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Imaging Diagnosis

Plain film roentgenograms of the abdomen are normal in mild cases. In severe cases, there is a pattern of mild ileus with air-fluid levels in the erect position. (Fig. 16.12C.) An upper gastrointestinal and small bowel series with barium is the most helpful radiological study in the evaluation of a patient with suspected tropical sprue. Although the esophagus, stomach and colon are affected in sprue, the findings are minimal and nonspecific: poor tone and moderate dilatation may be noted. (Figs. 16.12C,G and 16.13D.) It is the small bowel that shows the maximal abnormality. However, even the radiological findings in the small intestine are not specific for sprue, but can be produced by many other conditions causing malabsorption (Table 16.2). The diagnosis is often arrived at by exclusion.

It is therefore essential for the radiologist to have adequate clinical and biochemical data on the patient in order to perform a meaningful and contributory study and interpret it properly. The small bowel examination should include sequential radiography and fluoroscopy with occasional manual palpation of the loops of small intestine to separate them from one another and show their changing characteristics (Figs. 16.12 and 16.13.). Micropulvarized, nonflocculating barium should be used; regular barium tends to flocculate excessively in the presence of mucus in the small bowel. In sprue there is a considerable increase in the number of intestinal goblet cells; there is also excess absorption of unsaturated fatty acids, resulting in a hyperlipidemic condition which augments the secretion of more mucin. The unabsorbed or poorly saturated fatty acids in the lumen of the gut cause irritation and diarrhea and add to the flocculation. Cholinergic drugs may be used in selected cases, but the effect of drugs on small bowel motility and secretion has generally not proved helpful in patients with tropical sprue.

The evaluation of the radiological findings is difficult because there is a lack of "constancy" and a certain amount of change in the radiological pattern which is influenced by the individual or combined dysfunction of the following:

1. Auerbach's plexus--tone, caliber, peristalsis.

2. Meissner's plexus--tone, valvulae conniventes and local contraction.

3. Secretory factors--influenced by Meissner's plexus.

4. Mucosal integrity.

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