Water flush technique: a noninvasive method of optimizing visualization of the distal esophagus in patients with primary achalasia.

OBJECTIVE: The purpose of this study was to assess the use of a water flush technique to optimize visualization of the distal esophageal mucosa during barium esophagography of patients with moderate to severe primary achalasia. The water flush consists of having patients drink tap water at end esophagography in an attempt to clear the standing barium column. CONCLUSION: The water flush technique is a simple, noninvasive maneuver that improves the extent of diagnostic visualization of the distal esophageal mucosa in patients with moderate to severe primary achalasia. It facilitated detection of a tumor in one patient and identification of additional pathologic changes in two other patients in this series.

Duodenal switch gastric bypass surgery for morbid obesity: imaging of postsurgical anatomy and postoperative gastrointestinal complications.

OBJECTIVE: The purpose of our study was to evaluate the normal postsurgical findings and appearance of gastrointestinal tract complications in patients who have undergone biliopancreatic diversion with duodenal switch bariatric surgery. We performed a 4-year retrospective review of 218 patients who underwent duodenal switch surgery. CONCLUSION: The most common complications of duodenal switch surgery were bowel obstruction, followed by ventral hernias and anastomotic leaks. Only 2% of cases required repeat surgery for management.

Imaging findings in Roux-en-O and other misconstructions: rare but serious complications of Roux-en-Y gastric bypass surgery.

OBJECTIVE: The purpose of this study was to present the clinical and imaging findings of Roux-en-O and other misconstructions of Roux-en-Y gastric bypass surgery. The more common complications of Roux-en-Y gastric bypass have been described in the literature. Complications secondary to misconstructions are rare and difficult to diagnose. CONCLUSION: Roux-en-O or other misconstruction should be suspected in patients with chronic bilious vomiting after Roux-en-Y gastric bypass when no mechanical basis for obstruction can be identified. Fluoroscopic motility assessment is often critical in the diagnosis of these misconstructions.

Superior mesenteric vein thrombosis after colectomy in a patient with Crohn's disease.

BACKGROUND: An 18-year-old woman with a history of Crohn's disease presented in January 2004 with severe epigastric pain, nausea and vomiting of 4 hours' duration. The patient was diagnosed with inflammatory bowel disease, thought to be consistent with ulcerative colitis, in March 2003, but had no medical history up until this point. Initial treatment with mesalamine was unsuccessful and she subsequently presented with medically resistant fulminant colitis and required an urgent colectomy in June 2003. Her immediate postoperative course was uneventful and she was discharged on tapering doses of prednisone. In August 2003, an ileoscopy revealed inflamed, mildly ulcerated mucosa, and biopsies were consistent with Crohn's disease. Azathioprine was added to the treatment regimen and the patient tapered off prednisone. At this stage the patient continued to do well clinically up until presentation. INVESTIGATIONS: Small bowel series, abdominal CT scan, abdominal ultrasound, exploratory laparotomy. DIAGNOSIS: Acute mesenteric ischemia secondary to superior mesenteric vein thrombosis. MANAGEMENT: Resection of necrotic bowel, antibiotics and systemic anticoagulation.

Atypical complications of gastric bypass surgery.

Although gastric bypass surgery continues to grow in popularity for weight loss and weight maintenance in the morbidly obese, there has been little attention given to the imaging of complications associated with these surgeries. The purpose of our study is to demonstrate the variety of gastric bypass surgery complications that can be identified radiographically, with attention to the more unusual complications. This study was performed with institutional Internal Review Board approval. We performed a 5-year retrospective review of all patients who had undergone gastric bypass surgery, had complications of the surgery, and had studies performed in our department to image these complications. These studies consisted of contrast fluoroscopy and CT. We identified the more common complications of anastomotic stenoses and anastomotic leaks. We also identified six unusual complications as follow: (1) internal herniation through the small bowel mesentery, (2) internal herniation through the transverse mesocolon, (3) external herniation through the abdominal wall incision, (4) enterocutaneous fistulas, (5) antiperistaltic construction of the Roux-en-Y, and (6) incorrect anstomoses of the Roux limbs resulting in a Roux-en-O configuration. Our findings show that a thorough understanding of expected postoperative bowel configuration is essential in the evaluation of these patients. In addition, fluoroscopic evaluation should assess not only anatomy, but also motility.

Low-frequency stimulation of STN-DBS reduces aspiration and freezing of gait in patients with PD.

OBJECTIVES: To study whether 60-Hz stimulation, compared with routine 130 Hz, improves swallowing function and freezing of gait (FOG) in patients with Parkinson disease (PD) who undergo bilateral subthalamic nucleus (STN) deep brain stimulation (DBS). METHODS: We studied 7 patients with PD who experienced FOG that persisted despite routine 130-Hz stimulation and dopaminergic medication. Each patient received 3 modified barium swallow (MBS) studies in a single day under 3 DBS conditions in the medication-on state: 130 Hz, 60 Hz, or DBS off, in a randomized double-blind manner. The laryngeal penetration and aspiration events were cautiously assessed, and a swallowing questionnaire was completed. The Unified Parkinson's Disease Rating Scale, Part III motor score, axial subscore, tremor subscore, and FOG by a questionnaire and stand-walk-sit test were also assessed. The best DBS condition (60 Hz here) producing the least FOG was maintained for 3 to 8 weeks, and patients were assessed again. Changes in measurements between the 60 Hz and 130 Hz were analyzed using paired t test, with swallowing function as primary and the remainder as secondary outcomes. Changes between other DBS conditions were further explored with Bonferroni correction. RESULTS: Compared with the routine 130 Hz, 60-Hz stimulation significantly reduced aspiration frequency by 57% on MBS study and perceived swallowing difficulty by 80% on questionnaire. It also significantly reduced FOG, and axial and parkinsonian symptoms. The benefits at 60-Hz stimulation persisted over the average 6-week assessment. CONCLUSIONS: Compared with the routine 130 Hz, the 60-Hz stimulation significantly improved swallowing function, FOG, and axial and parkinsonian symptoms in patients with PD treated with bilateral STN-DBS, which persisted over the 6-week study period. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for patients with PD who experience FOG, STN-DBS at 60 Hz decreases aspiration events observed during MBS compared with DBS at 130 Hz.

Gastroesophageal reflux disease and antireflux surgery-what is the proper preoperative work-up?

BACKGROUND: Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD). AIMS: The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS. PATIENTS AND METHODS: One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient. RESULTS: Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n = 78, 58 %) and GERD- (n = 56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD- patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD- patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups. CONCLUSIONS: The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.

Enteroclysis and computed tomography enteroclysis.

Enteroclysis, the most detailed radiologic examination of the small bowel, can be a challenge for both patient and radiologist. This article broadly outlines the principal technical features of the standard enteroclysis procedure and discusses its diagnostic advantages and indications, as well as its limitations and difficulties. A comparative assessment of computed tomography-enteroclysis and the emerging magnetic resonance adaptation complements the survey of current approaches to radiologic small bowel diagnostics.