Postgraduate Medical Journal (January 1970) 46, 44-51.

The radiology of small bowel lesions

OSCAR CRAIGF.R.C.S.I., D.M.R.D., F.F.R.

Consultant Radiologist, St Mary's Hospital, London, W.2;and Bolingbroke Hospital, London, S. W. 11

SummaryThe techniques of radiological examination of thesmall bowel are considered.The importance of the routine barium meal and

follow-through examination is stressed.The vast majority of lesions present a diagnostic

problem in interpretation rather than in detection.Some examples of small bowel pathology are

discussed and the need for interpretation in the lightof the clinical picture is emphasized.

Important radiological signs to be appreciated areconsidered. /

IntroductionPlain-film examination of the abdomen plays a

very useful role in the investigation of small bowellesions. Numerous contrast examinations are avail-able to assist in the diagnosis of small bowelpathology:

(1) Barium meal and follow-through examina-tion.

(2) Hypotonic duodenography.(3) Small bowel enema.(4) Barium enema with reflux into the terminal

ileum.(5) Angiography.(6) Lymphangiography.

Vascular lesions may be demonstrated by angio-graphy. In some cases of protein-losing enteropathy,lymphangiography may assist in the diagnosis ofintestinal lymphangiectasis. These specialized pro-cedures and the plain film changes will not be con-sidered in this paper which will emphasize the radio-logical findings on barium examination.

Hypotonic duodenographyThis was described by Mallet-Guy & Jacquemet

in 1963. Raia & Kreel described their techniqueusing the Scott-Harden tube in 1966. This double-lumen tube is passed into the stomach, and the innertube manipulated into the second part of theduodenum. Four milligrams of oxyphenonium(Antrenyl) are given intravenously. Xylocain (2 mlof 4% solution diluted to 10 ml) is injected into the

second part of the duodenum, after which barium isintroduced. Three minutes after the intravenousinjection of oxyphenonium the duodenal loop canbe seen to become flaccid and immobile. This isassisted by the local application of xylocaine. Aforced oxygen insufflation of the loop is thenperformed and spot films taken. It is hoped by thisprocedure to demonstrate minor distortions of theduodenal mucosa, lesions of the head of the pancreas,and papilla of Vater. Since the description of thistechnique, modifications have been made. Manyauthorities feel that it is adequate to produce duo-denal relaxation with oxyphenonium and manipu-late gastric air into the duodenum along with thebarium taken conventionally during a barium mealexamination. Supine spot films of the duodenal loopare then taken.

Small bowel enemaThis was suggested by Schatzki in 1943. Scott-

Harden in 1960 described his technique using thedouble-lumen tube. Having passed the tube into thestomach and the inner tube as far as possible alongthe duodenal loop, 20-30 ml of non-flocculatingbarium diluted with water to 60-90 ml are injected.This is followed by i-1 pint of water, to which asmall teaspoonful of magnesium sulphate has beenadded. The whole small bowel should be outlinedwithin 10-15 min of the start of the injection. Thebarium passes to the caecum but leaves behind smallbowel outlined by mucosal adhesion. There is thus adouble contrast examination and the tendency forloops to obscure each other is reduced. This tech-nique gives good results in the jejunum and proximalileum, but frequently fails to give good visualizationof the terminal ileum. To improve this, Trickey,Halls & Hodgson (1963) described the use of a0-75% solution of prepacol, as the 'flushing' agent,following the introduction of barium.Whereas this technique may supplement the

routine barium meal and follow-through, it has neverbeen suggested that it should replace it. In theexamination of patients suspected of having a smallbowel lesion, it is only rarely that the difficulty lies

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Radiology of small bowel lesions

in demonstrating the lesion. This may certainly be so,in some cases of small benign tumours, angioma andcarcinoid tumours, but in the vast majority thedifficulty lies in the correct interpretation ofabnormalfindings. These abnormal findings can usually bereadily demonstrated by the routine barium meal andfollow-through examination, and the conditionsdescribed in this paper have been examined by thismethod.

TechniqueThe patient takes the barium orally, and an

examination of the oesophagus, stomach andduodenum are performed in the routine manner.Four to 8 oz of barium are given according to thepresenting problem. Films of the bowel can be takenroutinely, at 2, 4, 6 and 24 hr, but this timing can bemodified. Earlier or more frequent films may berequired. Maxolon 10 mg orally 15-20 min beforethe examination produces 'intestinal hurry' andenables visualization of the small bowel to theterminal ileum within 1-2 hr. This can be of greatadvantage where the time factor is important to theradiologist. However, where disorders of motilityare likely, no bowel stimulants should be given.

In cases where the malabsorption syndrome islikely then a non-flocculable barium, e.g. Raybar,should be used. Where a dissacharidase deficiency ispossible, 20 g of lactose should be added to thebarium mixture. Some authorities think that lactoseshould be added in all cases for its screening value inthis respect.

Spot compression films of the terminal ileumshould be taken as a large number of small bowellesions involve this area. When doubt arises aboutthe terminal ileum in the conventional follow-through examination, this area can also be visualizedby a barium enema, efforts being made to producereflux into the terminal ileum.No attempt will be made to cover all the possible

lesions of the small bowel, which is beyond the scopeof this paper. Selected conditions will be considered,and although some are rare, they are amongst thosethat it is one's daily task to either search for orexclude in routine examinations.

Duodenal carcinomaIn routine barium meal examinations, the whole

of the duodenal loop should be examined. It ispossible for the fourth part of the loop to be hiddenbehind the stomach, and in these cases, to visualizethis area it is necessary to take a film with thepatient prone, lying on a compression pad. This willdisplace the stomach upwards, uncovering thefourth part of the duodenum and the duodeno-jejunal flexure. Carcinoma of the duodenum is saidto be rare, but Jefferson (1916) remarked that inch

for inch the duodenum is more likely to undergocancerous change than the jejunum or ileum. Bockus(1964) states that carcinoma of the duodenum makesup 3%/ of all intestinal carcinomas. In a series oftwenty-two malignant lesions of the duodenum,Serrano & McPeak (1966) reported that a pre-operative diagnosis was only made in nine. Hoffman& Pack (1937) reported six cases of infra-ampullaryduodenal neoplasms, none of which was diagnosedby experienced radiologists. Kreel & Mackintoshreported four cases of duodenal carcinoma in Gut in1968 and eight cases were recorded in the BritishJournal of Surgery (Craig, 1969). One of these caseswas a 78-year-old man with a history suggestive ofhiatus hernia. The patient complained of regurgita-tion of bilious fluid with lower retrosteral discom-fort worse in bed and on stooping. There were norelevant physical findings but there was a weaklypositive occult blood in the faeces. On examination,no hiatus hernia was seen, but there was gastro-oesophageal reflux. Examination of the duodenalloop revealed a stricture in the descending limb,diagnosed as carcinoma, and confirmed at opera-tion. A further case in a female aged 70 presentedwith a history of two attacks of vomiting but noabdominal pain. A neoplasm was found in thefourth part of the duodenum lying behind thestomach. In yet another case the lesion lay behindthe stomach and was only found in the third bariumexamination. These cases illustrate the need for ahigh index of suspicion with regard to duodenalneoplasms on the part of the radiologist and hisclinical colleagues and the necessity of a completevisualization of the duodenal loop in the routinebarium examination.

Duodenal ileusObstruction of the duodenum due to compression

by the superior mesenteric artery is considered bymost physicians to be very rare. von Rokitansky firstsuggested this condition as a pathological entity in1849. The following case was of interest as a diag-nostic problem. The patient was a young woman of23 who complained of epigastric fullness andvomiting after meals. No abnormality was found onclinical examination. There were no abnormalbiochemical findings and the barium meal wasnegative. During the next year the vomiting increasedand there was a loss of 21 stones in weight. A repeatbarium meal was performed during an attack andthis showed an alteration in calibre in the third partof the duodenum with marked reversed peristalsis.There was a linear constriction where the superiormesenteric artery crossed the duodenum, not seen atthe previous examination, and there was slight hold-up of barium proximal to this area. The patient wasexamined prone and the barium passed satisfactorily

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through this area. The examination was repeatedwith bread soaked in barium and similar findingswere reported.At laparotomy, the superior mesenteric artery

formed a tight band across the third part of theduodenum and the findings confirmed the radio-logical diagnosis of duodenal ileus.Although this condition is rare in the experience of

most clinicians, Bockus (1964) stated that he saw sixcases of distal duodenal obstruction annually, ofwhich 50% were due to vascular obstruction.

It is important for both radiologists and cliniciansto appreciate that in this condition there is inter-mittent delay in the passage of duodenal contentsand that when an initial barium examination isnegative, the meal should be repeated during anattack.

Disaccharidase deficiencyPatients with this complaint present with vague

abdominal pain, flatulence and diarrhoea. Lactasedeficiency is the most common cause for this anddeficiency of maltase and sucrase are very rareindeed. To test for hypolactasia 20 g of lactose areadded to the barium mixture and the patient lies onthe right side for 1 hr. An abdominal film is thentaken with the patient supine. If there is a lactasedeficiency, the following changes are seen:

(1) Intestinal hurry-the barium mixture will bewell along the colon by 1 hr.

(2) The whole of the small bowel and part of thelarge bowel are filled with very dilutedbarium, as water is 'attracted' into the bowellumen.

Malabsorption syndrome (Fig. 1)The radiological changes are in the vast majority

of cases non-specific and consist of flocculation ofbarium, a disordered mucosal pattern, and altera-tions in calibre of the small bowel. Raybar, a non-flocculable mixture, shows the mucosal pattern bestand demonstrates thickened and coarsened foldsin the jejunum. The rate of transit of barium throughthe bowel may be retarded. The best radiologicalsign of malabsorption is dilatation of small bowelcoils. It was shown by Laws in 1964 that dilatation ofjejunal coils is more closely related to the clinicalseverity of the malabsorption than any other radio-logical sign. Normal jejunum has a diameter of up to25 mm and anything over 30 mm in the adult can beconsidered as pathologically dilated.The list of causes of the malabsorption syndrome

is long, and apart from idiopathic steatorrhoea,includes Crohn's disease, scleroderma, Whipple'sdisease, Hodgkin's disease and lymphosarcoma.Pancreatic, biliary and post-operative causes, e.g.

FIG. 1. Alteration in bowel calibre, mucosal thickening,flocculation and segmentation in a case of idiopathicsteatorrhoea.

blind loops, resections, etc., also need consideration.It is the duty of the radiologist to have these in

mind during his examination and search for anysigns that might indicate the underlying aetiology.Some of the cases to be quoted in this paper mayillustrate this point.

Regional enteritisThe terminal ileum is the most frequent site of

involvement in regional enteritis and this area iseasily visualized by spot films in a routine bariummeal and follow-through examination. Early cases ofinvolvement can be difficult to detect as there may beonly a minimal alteration in the mucosal pattern orperistaltic activity. Later signs are thickening of themucosa, patchy filling defects and narrowing of thelumen. The string-sign is almost pathognomonic ofregional enteritis, but does not always indicate anon-reversible phase of the disease. It can also beseen due to spasm and irritability. Although com-plete intestinal obstruction is rare, fistulae andperforation may occur.

Fig. 2 shows the findings in a 10-year-old patientwho had Crohn's disease involving a large area ofjejunum and also the duodenum.

Approximately forty-seven cases of Crohn'sdisease of the duodenum have been described in theliterature, but it seems highly likely that this is not atrue estimate of its frequency owing to the reluctanceof many authors to report single cases. In a review of

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Radiology of small bowel lesions 47

i:~:i'J:!i.;';.~ :.';. :':; .i ,;,.'., -.B.'^ ......... :.. -

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FIG. 2. Stricture formation, mucosal irregularity with'cobble stone' deformity in regional enteritis. Note the'pseudo-diverticula'. These are normal areas of bowelbetween the 'strip areas'.

148 cases of small bowel Crohn's disease by Marshak(1961), four cases had duodenal involvement.Thirty-one cases of duodenal Crohn's disease werereviewed by Pryce-Davies in the Journal of ClinicalPathology in 1964. Of these, only three were con-fined to the duodenum, the remainder having lesionselsewhere in the small bowel. A routine barium mealand follow-through will usually demonstrate Crohn'sdisease quite readily at the time the patient presentswith symptoms. If there is any doubt about theterminal ileum or caecum, a barium enema can beperformed to show both these areas.

Lymphosarcoma and Hodgkin's diseaseFig. 3 illustrates the case of a 48-year-old female

patient with Hodgkin's disease. In 1963 this patientpresented with severe cramping abdominal pain,nausea, vomiting and diarrhoea. A jejunal ulcer wasfound at laparotomy and excised. The histology wasthat of non-specific ulceration. One year later thesymptoms recurred. The barium meal and followthrough showed a jejunal ulcer just beyond theduodeno-jejunal flexure and irregularity of smallbowel loops below this. At laparotomy four ulcerswere found in the small bowel. The histology demon-strated malignant Hodgkin's disease.

Fig. 4 shows the contrast examination on a 70-

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FIG. 3. Areas of ulceration and stricture formationhigh in the jejunum due to Hodgkin's disease.

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FIG. 4. Areas of narrowing and marked dilatation seenin lymphosarcoma.

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year-old female patient on whom a clinical diagnosisof idiopathic steatorrhoea had been made. The filmsshow an abnormal jejunal pattern with areas ofnarrowing and dilatation of the bowel. There was noresponse to a gluten-free diet. The patient's conditiondeteriorated and she developed attacks of abdominaldistention with vomiting and an increase in thediarrhoea. There was a poor response to steroidtherapy and laparotomy was undertaken. Fourstrictures were found in the small bowel. The histo-logy report was lymphosarcoma.

Malignant intestinal lymphoid tumours occurmost frequently in the stomach. Dawson, Comes &Morson (1961) reported thirty-seven cases of smallbowel lymphomata seen in three major centres overthe past 25 years. They reviewed 140 cases in theliterature. These cases were divided into:

Giant follicle lymphoma.Lymphosarcoma.Hodgkin's disease.Hodgkin's sarcoma.Reticulum cell sarcoma.

The Mayo Clinic reported 659 small boweltumours of which 8% were malignant lymphomata(Good, 1963). Three varieties of lymphomatousinvolvement have been described:

(1) Mucosal type-like an adenocarcinoma.(2) Aneurysmal type.(3) Diffuse type.

Lymphomatous involvement of the small intestinecan closely mimic adult coeliac disease both radio-logically and clinically. There may be steatorrhoeaand laboratory evidence of malabsorption may beidentical in both. Even biopsy with a Crosby capsulemay show flattened mucosa in both. However, failureto respond to a gluten-free diet should alwayssuggest a diagnosis other than primary idiopathicsteatorrhoea. The major clinical presentations ofsmall bowel lymphomata consist of:

Intestinal obstruction 67%Intestinal bleeding 53%Abdominal mass 31%Perforation 11%

Clinically, the triad of a short clinical history, apalpable tumour and the absence of significantwasting should suggest a lymphoid tumour ratherthan a carcinoma.

Radiologically, the presence of multiple strictureswill exclude an idiopathic steatorrhoea. Areas ofquite marked dilatation may occur in lympho-sarcoma due either to direct infiltration of the bowelor involvement of local nerve plexuses.

Whipple's diseaseThis was first described in 1907 at the Johns

Hopkins Hospital following the post mortem on a36-year-old physician missionary (Whipple, 1907).In 1957 Ammann collected seventy-two acceptablecases from the world literature, all but twelvereported since 1942. Since 1947 there have been atleast forty more reported cases. The symptomsappear in the middle or later years of life and there isa male preponderance of 8: 1 (Bockus, 1964).On barium meal examination, the appearances

may strongly resemble those of idiopathic steator-rhoea, but usually the segmentation and flocculationare not so marked. However, some important signsthat may suggest this condition are:

(1) Arthritis, which frequently antedates thegastro-intestinal symptoms for some years.This affects both large and small joints. Thearthritis may decrease in severity with the onsetof gastro-intestinal disturbances.

Radiologically, involvement of the sacro-iliac joints may be seen. These may showpartial fusion or irregularity, narrowing andsclerosis.

(2) Mediastinal glandular enlargement may occur.(3) Bowel loops may be displaced by enlarged

abdominal glands. There may be an extremedegree of wasting and weakness. Pigmentationof the skin is frequently seen. Enlargedcervical, axillary or groin glands may be found.

Henoch-Schonlein purpuraFig. 5 shows the barium findings in a 17-year-old

boy who presented with a purpuric rash. While in thehospital he developed severe abdominal pain,diarrhoea and melaena. The barium examinationshowed mucosal irregularity with oedema, involvingthe duodenum, jejunum and ileum. 'Thumb-printing' and 'picket fence deformity' are radiologicalsigns of intramural haemorrhage. Haemorrhageinto the wall may precipitate an intussusceptionleading to intestinal obstruction.

Carcinoid tumourFig. 6 shows multiple filling defects involving

the small bowel due to 'masses' encroaching on thebowel lumen from the bowel wall. These were due tocarcinoid tumour deposits. The patient complainedof diarrhoea, flushing attacks and palpitations. Inthis case, these symptoms were more marked duringdefaecation, as the result of multiple deposits in therectal wall.

Carcinoid tumours were first described by Merlingin 1808. The majority are found in the appendix orterminal ileum. Of 659 tumours of the small bowelreviewed between 1938 and 1957 at the Mayo Clinic,23% were carcinoids (Good, 1963). The tumoursmay be single or multiple, benign or malignant.

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FIG. 5. 'Picket fence' deformity in the jejunum andaltered duodenal outline due to intra-mural haemorrhagein Henoch-Schonlein purpura.

Although they make up less than 1% of the tumoursof the total gastro-intestinal tract, they form 20% ofall the malignant tumours of the small bowel. Theymay produce symptoms due to:

(1) Mechanical effects.(2) Metastases.(3) Pharmacological effects. It is said that 28%

of malignant carcinoids secrete serotonin.Good in 1963 stated that attempts at radiological

diagnosis of carcinoid tumours had been veryunsuccessful at the Mayo Clinic. The difficulty arisesin that the tumour is often very small and that signsare only produced when the tumour extends into theneighbouring glands, causing kinking of the bowel,abdominal masses or obstruction. A moderatefibrotic reaction occurs within and about the tumour.Kinking of the bowel, although not specific, iscertainly highly suggestive of carcinoid tumour.

EndometriosisThis most commonly affects the rectum or sigmoid

colon, but it may also affect the small bowel. The

history of abdominal pain, nausea, diarrhoea andsometimes abdominal distention, with exacerbationsat menstruation suggests the diagnosis. The radio-logical changes are usually non-specific but bariumexamination may show bowel irregularity due tosingle or multiple masses encroaching on and distort-ing the bowel lumen.

SclerodermaInvolvement of the small bowel may occur in

scleroderma and most often accompanies oesopha-geal involvement. However, on rare occasions, smallbowel lesions may occur without obvious radiologicalchange in the oesophagus. For this reason it is worth-while performing a barium meal and follow-througheven in cases where the oesophagus appears normalradiologically.

Fig. 7 shows the findings in a 50-year-old patientwho presented with dysphagia but who also hadsteatorrhoea. Radiologically, there may be dilationof bowel loops, coarsening and thickening ofintestinal mucosa. Areas of fibrous narrowing mayalso occur. There is evidence of bowel atony, withdelay in the passage of barium through the smallbowel, and often delay in gastric emptying. Pseudo-diverticula have been described in the large bowel.The general systemic manifestations, with skin

involvement, lung changes and often Raynaud's typelesions suggest the diagnosis.

Meckel's diverticulumAlthough frequently searched for, it is not com-

mon to demonstrate a Meckel's diverticulum bybarium meal and follow-through examination. Thisis partly due to the overlapping of bowel loops, butmostly due to the fact that the diverticulum has awide mouth and does not retain barium in its lumen.

Fig. 8, however, shows the findings in a patientwith recurrent abdominal pain and distention,diarrhoea and positive occult blood. A Meckel'sdiverticulum was found on a long stalk lyingbetween two coils of jejunum. Irregularities at thebase of the diverticulum were due to associatedinvolvement by Crohn's disease.

Eosinophilic enteritisThe first radiological description of this condition

was by Herrera & de la Guardia in 1948, althoughthe first reference to the condition was made by Mockin 1931. The condition may present as a localizedpolypoid tumour, most often involving the pyloricantrum, or as a diffuse eosinophilic infiltrationinvolving scattered areas of the stomach or smallbowel. A blood eosinophilia is most often seen withthis latter variety and an allergic history can often beelicited.

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50 Oscar Craig

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FIG. 6. Irregularity of bowel, kinking and stricture formation due to carcinoid tumour.

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FIG. 7. Areas of fibrous narrowing and mucosal irregu-larity in scleroderma.

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FIG. 8. A Meckel's diverticulum on a long stalk and lyingbetween two coils of jejunum. Filling defects in the sur-rounding bowel were due to associated Crohn's disease.

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Radiology of small bowel lesions 51

Radiologically, there may be a filling defect onbarium examination or irregularity, oedema andnarrowing of scattered areas of small bowel. Thesechanges may resemble regional enteritis, lympho-sarcoma or Hodgkin's disease. The diagnosis is sug-gested if these radiological changes are found in apatient with a history of recurrent abdominal pain,vomiting, diarrhoea and often an allergic history anda blood eosinophilia.

ConclusionA number of lesions involving the small bowel

have been considered. The cases described illustratethat the main difficulty is not in demonstrating thelesion but in interpreting the abnormal findings. Itis especially important in these cases that the radio-logical changes are considered in conjunction withthe clinical history and physical findings. Certainhelpful radiological points should, however, beemphasized:

(1) The importance of constantly viewing thecomplete duodenal loop in a routine bariumexamination.

(2) The consideration of vascular duodenal com-pression in otherwise negative cases. Theevaluation of 'cog-wheel' duodenal movementand the necessity of examining patients duringan attack.

(3) The careful examination of the duodenum inhigh jejunal Crohn's disease.

(4) The importance of small bowel 'kinking' dueto fibrosis in the search for carcinoid tumours.

(5) The value of a barium examination of thesmall bowel in cases of scleroderma, even inthe presence of a normal oesophagus.

(6) In any malabsorption pattern, the presence ofstrictures, ulcers, filling defects or areas ofaneurysmal dilatation will exclude a simpleprimary idiopathic steatorrhoea and suggesteither a malignant or lymphomatous smallbowel pathology. The presence of glandularenlargement and involvement of sacro-iliacjoints may suggest Whipple's disease.

(7) Clinically, failure of a malabsorption syn-drome to respond to a gluten-free diet shouldraise the suspicion of a lesion other than idio-pathic steatorrhoea.

AcknowledgmentsI am grateful to the many colleagues who referred cases

for investigation and also express my thanks to Dr P. Cardew,Photographic Department of St Mary's Hospital MedicalSchool for his help.

ReferencesAMMAN, R.W. (1957) Zur Differentialdiagnose, Pathogeneseund Atiologie des Morbus Whipple. Helvetica medica acta,24, 118.

BOCKUS, H.L. (1964) Gastroenterology, 2nd edn, Vol. 2,p. 188. Saunders, Philadelphia.

CRAIG, 0. (1969) Duodenal carcinoma. British Journal ofSurgery, 56, 39.

DAWSON, I.M.P., CORNES, J.S. & MORSON, B.C. (1961)Primary malignant lymphoid tumours of the intestinaltract. British Journal of Surgery, 49, 80.

GOOD, C.A. (1963) Tumors of the small intestine. AmericanJournal of Roentgenology, Radium Therapy, and NuclearMedicine, 89, 685.

HERRERA, J.M. & DE LA GUARDIA, J. (1948) Un raro caso deoesinofilia gastro-intestinal motivadora de un cuadroorganico de estenosis pilorica. Archivos de Hospital deSanto Tomas, 3, 19.

IHOFFMAN, W.J. & PACK, G.T. (1937) Cancer of the duo-denum: clinical and roentgenographic study of 18 cases.Archives of Surgery, 35, 11.

JEFFERSON, G. (1916) Carcinoma of the suprapapillary duo-denum causally associated with pre-existing simple ulcer.British Journal of Surgery, 4, 209.

KREEL, L. & MACKINTOSH, C. (1968) Carcinoma of theduodenum. Gut, 9, 222.

LAWS, J.W. (1964) The small intestine. Recent Advances inRadiology (Ed. by T. Lodge), 4th edn, p. 108. Churchill,London.

MALLET-GUY, P. & JACQUEMET, P. (1963) R6sultats de 500cas de duod6nographie hypotonique. Journal de radiologie,d'electrologie et de medicine nucleaire, 44, 249.

MARSHAK, R.H. (1961) Roentgen findings in lesions of thesmall bowel. American Journal of Digestive Diseases, 6,1084.

MERLING (1808) Quoted by STEGER, C. & AVANZINI, C.(1953) Ricerche isotopatologiche ed istochimiche suicarcinoidi. Rivista di anatomia patalogica e di oncologia,7, 1091.

MOCK, H.E. (1931) Infective granuloma: non-specific chronictumour-like productive inflammations of the gastro-intestinal tract. Surgery, Gynecology, and Obstetrics withInternational Archives of Surgery, 52, 672.

PRYSE-DAVIES, J. (1964) Gas-distension, double-contrastduodenography using the Scott-Harden gastroduodenaltube. Gut, 7, 420.

RALA, S. & KREEL, L. (1966) A Manual of PathologicalAnatomy, Vol. 2. Sydenham Society, London.

SERRANO, J.F. & MCPEAK, C.J. (1966) Primary neoplasms ofthe duodenum. Surgery, 59, 199.

SCHATZKI, R. (1943) Small intestinal enema. AmericanJournal of Roentgenology, Radium Therapy, and NuclearMedicine, 50, 743.

SCOTT-HARDEN, W.G. (1960) Examination of the smallbowel. Modern Trends in Diagnostic Radiology (Ed. byJ. W. McLaren), 3rd series, p. 84. Butterworths, London.

TRICKEY, S.E., HALLS, J. & HODSON, C.J. (1963) A furtherdevelopment of the small bowel enema. Proceedings of theRoyal Society of Medicine, 56, 1070.

WHIPPLE, G.H. (1907) A hitherto undescribed diseasecharacterized anatomically by deposits of fat and fattyacids in the intestinal and mesenteric lymphatic tissues.Bulletin of the Johns Hopkins Hospital. 18, 382.

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