Evaluation of a radiographer provided barium enema service
The evaluation of a radiographer provided barium enema service
RL Law*, DR Titcomb, Helen Carter*, AJ Longstaff* Nicky Slack*, AR Dixon
Depts. Radiology* & Colorectal Surgery, Frenchay Hospital, North Bristol NHS Trust, Bristol
Dept Radiology* & Colorectal Surgery
Frenchay Hospital, North Bristol NHS Trust, Bristol, UK, BS16
Correspondence to Mr AR Dixon
Aims. Radiographers performed & reported 5516 Double Contrast Barium Enemas (RDCBEs) over 4yrs to Oct. 2001. This study was undertaken to assess accuracy of RDCBE and sensitivity for diagnosing colorectal cancer (CRC).
Methods 224 consecutive outpatient RDCBEs were reported; normal (C1), diverticulosis (C2), diverticulosis with filling defect (C3), diverticulosis & other pathology (C4) and abnormal (C5). RDCBEs were then reported by a radiologist (AL, NS) and the two reports compared. Of 450 CRCs, 153 had undergone DCBE; 152 RDCBEs. Reports were analysed to establish concurrence between radiographer and radiologist and final CRC diagnosis.
Results by category; C1–37%, C2–31%: C3–21%: C4–11%, C5 –0%. C4s included polyps (50%), cancer (12.5%), disrupted anastomosis (8%) and colitis (4%). There was no discrepancy between RDCBE and radiologist reports. Radiology and CRC diagnosis agreed in 145 of 152 DCBEs. There were three exclusions: DCBEs occurred outside the study period (2), 1 only raised the possibility of malignancy. Of 8 remaining RDCBEs, 7 were false negatives and one false positive. Sensitivity for RDCBE was 95.5%. Double reporting by a radiologist did not improve sensitivity.
Conclusion RDCBEs are as accurate as those performed by radiologists and have a very high sensitivity for CRC. In a time of ever increasing demands for complex staging investigations for CRC and interventional radiology the ACPGBI needs to reconsider its guidelines on radiographers not only performing but reporting DCBE.
Key words: Radiographer provided, double contrast barium enema, sensitivity, colorectal cancer guidelines
In their 2001 guidelines1 for investigating of patients with presumed colorectal cancer the ACPGBI state that barium enemas should be double contrast, double read by a consultant radiologist and that the performing radiographers should work to agreed protocols and be specially trained.
Radiographers have been performing double contrast barium enemas in our trust since 1986. Originally there was a single radiographer (RL), however by 1996, three radiographers were undertaking all routine barium enemas; 5516 RDCBEs were performed over the 4-years up to January 2002. In our 19992 retrospective study, we confirmed a very high pathological detection rates for radiographer performed DCBE. As part of ongoing audits within our multidisciplinary team, we decided to undertake a prospective study to audit the accuracy of RDCBEs in addition to their sensitivity for diagnosing colorectal cancer.
A prospective study was undertaken to assess the feasibility and accuracy of radiographers performing and reporting these examinations. Over a two-month period 224 consecutive RDCBEs were analysed. Inpatient examinations were excluded as all positive results were discussed with a radiologist. All 224 patients were sent a standard bowel-cleansing agent and all RDCBEs were double contrast. Investigations were carried out in standard fashion by one of three radiographers working to agreed protocols. This included the use of manual abdominal palpation and the taking of extra views as considered necessary. On completion of the examination, the films were then reported by the performing radiographer and placed in one of five categories: normal (C1), diverticulosis (C2), diverticulosis with filling defect (C3), diverticulosis and another pathology (C4) and abnormal pathology (C5). Each RDCBE was then given blind to one of two radiologists for formal reporting using the same matrix. The two reports were then compared (DT & ARD) and a final report issued.
During the 4year period to January 2001, 450 consecutive people with newly diagnosed colorectal cancer (CRC) were entered into our electronic database. Cross-reference with the radiology database identified 157 patients who had undergone DCBE; 156 RDCBE. The reports were analysed and compared with the final CRC database (site of cancer, final histology). Results were classified as either concurring, false positive or false negative. The diagnostic sensitivity was calculated and compared with published data.
Both radiographer and radiologist considered 37% of RDCBEs as being normal. Further analysis by diagnostic category comprised: C2–31%: C3–21%: C4–11%. No RDCBEs were reported as being “only abnormal” or C5. Category C4 diagnoses included polyps (14), carcinomas (3), anastomotic disruption (2), lymphonodular hyperplasia (2), diverticular stricture (1), lipoma of the ileo-caecal valve (1), ulcerative colitis (1), coincidental renal calculi and cholelithiasis (1).
There was 100% correlation between the grouping of the diagnostic categories by both radiographer and consultant radiologist. The only differences in the format of the reports comprised grammar and vocabulary.
For the second part of the study, 156 RDCBE reports were analysed. There was concurrence in 145 cases between RDCBE report and our CRC database (anatomical site, histopathology) i.e., a 94.5% sensitivity for diagnosing CRC. Three reports were discounted; two (both reported as cancer) were performed outside the study period and one because the report was only “highly suggestive” of malignancy. There were seven false negatives and one false positive.
FALSE NEGATIVES: two reports diagnosed sigmoid diverticulosis. One developed a small malignant rectal polyp 27 months after the RDCBE. The other patient underwent a colonoscopy for continuing symptoms four months later and was found to have a carcinoma of the rectosigmoid. Two further RDCBEs identified solitary polyps; one was described as “appearing malignant”. In the first patient a colonoscopy identified a synchronous malignant polyp. The other patient underwent a right hemicolectomy and on follow up at 6 months was found to have a synchronous carcinoma of the rectosigmoid junction. Continued follow up of a patient who had had a normal DCBE demonstrated a carcinoma at the level of the anal sphincters. In a further case a large amount of faecal residue, prompted a report suggesting the need for a repeat DCBE; colonoscopy demonstrating a large malignant sigmoid polyp. The final report was “suspicious of a narrowing” in the ascending colon and “suggested a limited repeat examination”. This again proved inconclusive and a subsequent colonoscopy diagnosed a carcinoma. If RDCBE were combined with rigid sigmoidoscopy and rectal examination the sensitivity for cancer would rise to 96.5%.
FALSE POSITIVES: this one report suggested a “plaque like lesion in the rectum”. Colonoscopy diagnosed ulcerative colitis.
The demands on radiological time continue to increase as the number and complexity of radiological investigations for staging and interventional therapy expands faster than the number of consultant radiologists. In order to accommodate the drive for straight to test for suspect CRC patients new approaches are required. The ACPGBI guidelines1 demand that all radiographer performed DCBEs are double-read and that one reporter be a consultant radiologist. We believe that this may be an unnecessary use of an already overstretched resource.
We have shown that within our trusts gastrointestinal radiology department, appropriately trained radiographers adhering to agreed protocols are not only very good at performing independent DCBEs, but are also able to report them in a timely, accurate and unambiguous fashion. We have also shown that there is no improvement in overall diagnostic yield when consultant radiologist’s double read these RDCBEs. More importantly, we have also shown that radiographer performed DCBEs is a sensitive (94.5%) diagnostic tool in the detection of colorectal malignancy. In these times of financial strife it is also an efficient use of highly skilled and motivated staff. Similar sensitivities for CRC detection have been described; 82.9% - 94.4 %2-6. In light of these studies, our radiographers now issue final reports and have expanded the service to include small bowel enemas, defecating proctograms and all fluoroscopy.
Whilst recognising that the standard of radiography services is variable throughout the country, we believe that as radiological services evolve within the setting of addressing the need to meet national cancer and waiting time targets, then there should be more flexibility within the guidelines to allow trusts to offer greater efficiency within their radiology departments. To embrace role development and attain the ability to provide independent practice requires on the part of the radiographer, acceptance of all the responsibilities attached to the developed clinical role. If radiographers are to achieve any degree of autonomy they need to seek out areas of poor service delivery and patient management and demonstrate how, with role extension that it can be improved. Service delivery and patient outcomes must be as good, or better, when provided by a radiographer in order for a radiologist to feel comfortable in developing responsibility. The Department of Health7 has acknowledged the skills and competencies of allied healthcare professionals and encouraged them to extend their roles to fulfil local needs. That said there is no nationally accepted training programme for radiographers to progress to consultant status.
This study concurs with ACPGBI guidelines1 in ensuring ways for increasing the sensitivity of DCBE for the diagnosis of CRC. As our results indicate, rectosigmoid and anal tumours can be missed on DCBE. All examinations should be performed in conjunction with sigmoidoscopy, either flexible or rigid. Difficulties arise when patients are referred for open access DCBE without previously undergoing sigmoidoscopy. In these cases, clinical history should override a normal report. Our findings also highlight the potential problems of sending patients direct to test in order to meet the cancer targets8, particularly as more than 17% of patients with normal examinations are re-referred by their GP within 6months. The large Wessex audit.4 made comment on the diagnostic accuracy of DCBE in the presence of marked sigmoid diverticulosis. Our study also highlights the problem of synchronous carcinomas; colonoscopy identifying two cancers missed in the presence of this dual pathology. Barillari9 found colonoscopy to be more sensitive in the diagnosis of synchronous tumours than initial DCBE; however they do allow for the fact that the standard of these investigations may vary.
Finally, cost analysis studies have shown that radiographers performing barium enemas not only liberates radiologist time; working out at 25% cheaper, it is also a cost-effective method of providing an out-patient barium enema service10.
1 The Association of Coloproctology of Great Britain and Ireland. Guidelines for the management of Colorectal Cancer. 2001
2 Law RL, Longstaff AJ, Slack N. A retrospective 5-year study on the accuracy of the barium enema examination performed by radiographers. Clinical Radiology 1999; 50: 80-84
3 Rex DK, Rahmani EY, Haseman JH, et al. Relative sensitivity of colonoscopy and barium enema for the detection of colorectal cancer in clinical practice. Gastroenterology 1997;112 : 17- 23.
4 Thomas RD, Fairhurst JJ, Frost RA. Wessex regional audit: Barium enema in colorectal cancer. Clinical Radiology 1995; 50: 647-650
5 Brady AP, Stevenson GW. Colorectal cancer overlooked at barium enema examination and colonoscopy; a continual perceptual problem. Radiology 1994; 192: 373-378.
6 Culpan DG, Mitchell AJ, Hughes S, Nutman M, Chapman AH. Double contrast barium enema sensitivity: a comparison of studies and radiographers. Clin.Radiol. 2002; 57: 604-7.
7 Department of Health 2000. Meeting the Challenge: A stratergy for the allied health professionals.
8 Clancy DG, Card M, Sylvester PA, Thomas MG, Durdey P, Calloway M, Virgee J. Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer. Colorectal Dis. 2005 May; 7: 241-4.
9 Barillari P, Rammacciato G, De Angelis R et al. Effect of preoperative colonoscopy on the incidence of synchronous and metachronous neoplasms. Acta.Chir.Scand 1990; 156: 163-166
10 Brown L, Desai S. Cost-effectiveness of barium enemas performed by radiographers. Cli.Radiol. 2002; 57: 129-31.