Case report: identification of the transverse mesocolon and root of small bowel mesentery; a new sign of pneumoperitoneum.

A new sign of pneumoperitoneum was observed in a patient with perforation of the ascending colon. The presence of free air in the peritoneal cavity allowed identification of the transverse mesocolon and the root of the small bowel mesentery on plain abdominal radiographs obtained in the supine and in the prone position. This sign may be an aid in the diagnosis of pneumoperitoneum.

[Rehabilitation of oro-pharyngeal dysphagia of neurogenic etiology using radiological examination: preliminary results]. / Riabilitazione della disfagia oro-faringeaad eziologia neurogena guidata dall'indagine radiologica: risultati preliminari.

Dysphagia is more frequently observed in patients with neurologic diseases (stroke, bulbar or pseudo-bulbar syndrome, amyotrophic lateral sclerosis, cranial trauma). Furthermore, the presence of this pathology is obviously more frequently noted in the light of the increase in the length of the human life span. It has become evident that alternative feeding procedures such as the nasogastric tube or gastrostomy may bring about complications and deprive patients of the oral phase of deglutition which plays a leading role in stimulating digestive functions. The Authors report a systematic research on the rehabilitation aspects of neurogenous dysphagia. All the patients studied underwent a neurological examination and oropharyngeal functional evaluation using echo-videorecording of the oral phase of deglutition and fluoro-videorecording of the pharyngeal phase. The data obtained allowed for the selection of five patients considered suitable for the rehabilitation program. One of them had a multi-infarct encephalopathy, two a spastic hemiplegia f.b.c., a fourth a cerebellar syndrome and the last a sequela of meningioma removal of the ponto-cerebellar angle with peripheral paralysis of the right VII, IX, X, XI cranial nerves. This last patient also underwent a crico-pharyngeal myotomy. Therapy consisted in making the patient sensitive to swallowing movements and in training them to assume a compensatory posture as well as functional rehabilitation of the organs involved in deglutition. The first datum emerging from the study is the lack of etiological homogeneity found in the cases treated with evident variability in different deglutition organ impairment, even though there was the common denominator of the dysphagia symptom. With regard to the results obtained, there was a complete resolution in one patient, while in the other four there was such an improvement as to allow the patients a safe autonomous oral assumption of food. The positive results obtained are not only linked to the recovery of damaged organs, but also to the development of compensatory strategies such as the choice of appropriate food consistency and the assumption of postures which protect the respiratory tract from aspiration and favor crico-pharyngeal relaxation.

Normal small-bowel measurements by enteroclysis.

Small-bowel length, number and thickness of folds in the jejunum and ileum, diameter of the loops, and thickness of the bowel wall were measured on double-contrast small-bowel enema radiographs, obtained from 182 patients with no jejunal or ileal morphologic abnormalities. The length of the small bowel ranged from 160 to 430 cm, with an average length of 291 cm. No correlation was observed between the number of folds and the total length.

Sonographic evaluation of physiologic bolus volume in oral swallowing.

Twenty-two nondysphagic normal subjects were sonographically studied to define the average volume of a physiologic fluid bolus. Several varying volumes (5, 10, 15, and 20 ml) of water were given to assess the average size of the swallowed bolus. At the onset of oral deglutition, when placed between the dorsum of the tongue and the groove of the hard palate, the bolus has an ellipsoidal shape, thus permitting sagittal, axial, and coronal measurements. Our results indicate that swallowed bolus volume rises proportionally to water bolus given up to 15 ml and that the average size of a physiologic fluid bolus is 7 ml.

[Radiologic patterns of the metastatic tumours of the large intestine (author's transl)]. / Il quadro radiologico dei tumori secondari del grosso intestino.

The metastatic tumours of the large intestine are not unfrequent. In the majority of cases they are due to the direct invasion from endo or retro peritoneal tumours, especially of the stomach and the pancreas. The radiologic findings of such lesions are described, and a correlation is made with the pathologic, pathogenetic and clinical aspects.

[Indications for enteroclysis. Retrospective study on 365 patients]. / Considerazioni sulle indicazioni dell'enteroclisi. Studio retrospettivo su 536 pazienti.

Small-bowel enema was performed in 536 patients referred for suspected malabsorption, enteritis, abdominal pain or obstruction. Lesions were found in 54% of cases. The positivity of the investigation was particularly high in clinically well-defined cases, such as suspected obstruction (80%) and enteritis (72%). The main indications and criteria of application of the investigation are discussed.

Small bowel length measured by radiography.

The jejunoileal length was measured on double-contrast small bowel enema radiographs, obtained from 10 patients who had been investigated for abdominal pain. Previous endoscopic and radiologic examinations had excluded lesions of the upper and lower GI tract. The length of the small bowel ranged from 230 to 370 cm, with an average length of 280 cm.

[Plain abdominal film in neoplasms of the large bowel. - A comparative study with a population of normal subjects (author's transl)]. / La significatività dell'esame radiografico diretto dell'addome nei carcinomi del grosso intestino. Studio comparativo con una popolazione di soggetti normali.

A comparative study was performed between plain abdominal films of 110 patients with neoplasms of the large bowel and 52 normal subjects for control. In neoplasms of the right colon the failed spontaneous visualization of caecum and ascendent colon or the direct recognization of lume's deformation allow us to suspect such a lesions in about 90% of the cases. Neoplasms of the other tracts of the large bowel may be suspected only when plain abdominal film demonstrates direct evidence of an obstruction: in about 25% of the cases.

[Double-contrast study of the small intestine using enteroclysis. Considerations on the results in 250 patients]. / Lo studio a doppio contrasto dell'intestino tenue per enteroclisi. Considerazioni sui risultati in 250 pazienti.

The value of double contrast small bowel enema via duodenal intubation using barium sulphate and methylcellulose as contrast media was assessed in 250 patients. In cases of small bowel obstruction it represented the first-line investigation after a plain abdominal film. It was performed electively in patients of painful bowel syndrome, in cases of malabsorption, in cases of endoscopically or radiologically diagnosed colitis and in patients with Crohn's disease. On the basis of our results we believe double contrast small bowel enema to be the most reliable investigation in the localization and identification of small bowel lesions.

Ultrasonographic evaluation of piecemeal deglutition in normal adults.

OBJECTIVES: To evaluate the range of multiple swallowing in normal subjects by ultrasonography. METHODS: Twenty-two normal subjects swallowed 5 or 10 ml of tap water or a semisolid meal. RESULTS: With water multiple swallows were seen in 41% of the subjects examined and was related to the volume of the bolus:18% of the cases were 5 ml and 36% were 10 ml. Sixty-eight percent of subjects had multiple swallows with semisolid boluses. CONCLUSION: These results differ from those reported with videofluoroscopy of modified barium swallowing. Ultrasonography should be used in future studies of normal and pathological oral swallowing.

Relationship between clinical and laboratory parameters and length of lesion in Crohn's disease of small bowel.

The correlation of 22 commonly used clinical and laboratory abnormalities with linear extent of the lesion was studied in 70 patients with Crohn's ileitis, 16 of whom had inactive disease and 54 active disease. Extent was measured radiologically using a well-validated double-contrast technique. In the patients with active disease, lesion length was significantly correlated with weight loss, serum albumin, total protein, and serum iron. In the group without active inflammation, pain and abdominal mass were significantly correlated with lesion extent. No correlation was found between linear extent of lesion and the following: an index of inflammatory activity (New Crohn's Disease Activity Index), several acute-phase reactants, and the components of the complete blood count. Only total protein and serum iron had a significant regression coefficient following a procedure of stepwise regression. No mathematical model was found capable of satisfactorily predicting the length of lesion.

[Morphological lesions of the choledochus studied with combined percutaneous transhepatic cholangiography and hypotonic duodenography]. / Lesioni morfologiche del coledoco studiate con colangiografia percutanea transepatica e duodenografia ipotonica associate.

Twenty two patients obstructive jaundice were investigated by combined fine needle percutaneous cholangiography and hypotonic duodenography. The association of the two techniques enables prompt localization of the site of obstruction and definition of the nature of the lesion. It proves to be of particular use in the differential diagnosis of carcinoma of the head of the pancreas, carcinoma of the distal choledochus and carcinoma of the socalled choledochoduodenal junction.

[Echography of the oral phase of deglutition]. / L'ecografia nello studio della fase orale della deglutizione.

Neither cineradiography nor videorecording are satisfactory techniques for the dynamic study of the oral phase of deglutition. Therefore, oral swallowing was studied by means of real-time sonography (US) in 20 asymptomatic patients. Both anatomy and motility of the muscles of the mouth and tongue were clearly demonstrated. Real-time US proved thus to allow an accurate and dynamic visualization of the oral phase of deglutition.

[Intestinal tuberculosis. The radiologic aspects of a disease not to be overlooked]. / Considerazioni sulla tubercolosi intestinale. Aspetti radiologici di una malattia da non dimenticare.

Intestinal tuberculosis still exists in the Western world, where it is usually underestimated and often mistaken for Crohn's ileo-colitis or cancer. The authors report the results of 4 cases of intestinal tuberculosis observed between 1983 and 1988. The cases are discussed in the light of the epidemiological data emerging from a review of recent medical literature. The danger is that the disease, which is endemic in Asian and African regions, may spread again in the Western world fostered by intensifying migrations of people and by the spreading of AIDS. According to recent experience, a negative chest film and Mantoux skin-test no longer have a negative predictive value for intestinal tuberculosis. In the radiological differentiation from Crohn's disease it is useful to keep in mind some topographic features of TBC: the systemic non-discontinuous involvement of both sides of ileocecal junctions; the unusual presence of ileal lesions, with no cecal lesions, and localizations below the transverse colon. Useful differential morphological criteria can be: star-like or transverse ring-shaped profile of isolated ulcerations, tubular ileocolic junction with retracted cecum and open valve, and uniformity of lesion in the comprehensive picture of the clinical case.

[The echographic visualization of the lingual bolus. The reference point in a study of dysphagia]. / La visualizzazione ecografica del bolo linguale. Punto di riferimento nello studio delle disfagie.

The videotape recording of the cinefluorographic images obtained with barium swallowing, proved to be very useful in studying pharyngo-esophageal motility. On the contrary, the method failed to be exhaustive in the study of the oral phase of swallowing. In 1983 Shawker et al. were the first authors to suggest the use of US to record tongue motility and the upward movement of hyoid bone. In a previous paper the authors had reported on the value of US videorecording in the dynamic study of oral swallowing, and of lingual bolus development and shape. In the present paper, the authors investigated how frequently the formation of lingual bolus can be recorded by means of US in patients with no dysphagic disorders. Sagittal and transverse scans were acquired in all patients with US units with 5 MHz probes connected to a U-matic videorecorder. In 98% of 50 examined patients, US demonstrated the presence of a lingual bolus in the preparatory phase of oral swallowing. Since lingual bolus formation in the oral phase of swallowing can be considered quite a normal event, the authors believe this finding to be a reliable reference-point in the study of oral swallowing.

[Radiologic assessment of extent of ulcerative colitis in acute phase]. / Valutazione radiologica dell'estensione della colite ulcerosa nella fase acuta.

One of the major reference points for both prognosis and treatment of ulcerative colitis is the assessment of its extent. Plain abdominal radiographs were performed on 97 patients previously diagnosed, by means of rectoscopy and histobiopsy, as having acute ulcerative colitis. Within the following 36 hours they underwent either full colonoscopy or colectomy. The extent of colitis was evaluated by means of double-blind radiography. The results were then statistically compared with those obtained from endoscopy or from direct study of surgical colonic specimens. There was agreement between the final X-ray results and the actual extent of ulcerative colitis in 78 of 97 patients (80.4%, r = 0.86). The highest agreement was observed in those patients whose lesions were localized in the rectosigma (81%) and in those with fully extended colitis (90%). The most useful radiological findings in predicting the extent of colic lesions were irregular mucosal profile and thickening of colic wall. The presence of these two signs, together with the flattening or swelling of interhaustral folds and the impossible visualization of the right colon, are invariably suggestive of fully extended colitis. On the contrary, no abnormal findings were present on plain abdominal films in 74% of proctosigmoiditis cases. Plain abdominal radiography seems to be useful for the initial evaluation of acute ulcerative colitis. It allows the early discrimination between diffuse and localized forms, and makes it possible to postpone more invasive and dangerous investigations to a remissive phase of the disease.

The plain abdominal film accurately estimates extent of active ulcerative colitis.

The aim of our study was to establish whether plain abdominal film can accurately assess the extent of active ulcerative colitis. Ninety-seven ulcerative colitis patients were studied, in whom the extent of the macroscopic lesion was established either by colonoscopy (n = 75) or by resection (n = 22). Of these, 42 had proctosigmoiditis, 12 left-sided colitis, 12 subtotal colitis, and 31 total colitis. Nine well-tested features were used for the radiological classification of lesion extent. The radiologists were not given any clinical information. Seventy-eight patients (80.4%) were correctly classified by plain abdominal film (r = 0.86); the best concordance was achieved for proctosigmoiditis and total colitis (80.9 and 90.3%, respectively). In total colitis the most reliable radiological features were "irregularity of the mucosal edge" and "increased thickness of the colon wall, " which were present in 74.2 and 67.7%, respectively, of the correctly classified patients. The fourfold combination of these two features with "loss of haustral clefts" and "empty right colon" was present only in patients with total colitis, and at least one of these features was present in all but one of them. Conversely, all nine abnormalities were absent in 73.8% of patients with proctosigmoiditis. In conclusion, plain abdominal film is a reliable tool for judging the extent of lesion in active ulcerative colitis. It seems particularly accurate in total colitis, where, in the acute phases, it is most important to avoid invasive examinations.

[Dynamic study of oro-pharyngeal deglutition]. / Lo studio dinamico della deglutizione oro-faringea.

Oropharyngeal swallowing is too fast and complex a motion for the human eye to seize its various phases and subsequently evaluate morphology and function of the anatomical structures involved. A chronological subdivision of the swallowing act is needed for a step-by-step analysis. Dynamic evaluation of oropharyngeal swallowing by means of fluoroscopic and US videorecording proved to be a reliable method. Echovideorecording allowed tongue movements to be depicted, together with bolus formation and propulsion. Fluorovideorecording (U-matic Sony unit, 25-30 images/sec) demonstrated pharyngeal and esophageal phases. A series of chronological and morphological reference points, which characterize oropharyngeal swallowing, were employed to analyze videorecorded images. Slow-motion mode, "freezed" images, and rewinding allowed an easy and accurate evaluation of swallowing details. Combined chronological and morphological pieces of information allow a comprehensive evaluation of the swallowing act.

[The extent of Crohn's disease. Radiological measurements. Correlation with surgical findings]. / La estensione dell'enterite di Crohn. Misurazione radiologica. Correlazione con i reperti chirurgici.

Twenty-three patients with small intestinal Crohn's disease were studied by barium-methylcellulose infusion. All patients underwent surgery within 1-24 months (average 7 months). The extent of the lesions and the small bowel length were radiologically evaluated by means of a map measurer. The same measurements were performed at surgery. Radiological and surgical data concerning the extent of enteritis were statistically correlated (r = 0.7). The correlation between radiological and surgical measurements of total small bowel length was not significant.