Common bile duct obstruction by free floating tumor.

UNLABELLED: Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion [1] and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. CONCLUSION: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.

Iatrogenic femoral arteriovenous fistula.

Twelve iatrogenic femoral arteriovenous fistulas are reported, 11 of which arose from the superficial or deep femoral arteries. All but two occurred in association with cardiac angiographic procedures. It appears that the femoral crease was used as a landmark to establish the cutaneous entry point for vascular puncture and resulted in an excessively distal puncture site. The femoral crease is an unreliable landmark in many patients. This complication may be minimized by using physical examination to identify the level of the inguinal ligament or fluoroscopy to localize the distal half of the femoral head.

CT of thoracic aortic aneurysms.

Aneurysms of the thoracic aorta are most often the result of arteriosclerotic disease. Other causes include degeneration of the medial layer of the aortic wall, either idiopathically or due to genetic disorders such as Marfan syndrome; aortic dissection; trauma; syphilis and other bacterial infection; noninfective aortitis; and congenital anomaly. We review normal anatomy of the aorta and discuss our technique and interpretation of computed tomography (CT) in the evaluation of the thoracic aorta. We illustrate the CT appearance of different types of aortic aneurysms as well as discuss the use of CT for assessing complications of aneurysms, for postoperative follow-up, and in the differentiation of aortic aneurysm from a paraaortic mass.

Effect of contrast media on prostaglandin synthesis in vivo.

Since systemic reactions to contrast media (CM) in patients often resemble pathophysiologic conditions associated with prostaglandin metabolites prostacyclin (PGI2), and thromboxane B2 (TXB2), plasma levels of these mediators are likely to provide an index of CM pathogenesis. In this study, patients undergoing peripheral arteriography were injected either with a hyperosmolal CM sodium diatrizoate or with a newer low osmolal CM, iohexol. Arterial blood samples were collected before and after the procedure. Prostacyclin and thromboxane were quantified as 6 ketoprostaglandin F1a (PGF1a) and TXB2 by using radioimmunoassay kits. Diatrizoate caused prostaglandin I2 (PGI2) release in 60% of patients, whereas 66% receiving iohexol also exhibited increased levels of PGI2 in their plasma. TXB2 concentration remained unchanged. No clinically adverse reactions were seen following the procedure. These results indicate that both high and low osmolality CM are capable of stimulating vascular endothelium, thereby causing prostacyclin release. Molecular mechanisms, however, remain to be determined.

Computed tomographic demonstration of anomalous inferior vena cava with azygos continuation.

A case of anomalous inferior vena cava with azygos continuation first diagnosed by computed tomography (CT) and later confirmed by venography is presented. In addition to identifying the dilated azygos vein in the chest, CT can determine the direction of flow in the vein by means of a bolus contrast medium injection. Once this is established, a search for the etiology of the dilated vein can be directed to the appropriate anatomic area.

Esophageal carcinoma presenting as a primary renal tumor.

A patient with esophageal carcinoma presenting with hematuria is described. Initial studies confirmed the presence of a renal mass that was thought to be a primary renal neoplasm. Further studies to evaluate anemia before a renal operation led to the discovery of an unsuspected esophageal carcinoma. Although metastases to the kidneys are relatively common it is uncommon for these lesions to be clinically apparent or responsible for producing initial symptomatology. Only after discovery of the esophageal lesion was the possibility of a secondary renal neoplasm considered. Intractable hematuria was treated successfully by embolizing the renal artery of the bleeding kidney with gelatin sponge fragments.

Visualization of the gallbladder wall at excretory urography: implication for infusion tomography of the gallbladder.

Visualization of the gallbladder wall during intravenous infusion of diatrizoate has been equated with cholecystopathy. However, a large control group of patients without biliary tract symptoms has not been studied. The authors examined a group of 2,867 such patients who underwent excretory urography; the results suggest that visualization of the normal gallbladder wall occurs frequently enough to severely limit the usefulness of infusion tomography of the gallbladder in the diagnosis of cholecystopathy.

Pseudocysts: diagnosis in the adult by total body opacification.

Recent use of higher doses of contrast material for excretory urography in adults has made differentiation between cystic and solid masses feasible in adults just as it has been in children. The first two adults to have the cystic nature of their pseudocysts ascertained by total body opacification are presented. In one case, the mass was not palpable because the abdomen was markedly tender, suggesting that total body opacification may be helpful in the examination of the acute abdomen. The second case suggests the importance of the prone position.

Demonstration of dilated biliary ducts by total-body opacification. Differentiation of surgical from nonsurgical jaundice.

Differentiation of surgical from medical jaundice remains a difficult clinical problem. Dilated biliary ducts can be demonstrated by total-body opacification (TBO) and their typical appearance is presented. This suggests that TBO may represent a noninvasive adjunct in distinguishing surgical from medical jaundice.

Hepatic abscess. Diagnosis in the adult by total body opacification.

Two adults had the hypovascular nature of their hepatic abscesses ascertained by total body opacification. In one, total body opacification identified the hypovascular nature of the lesion, facilitating its differentiation from vascular hepatoma. In the other, the clinical diagnosis was acute cholecystitis with empyema of the gallbladder, and the liver was normal to inspection and palpation at celiotomy. Total body opacification may be helpful in the examination of abdominal masses.