(Radiology. 1999;210:861-864.)
© RSNA, 1999
Pancreas: Does Hyoscyamine Butylbromide Increase the Diagnostic Value of Helical CT?
Andrik J. Aschoff, MD1,
Johannes Görich, MD1,
Roman Sokiranski, MD1,
Andrea Rieber, MD1,
Hans-Jürgen Brambs, MD1 and
Stefan C. Krämer, MD1
1 Department of Diagnostic Radiology, University of Ulm, Steinhövelstr 9, D 89075 Ulm, Germany.
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Abstract
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Among 50 patients referred for helical computed tomography (CT) of the pancreas, 24 randomly selected patients received 40 mg of hyoscyamine butylbromide to evaluate whether its administration improved image quality and diagnostic findings. Differences between the groups were not statistically significant. It was therefore concluded that hyoscyamine butylbromide does not contribute a diagnostic advantage at helical CT of the pancreas.
Index terms: Computed tomography (CT), comparative studies, 77.12114 • Contrast media, comparative studies, 77.12114 • Pancreas, CT, 77.12114
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Introduction
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The use of helical computed tomography (CT) of the pancreas results in a high tumor detection rate and increases sensitivity and specificity for tumor differential diagnosis and assessment of resectability (1). Before the examination, hyoscyamine butylbromide (Buscopan; Thomae, Biberach, Germany) is often administered under the presumption that it may promote distention of the duodenum and minimize artifacts due to peristalsis. The objective of the present study was to determine any additional diagnostic advantage after administration of hyoscyamine butylbromide in patients with tumors of the pancreas or pancreatitis examined at CT with optimized scanning parameters.
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Materials and Methods
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Fifty patients referred for CT of the pancreas were randomly assigned to one of two groups (Table 1). All patients provided informed consent. Randomization was performed by using a random number function (EXCEL, version 5.0a; Microsoft, Unterhaching, Germany). This function generates a random number between 0 and 1. Patients with a random number of 0.5 or less were assigned to the hyoscyamine butylbromide arm of the study, and those with a random number greater than 0.5 were assigned to the control arm. Twenty-four patients received 40 mg of hyoscyamine butylbromide intravenously immediately before injection of 160 mL of intravenous contrast medium (Solutrast 300, Byk Gulden, Constance, Germany; or Ultravist, Schering, Berlin, Germany) at a flow rate of 3.5 mL/sec, with an imaging delay of 25 seconds. Twenty-six patients did not receive hyoscyamine butylbromide before the intravenous contrast medium. Differences between the groups in terms of age, sex, and clinical impression were not statistically significant.
All CT studies were performed with a double-detector helical CT unit (Twin Flash; Elscint, Haifa, Israel) with uniform scanning parameters (collimated section thickness [nonenhanced phase, 5 mm; early arterial, 2.5 mm; portal venous, 5 mm], reconstruction interval [nonenhanced, 5 mm; early arterial, 1.6 mm; portal venous, 2.5 mm]; pitch [nonenhanced, 1.5; early arterial, 1; portal venous, 1]). Before the examination was started, while the patients were on the CT table, they consumed 500–1,000 mL of water (the amount depended on patient comfort). To improve duodenal filling, patients were placed with the right side of their bodies elevated 45° (Figs 1, 2).
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Figure 1a. Contrast material–enhanced helical CT studies with hyoscyamine butylbromide in a 59-year-old man with carcinoma of the pancreas. (a) Arterial phase scan shows excellent distention of the stomach (S) (rated 5), well-dilated proximal duodenum (arrows) (rated 4.33), and almost no motion artifacts. (b) Arterial phase scan shows a hypoattenuating pancreatic mass (m) adjacent to the sharply delineated duodenal wall (arrows) (rated 3.67), good distention of the distal duodenum (rated 4.33), and excellent contrast enhancement of the superior mesenteric artery (a) (rated 5) and splenic vein (v) (rated 4.33).
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Figure 1b. Contrast material–enhanced helical CT studies with hyoscyamine butylbromide in a 59-year-old man with carcinoma of the pancreas. (a) Arterial phase scan shows excellent distention of the stomach (S) (rated 5), well-dilated proximal duodenum (arrows) (rated 4.33), and almost no motion artifacts. (b) Arterial phase scan shows a hypoattenuating pancreatic mass (m) adjacent to the sharply delineated duodenal wall (arrows) (rated 3.67), good distention of the distal duodenum (rated 4.33), and excellent contrast enhancement of the superior mesenteric artery (a) (rated 5) and splenic vein (v) (rated 4.33).
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Figure 2a. Contrast-enhanced helical CT studies without hyoscyamine butylbromide in a 61-year-old man with an insulinoma. (a) Arterial phase scan shows excellent enhancement of the pancreatic tumor (arrows) and very good duodenal distention (d) and delineation of the head of the pancreas (both rated 4.67). A cyst is in the right kidney. (b) On the portal venous scan, the insulinoma vanished while image quality remains excellent. No motion artifacts are seen.
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Figure 2b. Contrast-enhanced helical CT studies without hyoscyamine butylbromide in a 61-year-old man with an insulinoma. (a) Arterial phase scan shows excellent enhancement of the pancreatic tumor (arrows) and very good duodenal distention (d) and delineation of the head of the pancreas (both rated 4.67). A cyst is in the right kidney. (b) On the portal venous scan, the insulinoma vanished while image quality remains excellent. No motion artifacts are seen.
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The evaluation was conducted independently by three blinded examiners (A.J.A., J.G., S.C.K.). The following criteria of examination quality were evaluated on a scale of 1 (very poor) to 5 (very good): filling of the distal stomach, duodenal filling (pars descendens duodeni), delineation of the duodenal wall against surrounding fat and the pancreas, delineation of the pancreas against the mesentery, and the presence of motion artifacts. Then, visualization of the celiac trunk, the superior mesenteric artery, and the portal venous system was also determined. Finally, it was decided whether the examination was of adequate diagnostic quality in supplying the required data, and examiners also assessed whether the given patient had received hyoscyamine butylbromide before the examination.
Statistical analysis of the former two evaluations was performed with the Mann-Whitney rank sum test. Statistical analysis of the latter two evaluations was performed with the Fisher exact test. Calculations were performed with a statistics program (SIGMASTAT, version 1.0 and SIGMAPLOT, version 1.02; Jandel Scientific Software, San Rafael, Calif); results are stated as the mean ± SD.
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Results
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For all evaluated criteria, the data for each individual reader were compared. Differences between the two groups were not statistically significant for any of the criteria (P < .5; range, from .16 to .87; Table 2).
Diagnostic adequacy was determined in 21 of 24 patients (88%) in the group with hyoscyamine butylbromide and in 24 of 26 (92%) in the group without hyoscyamine butylbromide. Differences in diagnostic adequacy or accuracy in assessment of whether the given patient had received hyoscyamine butylbromide were not statistically significant (P = .66 and .25, respectively). No significant individual reader variability was observed.
No complications were observed after the administration of hyoscyamine butylbromide. Only one control patient had a relative contraindication (prostatic hyperplasia requiring therapy) to hyoscyamine butylbromide. On the basis of patient history, no patient had an absolute contraindication to hyoscyamine butylbromide.
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Discussion
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Administration of hyoscyamine butylbromide has become a routine adjunct in the preparation for a range of radiologic examinations. It is given either to improve bowel distention (eg, in double contrast barium studies [2–4]) or to reduce motion artifacts due to bowel peristalsis (eg, in angiography [5], CT, and MR imaging [6]). An absolute contraindication to its use is the presence of glaucoma, whereas relative contraindications include cardiac arrhythmias and prostatic hyperplasia. In general, these contraindications seldom occur; this is reflected in the present study population, in which no instances of an absolute contraindication and only one instance of a relative contraindication (prostatic hyperplasia, 2%) were identified.
Allergic reactions to hyoscyamine butylbromide are rarely observed (7), and there is no known effect on contrast medium tolerance (8). Glucagon represents an alternative bowel relaxant, which is more expensive and shows no advantage to hyoscyamine butylbromide concerning its safety, frequency of side effects, and efficacy (2,9).
The onset of duodenal paralysis after intravenous administration of hyoscyamine butylbromide occurs within 20–120 seconds with an average of 45 seconds (9). The duration of spasmolytic activity has been reported as 3.7–20.0 minutes after intravenous administration (9,10). Thus, our practice of administering hyoscyamine butylbromide before the first contrast phase ensures a spasmolytic effect during both contrast phases, which take less than 2 minutes to accomplish with our study protocol.
In general, hyoscyamine butylbromide in the dosages used in radiologic practice (20–40 mg intravenously or subcutaneously) represents a safe, well-tolerated, and inexpensive drug (in Germany, the cost for a 20-mg ampule is less than US $1). Nevertheless, this does not justify its careless or superfluous use.
Helical CT examination of the pancreas is useful in the diagnosis of both inflammatory and malignant lesions of the pancreas (1,11–13). A special procedure is the so-called hydro-helical CT, in which contrast enhancement and distention of the bowel are achieved with water instead of with parenteral contrast medium (14). One of the greatest advantages is improved ability to recognize changes in the duodenal wall. Also, the absence of oral contrast medium facilitates image postprocessing involved in the production of CT angiograms (maximum intensity projection or three-dimensional images).
In theory, the adjuvant administration of hyoscyamine butylbromide should enhance duodenal distention and filling, while at the same time reducing motion artifacts due to peristalsis. In the present study, however, the group receiving hyoscyamine butylbromide showed no statistically significant difference in these criteria, nor was there any difference in the ability to evaluate the duodenal wall.
In the case of tumors of the pancreas, the degree of vascular infiltration is the single most important factor in determining resectability (15). An adequate helical CT examination of the pancreas is usually able to furnish the required data (16–18). In our study population, the ability to evaluate the celiac trunk and the superior mesenteric artery was assigned an average score of 4.9 (on a scale of 1–5), whereas the ability to evaluate the portal vein was assigned a score of 4.5. These represent scores between good and excellent.
Hyoscyamine butylbromide does not contribute a statistically significant diagnostic advantage to parameter-optimized helical CT of the pancreas. Despite its low rate of adverse effects, administration of hyoscyamine butylbromide for this indication should therefore be avoided.
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Footnotes
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Address reprint requests to A.J.A.
Author contributions: Guarantors of integrity of entire study, A.J.A., S.C.K.; study concepts and design, A.J.A., S.C.K.; definition of intellectual content, A.J.A., S.C.K., H.J.B., J.G.; literature research, A.J.A.; clinical studies, A.J.A., S.C.K., A.R.; data acquisition and analysis, A.J.A., S.C.K., J.G.; statistical analysis, A.J.A.; manuscript preparation and editing, A.J.A., S.C.K.; manuscript review, A.R., J.G., R.S., H.J.B.
Received January 28, 1998;
revision requested April 7, 1998; revision received July 22, 1998;
accepted October 20, 1998.
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Abstract
Introduction
