Nelson t't ill. OCTOBER,. 1973. GC= granulomatous colitis; UC= ulcerative colitis. Radiologist. Ulcerative ..... H. 1., LAwSoN,. T. L., MONTGOMERY,. C. K.,.
\OL.
No.
119,
2
ULCERATIVE
AND
VARIATIONS
IN OBSERVER ROENTGENOGRAPHIC AS RELATED
J. A. NELSON, M.l).,f J. W. 1’ENLON,
By
GRANULOMATOUS
A.
R.
HE
overlap
in clinical
graphic
findings colitis
granulomatous
emphasized et al.,4 and eases
pattern
diagnostic fore, to
confusion. determine
rectlv
differentiate
when
the
sets
of
intra-observer
the
films to
graphic
were
again
determine
to incorrect
From
the
had
series
The
From
the
t Trainee,
had
Department
Veterans
rate
we
colitis spersed
led
tous
to cor-
we
previously
at least
i
was
sets
of and
of Radiology,
Administration
examination
in was
University
were
of California
was
assembled.
which
proved the
ul-
patients
had
roentgenocases
also
these data
then
of
I I
packaged
as
a sepa-
envelopes of ulcerative were next randomly inter18 of the sets of granuloma32
films with colitis
atypical group
films
used
in
the
initial
series.
series thus consisted of films of cases of colitis-i8 of which already been analyzed by the This was
second
given
to
to be colitis
interpreted or ulcerative
as
series
of
of
sets
50
either colitis.
series the
of
roent-
3 radiologists
granulomatous After the second
roentgenograms
had
been read, 2 of the investigators (JAN, ARM) reviewed each analysis made by the 3 radiologists to determine which findings led to correct and which to incorrect diagnosis.
roentgenograms any identifying Training
“cases”
a total of 32 roentgenographic Each set of films from also had identifying was
genograms
exam ithat
interpretation
in a
a single
of granuloma-
series
an
3 radiologists. io
of cases
This
The
second 50 “unknown” had actually
selected
in
and case.
roentgeno-
proved granulothe patients had
roentgenographic
difficult. The 32 were first separated *
cases
et al.,4
The
put as
pathologically
yielded
This
of colitis
of
pattern.
masked
ascer-
recorded
of 32 roentgenographic basis of selection
patient
of
METHOD
pathologically colitis in which
a total
nations.
which
AND
Margulis of
each
commonly
then
was presented
barium enema examinations The criterion again was that of the examinations of each
comprised examinations. examinations
by
analyzed,
series
colitis
graphic
diagnosis.
MATERIAL
reported
be
set be
a second
cases
patient
to
session,
to
which
most
3
wanted
were
first
colitis,
had several were selected. at least I
viewed
and, several
was results
case
of the
cerative
a later
when
findings
cases matous
at
variation Finally,
or
films
of colitis.
of several
With
variation’ reread
unknown
Eleven
cases. we
Each to
colitis
were
separate
data masked. separate jacket
totis
granulomatous
colitis
as
M.D.,
CALIFORNIA
sis
of patients
proved
inter-observer each radiologist
same
the
cor-
of
each
participating,
wished
could
forms
2
from
ulcerative
radiologists
tained.
to
examinations
and
and
contribute
H. I. GOLI)BERG, AMBERG, M.I).
studied by 3 gastrointestinal radiologists, who were to determine if they represented granulom atous cohi tis or ulcerative colitis. Approximately 3 months after the analy-
dis-
2
IN
next
roentgeno-
disease
of films
presented
rect
also
pathologically
stud having
the
their
these
roentgenographic
and
recently Margulis
We decided, thereif radiologists who spe-
in gastrointestinal set
and
been
in
may
cialize
the
has
changes
graphic
colitis
roentgeno-
AND
F.F.R. (Hox.), M.D., and J. R.
FRANCISCO,
ulcerative
by Glotzer et al.,2 Schachter et al.3 As
progress,
wi th
and
of
M.l).,
‘I’. L. LAWSON, SAN
T
INTERPRETATIONS APPEARANCE TO TIME
MARGULIS,
M.D.,
COLITIS*
School
Program.
369
of Medicine,
San
Francisco,
California.
Nelson
370
OGISTS MADE
ROENTGENOGRAPHIC
AT VARIOUS PROVED
STAGES
14
B C
23
32
FIRST
18
AND
PROVED
GRANULOMATOUS
Ulcerative
called
ulcer-
(;rz,ntllomatoLls
coli
correctl
v
diagnosed Ulcerative
cob tis correctly
tis
II
8
8
10
10
8
21
Unanimous
50
ative
66
24
Interpretations
Interpretation Ulcerative coli tis called granulomatous colitis Granulomatous colitis called ulcer-
72
Cases 3
colitis
7
Granulomatous
coli tis correctly 6
diagnosed
It is important gists
used
to note
techniques
that
Ulcerative nosed
the 3 radiolo-
of interpretation
TABLE
Radiologist B B and C AandC
A and
GC= granulomatous
AGREEMENT SECOND SERIES
ON (32
7/18
6/i8
(%) (%)
colitis;
UC=
ULCERATIVE
19/32
(5c%)
19/32
(%)
18/32(56%)
8/18(44%)
ulcerative
diagi6 Total
Mixed
colitis.
32
Interpretations
Reading 2
Cases
correct and I incorrect (Of the I 2 errors, 8 occurred ulcerative ulomatous
colitis was colitis.)
correct and 2 incorrect (Of the 12 errors, when ulcerative colitis
I
granulomatous
12
when gran-
called
6 10
occurred WS called
colitis.)
‘l’otal
18
IV
INTERPRETATIONS
UC Correct
GC Correct
correctly
dif-
ferent from one another. One relied on his experience and general expertise. Another radiologist analyzed each case with a check list of differential findings considered typical of granulomatous versus ulcerative colitis.24 The last radiologist analyzed the series with residents in Radiology, as a teaching exercise. The time span covered by the several roentgenographic exami nations given each patient varied from I month to 8 years and 3 months; the average period was 36 months.
INTER-OBSERVER
colitis
50 ROENTGENOGRAPHIC 18 GRANULOMATOUS
EXAMINATIONS
OF
COLITIS,
GC called 8/i8 8/i8
(%) (%)
6/18(33%)
UC
C
COLITIS)
UC called 4/32 3/32
8 ()
diag-
nosed
Agreement (per cent)
B
granuloma-
colitis
COLITIs)
BandC AandC
called
Granulomatous ative colitis INTER1’RE’rATIoNs
B
colitis
totis colitis
EXAMINATIONS
Radiologist
COLITI5
A
II
(GRANULOMATOUS
ROENTGENOULCERATIVE
Observer
9
ON
50
PROVED
Interpretation
25
AGREEMENT
A and
COLITIS
Gran ulomatous Colitis
ROENTGENOGRAI’HIC SERIES
OF 32
8
tABLE
OF
SERIES
INTERPRETATIONS
EXAMINATIONS:
GRAPHIC
COLITIS
7
INIER-OIISERVER
OF
1973
III
SECOND SUMMARY
OF PATHOLOGICALLY
Ulcerative Colitis
A
RADIOL-
EXAMINATIONS
GRANULOMATOUS
Radiologist
OCTOBER,
tABLE
3 GASTROINTESTINAL
BY
OF 32
ill.
I
IABLE IN’rERI’RETATIONS
t’t
(13%)
(%)
5/32(16%)
GC
Agreement 76% 72% 74%
24
\OL.
No.
119,
Ulcerative
2
and
Granulomatous
VARIATION
GRANULOMATOUS
.
Radiologist
IN INTERPRETATION
COLITIS
.
ANALYZED
-
.
Diagnosis
OF
A SECOND
3/18
(i6%)
B C
2/18
(ii%)
8/iS
(%)
FIRST
the
initial
series
SERIES
sets
offlims
FINDINGS*
INCORRECTLY)
Cecum Ascending colon ‘l’ransverse colon l)escending colon Sigmoid Rectum Concentricinvolvement Eccen tric i nVolvemen Ulcer type Shallow
l)iagnosis on
2nd
correct reading
(#{231}6%)
10/18
(,%)
718
(,3’)
(83%)
9/18
(#{231}o%)
colitis
in
incorrect
9 instances
and
diagnosis
of
unani-
ulcerative
in #{231}.
Table III shows from the second graphic examinations
CASES
AND
Unanimous Reading (Total of 13)
ileum
OF
READING
-
SECOND
( io)
SERIES
the individual readings series of o roentgenoand tabulates the
VI INTERPRETED
FOR GRANULOMATOUS
GC correct
INIrIAL
correct
in
IN
FIRST
Terminal
(6i%)
EXAMINATIONS
A}1’ER
of proved
FABLE “TYPICAL”
Area of involvement Total colon
ii/i8
colitis
of
Table I. Table interobserver agreement for this series. There was unanimous correct diagnosis of granu-
OF
reading
mous
colitis are presented II is a tabulation of
FREQUENCY
Diagnosis on 1st
15/18
interpretations
of32
MONTHS
lomatous
roentgenographic
granulomatous
3
7/18
RESULTS
The
18 ROENTGENOGRAPHIC
TIME,
changed
A
71
V
‘FABLE INTRA-OBSERVER
Colitis
COLITIS SECOND
UNANIMOUSLY
(CORRECTLY
OR ULCERATIVE
SERIES
of GC
1Jnanimots
(Total
GC called
UC
OR
COLITIS
()
UC correct
(i6)
Reading of 22)
of UC
UC called
GC
1/10
0/3
6/16
2/6
7/10
0/3
/I6
o/6
0/3
7/16 7I6
2/6 26
8’,6
6 ‘6
8 io 4
io
7/10
0/3
8/io
i /
12/16
,
6/10
2/3
11/16
(,‘6 6 ‘6
‘i6
2/10
2/
Ii
7/10
2/3
11/16
/1
t
o
/
2/
‘6
66 16
/6
8/io
0/3
12/16
Deep
5/10
0/3
Collarbutton
I/Jo
1/,3
i/io
0/3
4/16 3/16 /i6
i/io
o/
i/i6
o/io
0/3
0/16
o/6 o/6
o/io
o/
3/16
o/6
o/io
0/3
o/i6
o6
2/10
i/
0/16
i/6
Fistula
2/10
1/3
0/16
Abscess
I/b
0/3
o/i6
o,/6 o/6
Pseudopolyps
Contracted
colon
Megacolon
Gaping
ileocecal
Focal
involvement
Cobblestone
*
Adapted
Gc=
valve
mucosa
from
granulomatous
Table
I of
colitis;
Margulis
a
UC
ulcerative
a!.,
1971.’
colitis.
4/6 /6 /6 i/6
(6)
Nelson
372
et
()uIOBER,
i/.
number
of
correct mary
unanimously
diagnoses. of inter-observer
correct
Table
1973
in-
and
iv gives agreement
a sumon the
second series. It is apparent from this table that granulomatous colitis was agreed upon correctly less than half the time. Table v shows the pretations lomatous
intra-observer variation in interof the i 8 examinations of granucolitis which were reread after a
3
interval
month
as
part
of
the
second
series.
Each
of
assessed
the the
for
#{231}o examinations presence or
accepted roentgenographic diseases,4 which are Cases that had been mouslv, either correctly the
A”:., .
l”Ii.
found
radiologists of
these that
ileocecal colitis
showed
smooth,
shortened
with
unanimous
ease,
by
findings
right-sided
ulcers.
\Vhen
fistula
led
anal’zed
vi).
were
of colonic
it to
then (Table correct
colitis
fluenced colon
a patulous valve led to an interpretation of ulcerative 1v’ all , radiologists. Histologic studs’ the lesion to be ulcerative colitis.
‘l’his
were findings
granulomatous
next the
was of
often
terminal disease,
diagnosis
for
It
readings most
occurred,
correct
of
findings in the listed in Table vi. interpreted unanior incorrectly, b’
2
each
was absence
in-
ileum
dis-
and
deep
a demonstrated of
granulo-
2. (4) Barium enema examination demonstrates diffuse colonic disease with deep ulcers and an abnormal terminal ileum. ‘l’his case was correctly diagnosed as granulomatous colitis by all . radiologists. (B) Roentgenogram of the same patient made years after A shows a smooth colon with decreased haustration. ‘l’his roentgenogram of a case of histologically proved granulomatous colitis was interpreted by all 3 radiologists to be ulcerative colitis.
1’IG.
VOL.
No.
119,
matous colitis
Ulcerative
2
colitis,
but
a fistula
was
incorrect
in
interpretations
difficult moos
to correct
ulcerative
of
low
account
and
occasionally,
a
showed
coli-
in 3 cases
were
persist.
unani-
for
readings often
of
total
rectal disease, involvement,
totally
ings
ulcerative
most
i nvolvement, concentric
ulcers,
Colitis
colitis (Fig.
incorrect were
ulcerative
Criteria
for.
Granulornatous
Unanimous
colitis
colitis
left-sided
of
misleading.
as granulomatous
tis
case
I
and
con trac
or shaland,
ted
zI and In
the
there
but
was such
an
ulcerative
roentgenograms changes did
not
cases
i i
any
of ulcer;tthat the changes that
opinion
l)tttern granulom noted by
never
the these
of
2
was
represented This was
had
atous coli tis ( Fig. 2 of the 3 radiologists, a conclusion unanimous.
colon A RV
1).
This ROENTGENOGRAIHIC
After were
the
films
total,
to
ease lution
the
pattern
64 examinations
processes.
each original case, in if change in the roent-
tive often
colitis tiTan
was
time
different
period
‘ears, colitis
one
extending
3 of with
the TO typical
original
evident
files
of evointo
institution
may
pattern
was from
found. i
Over
month
cases of granulomatous roentgenographic
a
3
to
reliability used be
individual
wide
enough
bias of
reading
of
iR
months
(i
i
later) 44 per
to
possibility
The the
from
of
colitis
case
3.
‘l’wo
as
specimen and poor contributed tation.
of
the
granulomatous
3
radiologiSts
interpreted
this
colitis. ‘l’he pathological it to be ulcerative colitis. Spasm
proved filling in the hepatic to the roentgenographic
flexure
probably misinterpre-
are roen other
and roen
A study logic
material
first was
made
3
enough about the
correct
diagnosis examination.
current
once again of a case
and and
previous
pathological
all of this max’
information occasionally
to
is arise
is in doubt or in must be recases of tilceracolitis
retain
ic characteristics of the disease, there
situations pattern unpredictable and
The the
granuloniatous
similar
was equi-
findings.
enema
tgenograph the course
sometimes tgenographic over an
it
reading
in which definite diagnosis which a previous diagnosis evaluated. Although most their throughout
repre-
the
also sul)stantial to raise doubts
its
for
roentgenograms
roentgenographic
data. Even when available, i nstances
tive
the
second
achieving
all
this
mans’
study;
pinpoint
(when
of
a
at
well
in this study stress for basing diagnosis on
colitis
clinical
this of
barium
findings necessity
various
the
more this
resl)onsible diagnoses.
to
was cent) of
strictly
in
sets
with
of
since
variation
compared
ulcera-
at
may
some
intra-observer
paints patlT-
2
correctl colitis
questioned,
however
nature
ulcerative
as criteria
variation
sent vocal
FIG.
of
such findings are apparently incorrect as well as correct Inter-observer
find-
cases
was diagnosed granulomatous The findings”
dis-
21
colitis once again patterns of the Data indicated that
institution. “classical
as the
evidence
of
granulomatous the overlapping
logic
the
progressed. No clear of i roentgenographic
entirely
and out
analysis
of
into
we reviewed determine
genographic
CHANGES
from
reassembled cases,
an
only
tive colitis roentgenographic
of
on B), but
S U iI
(Fig.
21
development
pattern 2,
373
this
highl-
in which one evolves to anperiod of time. but trained
using
histopatholo-
Nelson
374
gists should be interesting and contribute further to the understanding the set of conditions surrounding lomatous and ulcerative colitis.
University
of California
Francisco,
California
N.,
GEFFEN,
I’.
I.,
3.
Crohn’s
GLOTZER, HINRICHS,
disease
course New
of ulcerative England 7.
H. E., and MORSON, B. C. (regional enteritis) of large in-
testine. Gut, 1964, 5, 493-509. A. R., GOLDBERG, H. 1., LAwSoN, T. L., MONTGOMERY, C. K., RAMB0, 0. N., NOONAX, C. I)., and AMBERG, J. R. Overlapping spectrum of ulcerative and granulomatous colitis: roentgenographic-pathologic study. Au. J. ROENTGENOL., RAD. IHERAI’V & NUCLEAR
San
Francisco
94143
G.,
A.,
and
DE
DOMBAL,
GOLIGHER,
MED.,
J. C.
Radiological signs of ulcerative colitis: assessment of their reliability by means of observer variation studies. Gut, 1968, 9, o-i6. 2.
LOCKHART-MUMMERY,
and
colitis. 582-587.
1973
4. MARGULIS,
I)ARNBOROUGH,
WATKINSON,
features
and granulomatous Med., 1970, 282,
of granu-
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would
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et al.
1). J., GARDNER, H. R., ROSEN,
R. C., GOLDMAN, H., and ZETZEL,
H., L.
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1971,
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H.,
325-334.
M.
GOLDSTEIN,
J.,
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H., l”ENNEsSv, M. B., and KIRSNER, J. B. Ulcerative and “granulomatous” colitis validity of differential diagnostic criteria: study of 100 patients treated by total colectomy. Ann.
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