\OL. 107, No.

“TUBELESS” HYPOTONIC DUODENOGRAPHY: TECH-

NIQUE, VALUE AND LIMITATIONS*
By \VILLIAM MARTEL, M.D., PAUL A. SCFIOI.TEXS, M.l)., and LILY \V. LINI, Ml).
ANN ARIIOR, MiCH1G:X

H YPOTONI C duodenograph’ refers to

the technique of demonstrating duo-
denal anatomy withou t interference from
motility. This examination, described b\’
Liotta5 in 1945, and advocated by others
since then,’’3’”7’8 involves prior (luodenal
intubation, parenteral injection of an anti-
cholinergic drug to induce duodenal at-on
and visualization of the duodenum by the
delivery ofa barium suspension and air into
the tube (Fig. i). Mart-el6 has recently
called attention to the value of hvpotonic
duodenograph without i n tu bation-a tech-
nique which has been practiced at- the
University of Michigan ?sledical Center for
f *
the past i$ months. The purpose of this
report is to relate our experience with this 0’’

method in the last 50 consecutive exanu- <-

mat-ions in which it was employed. 1? ,4(
1’ E C H N I QU E

A conventional examination of the upper 11G. 1. Normal tube-type of

hvpotonic duodenograliL
gastrointestinal tract using 10-i 2 ounces of
a barium sulfate suspension is performed.
If an abnormality of the duodenunu or distended with barium to facilitate filling
of the duo(Ienum. \Ve have found it- helpful,
periduodenal area is suspected, tubeless hv-
particulanl if i’nuch of the barium has
potonic (luodenographv ma be emplo’ed.
Following visualization of the duodenum, already passed beVond the pvlorus, to ad-

30 mg. of probanthine is administered in-

nuinister dli additional 6 8 ounces at this
tinue. Fhe (luo(lenun will distend and ino-
tramuscularl’, assuming that there are n
tility will markedly (linuinish within ap-
contrai nd i cat-ions (e.g. , glau com a, cardiac
proximately 5 minutes. The patient is then
disease, prostatic hpertroph.)* and the
turned to a left posterior oblique position
patient is kept in the lateral position with
for a double-contrast view of the (luode-
the right side dependent. In some mdi-
num. Alternate shifting from the right
Vi(l1,Utls 6o mg. may be required I)ut this
lateral to the left posterior oblique position
(lose was employed in only 2 of our cases
is usually required for optimal visualization.
and was probably unnecessary in of them.
Utilizing this gravitational technique it has
C hildren requ i re proportiona tel\- sm aller
been possible to obtain both barium-filled
doses. It is important to have the stomach
and double-contrast views of the duode-
* These diseases are not abso1zte contraindications to this dos-
num, depending upon position. During the
age ofprobanthine as long as the patient is under treatment and
the drug is given with the advice of the referring physician. past year we introduced the use of Seidlitz

S Presented in an Address \V. ‘si. ) to the Central ( )hio Radioloiic Societ’ , November 4, ifS.
I’roni the I)e1artment of RadioIiit.v. ‘the t’niversitv of Nlichigan. Ann Arbor, \Iicliii.MLn.

I I ()
120 \\‘illianu ?slartel, Paul A. Scholtens and Lily W. Lim SEPTEMBER, 1969

ity and, to this tlate, the lesions were

verified histo1ogica11- in I 7 cases. The
cause of the duodenal lesion was corrob-
orated b’ 1vm phangiographV and periph-
eral h-mph node biops- in 2 additional
cases of malignant lvmphoma. In another
case in which the duodenum was felt to be
displaced b\’ an aortic aneur-sm, the latter
was verified by aortographv. There was

4 one other case of incomplete intestinal ro-

I: tat-ion
ance of
in which
the small
the roent-genologic
and large bowel
appear-
was
characteristic. ‘There were, therefore, 21

cases in which the nature of the duodenal

abnormality was clearly documented and
these are listed in Table .
A specific condition was correct-k diag-
nosed on the basis of roent-genologic exam-
mat-ion in 14 of the verified cases and, of
these, 6 were pancreatic or ampullar’ car-
cinomas. Ten patients, of whom s tinder-
went surgical exploration, had a nonspecific
roen tgenologi c diagnosis of ‘ ‘pancreatic

mass.” Tile surgical findings were those of

pancreatitis in 4 patients, 2 of whom had
pseu(locvsts. In tile fifth case, where the
11G. 2. Normal ‘ ‘tubeless” hypotonic duodenogram. descending duodenum was grossly de-
\isualization is excellent and quite coniparable to
formed, suggesting a pancreatic mass (Fig.
that in 1-igure 1.
.), the surgeon fotind a calculus in the
common bile duct and a “grossly normal
powder* dissolved in 2-3 ounces of water to pancreas.” However, the patient had a
gain better double-contrast views. This is duodenotomy i mont-h prior to the roent-
administered following the onset of hypo_ genologic examination and it is likel that
tonicity and preferably after spot roent- the (lefornuity was (lue to peniduodenal ad-
genograms of the barium-filled phase are hesions related to this operation. This was
obtained. The patient is turned to the left the only case in which there may have been
posterior oblique posi tion imme(liately after a false-positive diagnosis in a sense. To our
the Seidiitz powder is given to facilitate knowledge, there was only i false-negative
passage of the gas into the duodenum.
Spot roent-genograms are then oI)taine(l in TO;I,E I
various positions, prone an(l supine, wit-Il DUODENA I. AIINORMALIIIES IN IWENIV-ON E
and without compression, depending on tile VERIFIED CASES
site of the suspected abnormality (Fig. 2).

Carcinoma of pancreas or ampulla

RESUL’I’S Pancreatitis 5
I .vmphoma 2
‘I’went -six of the 50 cases had hypo-
Metastatic carcinoma 2
tonic duodenograms which were diagnostic II)therst 5
of a duodenal or para(luodenal abnormal-
t Includes annular pancreas, aortic aneurysm, duodenal adi-
* Seidlitz powder (Ni’ 12) contains sodium bicarbonate, potas- pose tissue and varices, incomplete intestinal rotation and non-
sium sodium tsrtrate (first part) and tartaric acid (second part). specific spasm.
\oi.. 107, No. “Tubeless” I-I ypotonic Duodenograpil\’ 121

diagnosis made in a jaundiced patient who ‘l.III.E 11

proved to have a small pancreatic carcino- iECHNIC.I. QUALIFY OF “FUIIEI.ESS’ HVIOF()N IC

ma which occlu(le(1 the common bile (bet DCOI)ENOGRAMS-50 CASES

but- was ilot a(ljacent to the duodenum

(;r(I) Quality No. of Cases Per Cent
( Case viii).
The examinations were rate(l retrospec-
I Excellent 66
tively as to qualit- as shown in Table ii. 2 Good 13 26
It is significant that approximatel\ 7c per 3 Poor 4 8
cent- were performed either by a staff menu-
ber or under his direct supervision. Of the
4 patients iii Group 3, one ha(1 a feeling of prol)anthine and this was probabl’ (tue to
faintness which interfered wit-lu the con(luct a(ljacent peritoneal irritation (Case x).
of tile examination an(l a second patient Ihe poor examination in the fourth case
ha(l a peculiar (luo(lenal loop which was was felt to be due to the examiner’s in-

difficult to project- awa\ from the ant-rum. experience with this technique.
A third patient had persistent duo(lenal
REPORI’ OF CASES
spasm despite a second o nug. (lose of
CASE I. (C.I’. No. i i 27662). A .o s-ear old
male lla(l an exploratory laparotomy for ab-
(1OFflifl5l pain at another hospital 6 weeks prior
to 1(lIlliSSi0Il and was found to have chronic
cluolecvsritis and pancreatitis. A biopsy of tlui
head of the pancreas was obtained. On tiue
tent-lu postoperative (lty, he developed fever
..
and chills, \\(lljcll persiste(1 until his aduuission
to the niversity Hospital 4 weeks later. He
also coiiuplained back
of pain uld weight loss.
Hvpoton ic duodenography revealed a large
uass in tile region of tile pancreas producing an
inlpression upon tile duodenum (Fig. 4) which

1-ic. 3. The appearance of the descending duodenum

suggests a mass in the head of the pancreas. This
constan t deforI1 i tV W as probabl v produced by
adhesions associated with earlier duodenotom v.
The common bile duct was not dilated. (Note T-
tube.) There is a duodenal diverticulum wllich is
at tile lower Illargin of the apparent impression. Fic. Case
4. I. Pancreatic abscess. There is an cx-
ilus was the only “false-positive” case in this trinsic impression producing a double contour in
series. the second and third portions of the duodenum.
 1 22 \Villiam Mart-el, Paul A. Scholtens and Lily W. Lim SEITEM1IF.11 1969

showed a mass compressing the second and

third portions of the duodenum consistent with
pancreatitis (Fig. 6, A and B).

CASE IV. (R.B. No. 1124130). A 7 year old

male was admitted to the University Hospital
for evaluation ofpurpura and epistaxis. He was
diagnosed as having leukemia with thrombo-
cytopenic purpura. Hypotonic duodenography
showed a constriction in the mid-part of the
second portion of the duodenum which was
diagnosed as annular pancreas (Fig. 7). The
diagnosis of annular pancreas was confirmed at-
subsequent necropsy.

CASE V. (B.S. No. 1130770). A 77 year old

female had pruritus andjaundice for io days, a
38 pound weight loss in 6 nuonths and epigastric
pain for I year. Hypotonic duodenography re-
veaied a lobulated mass adherent to the third
portion ofthe duodenunl with straightening and
Fic. . Case ii. Localized impression on the medial fixation of the mucosal folds (Fig. 8). The pre-
wall of the descending duodenum (arrows) prob- operative diagnosis was pancreatic carcinoma.
ably due to pancreatitis with pseudocyst. .At surgery ai inoperable adenocarcinoma of the
pancreas with extensive fixation to the retro-
was not evident on roentgenograms obtained 6 peritoneal structures was found.
weeks earlier. In view of the clinical history and
CASE VI. (D.B. No. 1130778). A 3 year old
rapid growth of the mass, the latter was felt to
male had a 3 week
history of discomfort in the
represent a pancreatic abscess. This diagnosis
upper abdomen and back, a 20 pound weight
was confirmed at surgery.
loss, nausea and jaundice. Hypotonic duoden-
CASE II. (E.R. No. 1123550). A 46 year old ography showed nuultiple small nodular iiui-

male was a chronic alcoholic who had been pressions on the duodenum with fixation and
hospitalized on numerous occasions because of distortion oft-he mucosal folds (Fig. 9, A and B).
epigastric pain with radiation to the back, The preoperative diagnosis was pancreatic car-
episodes of nausea and vomiting and, more cinoma which was confirmed at surgery. The
recently, a 20 pound weight loss. Hypotonic tumor was inoperable.
duodenography revealed a mass in the head of
the pancreas, causing an arcuate impression CASE VII. (F.M. No. i i i 1742). A 42 year old
upon the second portion of the duodenum (Fig. male with diabetes mellitus complained of
). There was no change in this appearance 3 epigastric pain which radiated to the back,
months later. Although the roentgenobogic anorexia and weight loss. jaundice developed i
week prior to admission. A conventional gastro-
diagnosis was that of a nonspecific mass, in
view of the chronic history, lack of change over in test-ma! examination suggested the possibility
of a pancreatic abnormality (Fig. io). Hy-
3 months and failure to develop jaundice de-
spite the lesion’s location, the diagnosis of potonic duodenography confirmed the presence
pancreatitis with pseudocyst was favored. of a mass involving the medial wall of the de-
scending duodenum (Fig. ii, A and B); the
CASE III. (A.M. No. i 121669). A io year old mucosal folds at the junction of the second and
girl complained epigastric pain of and had a third portions appeared straightened and pos-
serum aniylase of 528. She had had intermit- sibly fixed, but this was evident largely in the
tent epigastric pain since the age 013 years and prone position (Fig. 12, /1 and B). The roent-
a pseudocyst of the pancreas was found at. genologic diagnosis was carcinoma of the pan-
surgery at the age of 5 years. Hypotonic duo- creas with invasion of the duodenal wall. At
denography during the present hospitalization surgery, he was found to have an adenocar-
\OL. 107, No. i “Tubeless’’ H \pot-onic I)uodenographv 1 2

lic. 6. Case III. (1) Anteroposterior view, barium-filled phase. (B) Left posterior oblique view with double-
contrast pilase after Seidliti. powders. There is an extrinsic impression on the second and tllird portions of
the duodenuni (arrows) in a child known to have pancreatitis.

11G. 13. Case V. Pancreatic carcinoma. The superior

aspect of the tilird portion of the duodenum is
Iic. T. Case iv. Annular pancreas. A characteristic encroaciled ution by a nodular fllS5 (arrows)
ileformitv with intact mucosal folds is Present in vhkIh has caused fixation and stretching of the
the mid-descending duodenum. Note the duodenal flluCOStl folds.
diverticula.
124 \Villiam \Iartel, Paul A. Scholtens and Lily W. Lim 5E1’TEMBER, 1969

k #{149}.
.-‘

11G. 9. Case vi. Pancreatic carcinoma. (A) Posteroanterior view, barium-filled phase. (B) Anteroposterior
view, double-contrast phase. Multiple small nodular impressions are evident on the medial wall of the de-
scending duodenum. The mucosal folds are fixed, stretched and distorted.

cilloilla of tile ilead of the pancreas with gross

iilV1sD)Il of the mid-descending duodenum
( Fig. 13). ‘I’he tuiluor involved the uncinate
process and extended toward the base of the
small-bowel mesentery and the adjacent second
and third portions of the duodenum.

C:’iSE VIII. (F.H. No. 1131253). A 40 year

oki fenlale hid epigastric and right upper

quadraflt p1ifl for 3 nlonths and developed

jaundice I week prior to hospitalization. Oral
cllolecystograpily sllOWed 11011 V1SU alization of
the gallbladder and exploratory laparotonly at
another ilospital was said to Ilave revealed a
‘‘ leillon-sized” Illass in tile Ilead of tile 1l-
creas. Cholecvstoj ej U nostonl y was performed
aild the patient was referred to the University
of Michigan Iedical Center, where hypotonic
duodenography disclosed n evidence of a
pancreatic niass (Fig. 14, ‘1 and B). Pancreatic
arteriography, however, showed occlusion of
the posterior pallcreatic arcade and “encase-

lic. 10. Case vii. Pancreatic carcinoma. A con-

ment” of the gastroduodenal artery. At sur-
vefltioflal exalflillatiOn of the duodenum shows
gery, all adenocarcinonia, nleasuring I .8 cnu. ill
snlall nodular impressions (arrows) ith distortion diameter, was present in the superior part- of
and straightening of the adjacent mucosal folds. the head of the pancreas. The tumor occluded
 f -

11G. 1 I . Case viI. Hvpotonic duodenograpllv. Spot roentgenograms of the descending duo(lenunl, (‘I) with-
out compression, and (B) with compression. Fhe small defects in ligure io are not as conspicuous after
induction of hypotonia. This is due to duodenal over(listention and obscuration by tile barium. However,
conlpression discloses a nodular mass invading the mid-descending duodenum. Note tile compression device
in B.

_____

tic. 12. Case vii. Hypotonicduodenography. (A) Anteroposterior view. (B) Posteroanterio)r view. The
mucosal folds on the medial and superior aspects of the second and third portions of the duodenum, re-
spectively,appear blurred and slightly straightened in B but not in l and the large defect in tile descending
duodenum shown in Figure i i B is also more apparent in B. This difference may be due to tile eflect of the
patient’s Position on the relationship between the iancreas and duodenLilil and tile distribution of the
barium. Also, a certain amount of “natural compression” of the anterior abdomen ma be expected in the
prone position and this was probably a factor in this case. Multiple projections, with and Witilout compres-
sion, with barium-filling and witll double-contrast technique may be required to adequately evaluate a
suspected lesion.
126 William Mart-el, Paul A. Scholtens and Lily W. Lim SEPTEMBER, 1969

CASE IX. (H.L. No. 1127603). A nlale

alcoholic developed jaundice and vomiting 1

week prior to hospitalization. Physical exam ma-

tion revealed peripheral edema and ascites.

1. pper gastroi 11 testi n al exani i 11 ation disclosed
esophageal and gastric varices. Hypotonic
duodenography showed illultiple irregular fill-
ing defects on the Illedial wail of the descend-
ing duodenunu (Fig. ii). The possibility of
duodenal varices was raised, but pancreatic
carcinonla could IlOt be excluded. Pancreatic
arteriography showed “encasenlent of sIllall
pancreatic arteries” which suggested diag-
tile
I1OS1S of carcinoma of the pancreas. In addition,
the cystic artery was displaced indicating gall-
bladder enlargement. patient’s
The condition
lic. 13. Case vii. Horizontal section through the deteriorated and at necropsy the diagnosis of
head of the pancreas and mid-descending (100- advanced cirrhosis was contirllled. There were
denum showing submucosai invasion of the (100- esophageal and gastric varices. Gross exanlina-
denum by carcinoma. This is the lesion depicted in tion of the duodenum showed no evidence of
ligure IIB. The tumor also extended toward the varices, but the nlucosa of tile illedial aspect of
second and third portions of the duodenum which
the descending segment was redundant and
probably accounts for the appearance in Figure fornled slack folds. Microscopic examination of
12B. this region disclosed large collapsed submucosal
the common bile duct but was not contiguous veills with slightly thickened walls, and in ad-
with the duodenum and there were no nletas- dition, there were unusually extensive sub-
t ases. mucosal deposits of adipose tissue. The pan-

Fic. 14. Case VIII. False-negative hypotonic duodenogram. (il) Barium-filled phase. (B) I)ouble-contrast
view. A small carcinoma was present in the superior portion of the head of the pancreas but was not ad-
jacent to the duodenum. Note the compression device in both figures, the barium-filled gallbladder sec-
ondary to earlier cholecystojejunostomy and the undisplaced duodenal diverticulum.
\OL. 107, No. “Tubeless” H-potonic Duodenographv 127

creas appeared grossly normal but microscopic with nunerous tiny peritoneal no)dules wilicil on
examination showed focal acute and chronic illicroscopic exanlination proved to be foreign
pancreatitis. In retrospect it was felt that the body granulonias due to starcll granules. Nlallv
roen tgenobogic appearance of the duodenu Dl of these were in the vicinity of the duodenunl
was due to ullusual submucosal deposits of and, inasmuch as there was no illechanical oh-
adipose tissue and, possibly, to duodenal struction of tile latter, the spasm was judged
varices as well. to be Secondary to tile adjacent inflailunlation.
It was felt that tile starch granules were derived
CASE X. (C.H. No. 1093938). A year old fronl tile surgeon’s gloves at the previous
male had had an exploratory laparotomy for laparotoilly. A gastrointestinal exanlination 3
ulleXplaiIled hematemesis. He developed nausea weeks later showed the duode000l to be nor-
and vomiting i week after surgery. A conven- Ill ill.
tiOll al gastroin testi 11al exan i 11 at-ion revealed
extreille 5SIl1 of the duodenuill, wilich was CASE XI. (H.S. No. 1110153). A 7 year old
unrelieved after two 30 111g. doses of proban- illale complained of epigastric pain and a 20
thine given intranluscularly I 5 ulinutes apart. POLl 11db weight loss. Roen tgenologic exam in ation
The appearance of the duodenum suggested disclosed a carcinoma of the proxinlal stoIllacil
nonspecific spasill (Fig. i6, 1 and B), but an aIld, ill additioiu, there was a suggestion of a
organic lesion could not be excluded. At stir- distal duodenal abnornlality. Hypotonic duo-
gery there was diffuse peritonitis associated denography confirmed a retroperitoneal nlass
conlpressing the superior aspect of the distal
duodenunu and this was interpreted as nletas-
tasis to the lyfllpil nodes at the base of the small
bowel mesentery (Fig. 17). This impression was
confirmed at laparotomy and extensive pen-
toneal and retroperitoneal lymph node involve-
ment was found.

DISCUSSION

“Tubeless’ ‘ hvpotonic duodenography

represents a desirable simplification of the
“tube-method” previously utilized in that
it minimizes patient discomfort by avoiding
unnecessary intubation and yet, for prac-
tical purposes, is capable of displaying
duodenal anatomy wi th comparable clarity
and precision. Futhermore, this method
may be employed at the conclusion of a
conven tional upper gastroin test-i nal exam-
mat-ion and return visits to the X-ray
department for “special examinations” of
the duodenum can usually be obviated.
Now that most- radiolog\- departments are
equipped with rapid processing, roen tgeno-
grams may be examined before the patient
leaves the department and the decision may
then be made whether to proceed wit-h the
Fic. i5. Case ix. Multiple filling defects in the hvpotonic method. The time spent- by the
medial portion of the descending duodenum in a radiologist in evaluating the duodenum is
case of cirrhosis. This was probably due to an
minimized, although even the tubeless
unusual degree of submucosal fatty infiltration
and possibly to duodenal varices, both of which method requires additional effort. We have
were found at necropsy. Varices were documented been very selective in the cases chosen for
in the esophagus and proximal stomach as well. this examination and it is for this reason
1 28 \Villiam i\Iartel, Paul A. Scholtens and Lily W. Lim SEITEMBER, 1969

11G. i6. Case x. Nonspecific duodenal spasm. (A) After 30 mg. of probanthine. (B) Fifteen minutes later,
following an additional 30 mg. dose. The roentgenologic diagnosis was spasm but an organic lesion could not
be excluded. This was rated as a “poor examination” (Group 3).

that over 50 per cent of our patients had

significant abnormalities. It is conceivable
that intubation may prove necessary in
some cases of marked duodenal redundancy
or those in whom a suspected lesion is
obscured by the barium-filled stomach, but
this will probably rarely be necessary and
was considered as possibly desirable in only
I case early in our experience.
We have found 30 mg. probanthine given
intramuscularly to be a suthcient dose in
adults. Others have used 6o mg. routinely,
intramuscularly or intravenously, and it- is
perhaps for this reason that we have had
few side-reactions. The possibility that hi-
potension or urinari retention may be in-

Fic. 17. Case xi. Metastasis to retropenitoneal

lymph nodes from gastric carcinoma producing
distortion of the superior aspect of the distal
duodenum. Note the irregularity of the mucosal
folds which appear thickened and fixed. A com-
pression device is evident.
VOL. 107, No. “Tubeless” Hypotonic Duodenography I 19

duced suggest-s that- caution be exercised emphasized that roent-genograms which dis-
with nonhospitalized patients. Such pa- play the detailed morphology of a lesion
tients should be accompanied by another will frequently permit a specific diagnosis.
adult when undergoing this examination. The possibility of pancreatic carcinoma
Drugs other than probanthine have been cannot be excluded in a patient with a mass
tried by other investigators2’3 but we have in the head of the pancreas which causes a
found this drug quite satisfactory and its large arcuate impression upon the duode-
undesirable side-reactions are minimal corn- num. Pancreatit-is often co-exists with car-
pared to at-ropine. cinoma and may be responsible for much
Although hypotonic duodenography pro- of the pancreatic enlargement-, and cyst--
vides better visualization of morbid anat- adenocarcinoma characteristically produces
orny, it is conceivable that- it may also a large indention and displacement of the
obscure sigrnficant changes in duodenal mo- duodenum. However, the demonstration of
tility. Such functional disturbances could multiple, small, irregular nodular indent-a-
be a consequence of an adjacent pathologic tions in association with focal fixation and
process, for example. It is important that distortion of the duodenal mucosal folds
this possibility be recognized and that in- clearly indicates the diagnosis of a malig-
formation gained from the conventional nant neoplasm and this usually proves to be
examination be integrated into the total pancreatic carcinoma. Ampullary carcino-
roentgenologic evaluation. An additional mas which have infiltrated the paraduode-
possible limitation of this technique relates nal region may produce a similar appear-
to the positioning of the patient. A minimal ance. Slight straightening and even dis..
lesion may be indentifiable in some po- tortion of the mucosal folds may occasion-
sitions better than in others and inasmuch ally be observed in pancreatitis but in our
as the gravitational technique of “tubeless” experience this is much more likely to be
hypotonic duodenography relies to some seen in malignant neoplasms, particularly
extent on the position of the patient, this when it is associated with multiple, small
could theoretically prove to be a problem. nodular impressions. Some may question
To date we have not found this to be a the value of refinement in the technique of
significant detriment to the detection of hypotonic duodenography in view of the
minimal lesions and it has been possible to poor survival of patients with pancreatic
obtain adequate spot roent-genograms in carcinoma. It is true that a patient who has
multiple projections. Finally, the use of a a pancreatic carcinoma impinging upon the
hypotonic agent precludes the complete duodenum is not likely to survive and one
examination of the small intestine. We have who has a “false-negative” duodenogram
occasionally been able to confirm our im- is more likely to be cured by surgery. How-
pression of a retroperitoneal malignant neo- ever, earlier detection of these lesions may
plasm by demonstrating metastatic tumor improve the surgical cure rate and, further-
nodules in the wall of the mesenteric small more, it is often important for the radiol-
bowel in conventional gastrointestinal cx- ogist to be able to state that a neoplasm
aminations. It should be emphasized that has not been detected. Such a negative
the jejunum can still be evaluated to some result will have more significance with a
extent after probanthine administration hypotonic duodenogram than with the con-
but a complete study of the small intestine ventional method of examination.
will probably not be possible as part- of the The hypotonic method of examining the
same roentgenologic examination. How- gastrointestinal tract need not be limited
ever, this represents a small sacrifice for the to the duodenum. One may employ it suc-
advantage of carefully documenting a sus- cessfully in patients wit-h extreme hyper-
pected duodenal lesion. tonicity of the colon and in other intestinal
Our results with this technique have problems (e.g., the differentiation of colonic
130 William Mart-el, Paul A. Scholtens and Lily W. Lim SEPTEMBEk, 1969

carcinoma from divert-iculitis, and of ter- providing optimal delineation of duodenal

minal ileitis from ileocolic spasm). How- pathology with regularity and ease.
ever, inasmuch as anticholinergic drugs The possible limitations of this technique
have a lesser effect in the caudal portions of and our experience wit-h the last 50 cases in
the intestinal tract-, it will probably be which it was employed are discussed.
advisable to use a smooth muscle relaxant
such as papaverine in dealing wit-h the William Martel, M.D.
Department of Radiology
ileum and colon.
University Hospital
In considering the real value of this tech- Ann Arbor, Michigan 48104
nique, the fact that duodenal lesions are
frequently demonstrated par excellence RE FERENCES
without- the use of a hypotonic agent should
I. B1LBAO, M. K., FRISCHE, L. H., DOTTER, C. T.,
not be overlooked. This is particularly true and R#{246}SCH, J. Hypotonic duodenography.
in re-examinations where the initial study Radiology, 1967, 89, 438443.
has already indicated the site of the ab- 2. GRivAux, M., CORNET, A., and WATTEZ, E.
normality. Furthermore, it is rare that the Metocolpramide in digestive radiology. Semaine
hop. Paris, 1964, 40, 2338-2345.
hypot-onic method will show a lesion that
3. JACQUEMET, P., LiorrA, D., and MALLET-GUY,
one cannot suspect on a conventional ex- P. Early Radiological Diagnosis of Diseases o
amination. What then is the advantage of the Pancreas and Ampulla of Vater: Elective
hypot-onic duodenography ? Essentially, it Exploration of the Ampulla of Vater and the
permits the most optimal visualization of Head of the Pancreas by Hypotonic Duodenog-
raphy. Charles C Thomas, Publisher, Spring-
duodenal detail with considerable consis-
field, Ill.,
1965.
tency and less effort on the part of the 4. JACQUEMET, P. Early diagnosis of pancreatic and
radiologist-. However, finding the lesion is vaterian tumors by hypotonic duodenography.
one thing and interpreting its nature is :‘. de radiol., d’#{233}lecirol.et de med. nucl#{233}aire, 1966,
another. The latter will still require ex- 47, 264-266.
5. LiorrA, D. Pour le diagnostic des tumeurs du
perience, knowledge and good roentgeno-
pancreas: la duod#{233}nographie hypotonique.
logic judgement. Lyon chir., 1955, 50, 445-460.
6. MAR.TEL, W. Hypotonic duodenography without
SUMMARY
intubation. Radiology, 1968, 9!, 387.
The technique of “tubeless” hypot-onic 7. RAIA, S., and KREEL, L. Gas-distention, double-
contrast duodenography using Scott-Harden
duodenography is a desirable simplification
gastroduodenal tube. Gut, 1966, 7, 420-424.
of the “tube-method” and is a worthwhile 8. R#{246}SCH, J. Roentgenology of the Spleen and Pan-
adjunct to the conventional gastrointes- creas. Charles C Thomas, Publisher, Spring-
tinal examination. It-s chief value lies in field, Ill., 1967.