cases (11%) the study radiologist could incidence of other problems. not assess the adequacy of bowel preparation because no clinical question or relevant clinical data Discussion appeared on the requisition. Of the 22 patients Although we expected that the outpatients aged whose bowel preparation was judged to be inade75 years or more would be less able than the younger quate 16 (73%) had no follow-up tests of any kind. The three most common indications for barium patients to prepare their colons adequately for barienema were gastrointestinal (occult, melenic or um enema our data did not support this hypothesis. One explanation is selection bias. Only patients bright red) bleeding (in 42 [30%] patients), abdominal pain (in 26 [18%]) and change in bowel habit (in felt to be capable of withstanding the rigors of the 24 [17%]) (Table 2). There was no significant differ- preparation are selected to undergo barium enema; thus, frail or housebound elderly people would not ence between the three groups in these indications. Lesions suggestive of polyp or carcinoma were likely be selected on an outpatient basis. In addition, noted in 16 (11%) of the patients, and diverticulosis, in some patients selected to undergo barium enema, alone or in association with other disease, was problems might develop during bowel preparation Table 1: Characteristics of elderly outpatients who underwent barium enema
Characteristic Mean age (and standard deviation), yr
Sex, no. (and %) of patients Female Male Bowel preparation, no. (and %) of patients Adequate Inadequate Indeterminate*
55-64 (n = 46)
Age group, yr > 75 65-74 (n = 48) (n = 47)
(n
59.8 (2.9)
68.7 (3.1)
80.3 (4.0)
69.7 (9.1)
27 (59) 19 (41)
24 (51) 23 (49)
28 (58) 20 (42)
79 (56) 62 (44)
33 (72) 7 (15) 6 (13)
32 (68) 9 (19) 6 (13)
39 (81) 6 (13) 3 (6)
104 (74) 22 (16) 15 (11)
Total =
141)
*No clinical question or relevant clinical data were on the test requisition.
Table 2: Indications for barium enema by age group
Indication* Gastrointestinal bleeding Abdominal pain Change in bowel habit
Age group, yr; no. (and %) of patients > 75 Total 65-74 55-64 42 (30) 12 (26) 14 (29) 16 (35)
6(13) 5 (11)
Follow-up because of previous condition (e.g., history 7 (15) of polyps) Other (e.g., anemia or weight 16 (35) loss or unknown 'There was more than one indication for some patients.
MAY 15, 1991
12(26) 6 (13)
13 (27)
8(17)
26(18) 24 (17)
6 (13)
5 (10)
18 (13)
19 (40)
13 (27)
48 (34)
CAN MED ASSOC J 1991; 144 (10)
1259
and prevent the test from going ahead as planned. Because patients were entered in our study only after completion of the test we did not determine the proportion of those who failed to present for the procedure. In retrospect, it would have been useful to include these people because they are part of the population referred by clinicians for testing. This exclusion and the use in 96% of the cases of a single-contrast technique (with which the need for a clean colon is perhaps less pressing than with a double-contrast technique) suggest that our findings underestimated the magnitude of the problem of inadequate preparation. Nevertheless, an outpatient aged 75 years or more who presents for single-contrast barium enema is not more likely than younger patients to have inadequate results because of poor bowel preparation. Another form of selection bias may have occurred when patients found to have a serious condition on barium enema were quickly admitted to hospital for surgery, which would have prevented contact with us for the telephone interview. One of us (R.M.G.) knew of at least two patients excluded from the study who were admitted to hospital shortly after the test revealed carcinoma. One died immediately after surgery, and the other was un-
available because he was transferred to a convalescent hospital. Finally, the lack of difference between the three age groups in adequacy of bowel preparation may have been attributable to a 3 error. Information about the risks of diagnostic tests is often incomplete.7 A computer search identified only a few relevant articles, none of which specifically addressed the ability of elderly outpatients to prepare themselves adequately for barium enema. In one study8 age was not a factor in the successful preparation of patients; however, only 42 patients were involved, and just 8 (19%) were elderly. In another study9 the double-contrast barium enema was found to be feasible in the elderly; however, all patients whose colons were found to be poorly prepared by means of plain film examination just before the barium enema were excluded, but the number of exclusions was not reported. DiPalma, Brady and Pierson'0 reported that "the adequacy of barium enema cleansing . . . does not appear to be influenced by age"; however, the articles they cited6"'l did not address this issue. Although they examined 176 "older" patients the mean age was 66.5 (standard deviation 4.3) years; this suggested that few of the subjects were 75 years or older. In
Table 3: Findings of barium enema by age group
Finding* Normal bowel Diverticulosis Possible polyp or carcinoma Inadequate bowel preparation. as determined by Staff radiologist Study radiologist Other (e.g., calcified hilar nodes)
Age group, yr; no. (and %) of patients ?> 75 Total 55-64 65-74 22 (47) 14 (29) 28 (61) 64 (45) 15 (32) 17 (37) 27 (56) 59 (42) 7 (15) 5 (11) 16 (11) 4 (9) 1 (2) 7 (15)
4 (9)
9 (19)
0 6 (13)
5 (4) 22 (16)
2 (4)
4 (9)
3 (6)
9 (6)
'Some patients had more than one finding.
Table 4: Problems associated with barium enema reported by patients Problem* None Trouble with bowel
Age group, yr; no. (and %) of patients > 75 55-64 65-74 Total 23(50) 23(49) 21 (44) 67 (48)
preparationt
20 (44)
14 (30)
constipation
5 (11) 8(17) 4 (9)
6 (13) 7(15) 6 (13)
10 (22)
8 (17)
New or exacerbated Abdominal pain Weakness Other (e.g., insomnia or dizziness)
10((21) 7 (15) 1 (2)t 4 (8)
12 25)
44 (31)
18 (13) 16 (11) 14(10) 30 (21)
'Some patients reported more than one problem.
tProblems included difficulty swallowing laxatives or inserting suppositories. tp 0.04, as compared with the other two age groups. =
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addition, they did not state what proportion of their subjects were outpatients. A recent study involving elderly inpatients'2 revealed that 31% had an inadequately prepared colon; this compares closely with the rate of 26% among the outpatients in our study. One question that arises from our findings is whether any measures can be implemented to reduce the high rate of poor bowel preparation. Perhaps the rate could be reduced if clinicians and radiologists counselled their patients more carefully about the importance of proper preparation. A second measure would be to re-examine the current method of preparation to determine whether simple changes could significantly improve colon cleanliness. The likelihood of serious complications during barium enema such as bowel perforation has been reported to be quite low (1 in 2250 tests);'4 there were none in our study, but minor problems occurred in about 50% of the patients. These data have not been previously reported and should help clinicians to counsel their patients better on potential problems associated with bowel preparation for barium enema and the test itself. Of the 22 cases in which the preparation was judged to be inadequate by the study radiologist the staff radiologist's judgement was similar in only 5. In 15 of the remaining 17 cases the test had been ordered because of either a previous condition (e.g., polyps) or gastrointestinal bleeding. As such, good bowel preparation was mandatory in order to detect small polyps. Yet in none of the 17 cases did the staff radiologist report to the clinician that bowel preparation was inadequate to rule out polyps; the report often read "fecal residue" or "feces" in addition to the usual comment of "no gross abnormality demonstrated." It is not surprising, then, that no follow-up testing was ordered in any of these cases, because the referring clinician likely was unaware of the test's inadequacy for polyp detection. Although there was substantial disagreement between the study and staff radiologists the former did not have the benefit of viewing the colon under fluoroscopy and thus may have been more likely to label the bowel preparation as inadequate. Nevertheless, it is the responsibility of the radiologist4 to inform the clinician of whether the findings are positive or negative or whether the test must be
MAY 15, 1991
repeated. Therefore, in our hospital, and perhaps in others,'5 there was clearly room for improvement in the communication of information between radiologist and clinician. This study prompted our hospital's Department of Radiology to change its reporting practice significantly. In conclusion, age alone should not be a criterion for excluding outpatients from barium enema. Our results cannot be generalized to elderly inpatients or frail housebound people, among whom greater difficulty in bowel preparation and a higher complication rate may be encountered. In addition, our study shows that it is relatively simple for several hospital departments to cooperate on one audit to the benefit of all.
References 1. Knoepf LF, Suits GS: A comparison of barium enema and colonoscopy in the diagnosis of colon and rectal cancer. J SC MedAssoc 1984; 80: 7-9 2. Eddy DM: Screening for colorectal cancer. Ann Intern Med 1990; 113: 373-384 3. Miller RE: Detection of colon carcinoma and the barium enema. JAMA 1974; 230: 1195-1198 4. Idem: The clean colon [EJ. Gastroenterology 1976; 70: 289290 5. Sackett DL, Haynes RB, Tugwell P: Clinical Epidemiology: a Basic Science for Clinical Medicine, Little, Toronto, 1985: 28-31 6. Dodds WJ, Scanlon GT, Shaw DK et al: An evaluation of colon cleansing regimens. Am JRoentgenol 1977; 128: 57-59 7. Flegel K, Oseasohn R: Adverse effects of diagnostic tests. Arch Intern Med 1982; 142: 583-587 8. Gutwein I, Baer J, Holt PR: The effect of a formula diet on preparation of the colon for barium enema examination. Impact on health care and costs. Arch Intern Med 1981; 141: 993-996 9. Wolf EL, Frager D, Beneventano TC: Feasibility of double contrast barium enema in the elderly. AJR 1985; 145: 47-48 10. DiPalma JA, Brady CE, Pierson WP: Colon cleansing: acceptance by older patients. Am J Gastroenterol 1986; 81: 652655 11. Fork F, Ekberg 0, Nilsson G et al: Colon cleansing regimens. GastrointestRadiol 1982; 7: 383-389 12. Tinetti ME, Stone L, Cooney L et al: Inadequate barium enemas in hospitalized elderly patients: incidence and risk factors. Arch Intern Med 1989; 149: 2014-2016 13. Tinetti ME, Speechley M: Prevention of falls among the elderly. NEnglJMed 1989; 320: 1055-1059 14. Gelfand DW: Complications of gastrointestinal radiologic procedures: 1. Complications of routine fluoroscopic studies. GastrointestRadiol 1980; 5: 293-298 15. Heilman RS: What's wrong with radiology? N Engl J Med 1982; 306: 477-479
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