Introduction

Technologic advances have made small bowel imaging a rapidly changing field and a challenge to radiology. Radiological investigations dominated small bowel imaging for all of the last century until the advent of wireless capsule endoscopy (WCE) [1]. Although traditionally the simplicity, availability and low cost of small bowel follow through (SBFT) made it the most commonly performed examination, barium enteroclysis has been shown to have overall higher accuracy and reliability. However, this is at the expense of increased invasiveness and decreased patient tolerance without the use of conscious sedation [2, 3]. The disadvantage of all barium small bowel examinations is their inability to provide any extraluminal information that may have important clinical implications for patients with diseases of the small bowel. Much of the diagnostic information from barium studies was derived from the indirect mucosal and mural changes produced by lesions within or outside the lumen, allowing for substantial intra- and interobserver variation and difficulty in interpreting equivocal or even overt findings. This has become particularly apparent with the increased use of contrast-enhanced computed tomography (CT) studies [4-6]. A comparison of barium enteroclysis and abdominal CT done on the same patients with small bowel Crohn's disease has demonstrated a much higher success of CT in revealing mural and extraluminal manifestations of disease, including abscesses, while enteroclysis was superior for luminal abnormalities, including bowel obstruction (especially low-grade), sinus tracts, fistulae, and ulcerations, mainly as a result of the enteral volume challenge generated by the controlled infusion of the contrast agent [7]. It was only a matter of time until computed tomographic enteroclysis (CTE) was developed to overcome the individual deficiencies of these techniques and to combine the advantages of both examinations into one technique. Initially reported by Kloppel et al. in 1992 [8], CTE was shown to be highly accurate for the depiction of mucosal abnormalities as well as bowel thickening, fistulae, and other extraintestinal complications of Crohn's disease. The first North American report performed studies in patients with suspected small bowel obstruction [9]. Bender et al.

showed that CT enteroclysis was superior to conventional CT for the diagnosis of lower grades of bowel obstruction and was also able to reveal the nature of the obstructive lesion. Notably, in these patients, adhesions were inferred on conventional CT when no mass, inflammatory changes or any other significant pathology were seen at the point of obstruction.

The introduction of multislice CT technology with its ability to scan larger volumes at a faster speed and the use of thinner section collimation allowing acquisition of near isotropic voxels, have made high resolution reformatting in different planes a simple and practical procedure with newer software. This technology has also resulted in improved performance and feasibility of CT enteroclysis, leading to an increased use of this method around the world [10-13]. At the same time, progress in endoscopy has been remarkable. Wireless capsule endoscopy (WCE) and very recently, double-balloon enteroscopy have allowed full exploration of the small bowel, the latter completed with inter-ventional capabilities previously only available through in-tra-operative enteroscopy [14, 15]. This update examines the various modifications made to CTE that have evolved since its original description more than ten years ago, presents an overview of its clinical applications and analyzes its role in the investigation of small bowel diseases in the era of complementary endoscopy studies.

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