Obstructive jaundice and portal vein calcification.

Two patients with extrahepatic portal vein obstruction are described in whom calcification within the thrombus was identified during investigation for obstructive jaundice. Evidence from percutaneous cholangiography in one, and endoscopic cannulation of the common bile duct in the other, supported the view that the common bile duct was being partially compressed by the calcified cavernoma.

Primary malignant tumors of the heart.

Because of their rarity, primary malignant tumors of the heart continue to evade clinical preoperative diagnosis. In five cases of malignant heart tumor that were reviewed from the diagnostic point of view, the clinical symptoms and radiographic abnormalities were found to be similar to those produced by more common heart diseases. The diagnosis of malignant cardiac tumor should be considered in a patient with heart disease who has (1) an unusual cardiomediastinal silhouette, (2) an atypical cardiac calcification, and (3) clinical or radiographic cardipulmonary findings which do not conform to the expected behavior of the common forms of heart disease.

Detection and grading of oesophageal varices by fibre-optic endoscopy and barium swallow with and without Buscopan.

Detection of oesophageal varices is important in the diagnosis of portal hypertension. We have, therefore, compared the results of fibre-optic endoscopy and barium swallow in 56 patients with chronic liver disease. Oesophageal varices were graded as small, moderate or gross by independent observers for each technique. In 12 patients varices were not detected by either method, and in six cases varices were detected by endoscopy when the barium swallow was negative. In 15 of the remaining 38 patients varices were found to be one grade larger at endoscopy than on barium swallow. Since it is possible that varices appear larger at endoscopy because of the Buscopan (hyoscine N-butyl bromide) used as a relaxant, we carried out barium examinations after Buscopan 20 mg i.v. in 23 of the patients. In eight cases varices were one grade larger after Buscopan than on the standard barium swallow, and in two were only detected after Buscopan had been given. Eight cases negative after Buscopan were also negative at endoscopy. Although emergency endoscopy has particular value in locating the site of bleeding in patients with portal hypertension and acute gastrointestinal haemorrhage, the results of the present study suggest that a barium meal with Buscopan is as accurate as endoscopy in the detection of oesophageal varices.

The natural history of arthritis in idiopathic haemochromatosis: progression of the clinical and radiological features over ten years.

The natural history of arthritis associated with idiopathic haemochromatosis was studied in 18 male patients over a 10 year period. Chondracalcinosis was present radiologically in at least on joint in seven patients initially and developed later in 13, with the articular cartilages of the wrists and knees affected most frequently. During the period of observation seven patients developed chondrocalcinosis in the wrists, seven in the knees, three in the hips, one in the symphysis pubis and two in the spine. In no patient did the chondrocalcinosis decrease or disappear. The development and progression of chondrocalcinosis was not affected by treatment of iron overload by venesection. The presence of chondrocalcinosis in at least one joint was not related to the age of the patient at the initial or follow-up examination or to the amount of iron removed by venesection (p greater than 0.05, Wilcoxon rank sum test). Arthritis (loss of joint space, cysts, destruction of articular surfaces) usually with associated symptoms and signs affected the hands in eight patients initially and developed later in 13. Arthritis of large joints was uncommon and none of the patients in the present series developed destructive arthritis of hips or knees. This contrast with the finding in a retrospective survey of 93 patients with idiopathic haemochromatosis seen since 1967 at King's College Hospital in which seven patients had destructive arthritis affecting the hips.

Oral-contraceptive-associated liver tumours: occurrence of malignancy and difficulties in diagnosis.

Seven of ten women with oral-contraceptive-associated liver tumours were found to have hepatocellular carcinoma. The diagnosis was often delayed, although hepatomegaly was always present on examination, and liver-function tests and erythrocyte sedimentation-rates were abnormal in most cases. Other investigations, including routine technetium liver scans and biopsy, were sometimes misleading. There were important differences in alpha-fetoprotein concentration, vascularity on angiography, and survival between liver tumours in pill users and non-users.

PIP: A physician's personal series of 10 women treated from 1970-1979 for oral contraceptive-associated liver tumors is presented. Of the 10 women treated, 7 had hepatocellular carcinoma and 3 had benign adenomas. Symptomatology is described. Problems with diagnosis of liver dysfunctions included misleading biopsies and liver scans. The erythrocyte sedimentation rate was raised in all but 1 woman, and it was above 70 mm/h in 7. Changes in liver function tests were consistent with an intrahepatic tumor, with a striking increase in alkaline phosphatase in 9 (1170 IU/ml), and with only a slight rise in serum aspartate transaminase (mean 55 IU/ml). None of the patients had alpha fetoprotein levels above the upper limit of normal, and all patients were negative for hepatitis B surface antigen and antibody and anticore antibody. The carcinoma characteristics were similar in 7 patients (irregular trabecular arrangement with basophilic and dysplastic cells with nuclear pleomorphism and increased mitotic figures). When these oral contraceptive users were compared with 7 women diagnosed with hepatocellular tumors who had never used oral contraceptives, several striking differences were found. None of the poll users with carcinoma had raised alpha fetoproteins, whereas 4/7 nonpill users did. By arteriography, tumors in nonusers were much less vascular and less well defined. Survival rates also differed, with a 50% survival time of 1-8 years in nonusers compared with 4-8 years in pill users. The striking feature of this series is the delay in reaching a diagnosis in most of the 10 cases treated.

Late results of treatment of deep vein thrombosis.

Twenty-two patients who had an acute episode of thrombosis in the deep veins of the legs were studied by a new technique of ascending functional cinephlebography 6 to 12 months after the episode of thrombosis.If the condition was diagnosed within 36 hours and the thrombus was dissolved rapidly valve function was preserved. When diagnosis was delayed there was a very great risk of permanent damage to the valves.

Observer variation in the clinical and radiological assessment of hepatosplenomegaly.

The size of the liver and spleen of 32 patients was assessed by four clinicians from a clinical examination and by four radiologists from a plain radiograph of the abdomen. The latter assessment was found to be subject to less variation than the former, particularly in regard to the liver. Large livers and spleens were more easily seen radiologically than small ones. Most of the variation among the radiologists arose because of the 6% and 24% of cases in which the liver and spleen, respectively, were poorly seen on the radiograph. It is concluded that a plain radiograph of the abdomen, including the diaphragm and with the costal margin indicated, is a useful adjunct to clinical examination.

Medial arterial calcification and diabetic neuropathy.

X-ray examinations of the feet, knees, and hands were performed on 20 diabetics with severe neuropathy and 20 diabetics with no evidence of neuropathy but with a similar mean age and duration of diabetes. All were under 53 years old with no clinical evidence of peripheral vascular disease. Medial arterial calcification was much more common and extensive in the patients with neuropathy, occurring in the feet in 15 and in the hands in eight compared with in four (p less than 0.001) and none (p less than 0.001) of the controls respectively. Although there was some correlation between calcification and both proteinuria (p less than 0.05) and proliferative retinopathy (p less than 0.02), the association between calcification and neuropathy (p less than 0.001) was much stronger. Neuropathy, with sympathetic denervation of the smooth muscle of the tunica media, may be important in the aetiology of medial arterial calcification.

Incidence and pathophysiology of pulmonary edema in fulminant hepatic failure.

Thirty-seven of 100 consecutive patients with fulminant hepatic failure had clinical and radiological evidence of pulmonary edema. None of them had clinical evidence of left heart failure, and the pulmonary artery wedge pressure measured in 12 patients was normal. Similarly, there was no evidence to incriminate renal failure, endotoxemia, or hypoalbuminemia. However, there was a significantly higher incidence of pulmonary edema in patients with cerebral edema, suggesting either a central origin for the pulmonary edema or common factors predisposing to edema in both sites. An additional local factor may have been the presence of intrapulmonary vasodilatation. Detailed isotope studies in 11 patients showed a significantly increased pulmonary extravascular water volume in the patients with pulmonary edema which was in keeping with the severity of the radiological changes. Although the over-all mortality was higher in those patients with pulmonary edema than in those without, the difference was not significant, and early ventilation with positive and expiratory pressure achieved adequate oxygenation in all but 3 patients.

Comparison between iodamide and iothalamate in intravenous urography.

A number of iodinated contrast media such as Iothalamate, whose excretion depends on glomerular filtration are well established for use in intravenous urography. Iodamide, a relatively new iodinated contrast medium, is thought to be actively secreted by the tubules in addition to glomerular filtration. We set out to compare the nephrogram and pyelogram using these two types of contrast medium, injecting each either slowly or rapidly. Only patients with normal plasma urea and creatinine concentrations were included in the assessment. The results, although inconclusive, suggest that the quality of the nephrogram and pyelogram is better with Iodamide than with Iothalamate.

Mesentericocaval "jump" graft in management of portal hypertension: experience with 24 cases.

A series of 24 patients with cirrhosis have undergone mesentericocaval shunt operations for the relief of portal hypertension. Overall the results have been satisfactory. Four of the five patients treated as an emergency and 17 of the 19 who had the operation two to six weeks after haemorrhage had been controlled left hospital alive and well. Separation of the patients into three categories according to the findings of clinical and biochemical tests, however, showed that subsequent survival was satisfactory for patients in categories A and B but that all four patients in category C had died within one year after surgery. Assessment at three months showed that in three patients moderate hepatic encephalopathy had developed.Evidence that the shunt remains patent was shown by a low incidence of repeated gastrointestinal haemorrhage and a marked diminution in variceal size in 18 of the 19 cases examined serially. Radiographic techniques for confirming shunt patency were compared and cannulation of the graft via the femoral vein was found to provide a reliable and rapid means of assessment.

Treatment of bleeding oesophageal varices by infusion of vasopressin into the superior mesenteric artery.

Seventeen patients bleeding from oesophageal varices were treated by continuous infusion of vasopressin through a catheter inserted percutaneously and positioned in the superior mesenteric artery and in two other patients catheterization proved technically impossible. Bleeding was completely controlled on only four out of 18 occasions in the 17 patients treated. In seven patients, bleeding was controlled for two or more days but then recurred although the infusion was continued with an increased dose of vasopressin. There was a high incidence of complications, including bleeding from the site of catheter insertion in the groin and septicaemias. Sengstaken balloon tamponade and oesophageal transection had to be used to control bleeding in some patients but only six out of 17 survived to leave hospital.

Diabetic gastroparesis from autonomic neuropathy: surgical considerations and changes in vagus nerve morphology.

Two cases with intractable vomiting due to gastroparesis, a rare feature of diabetic autonomic neuropathy, are described. Both required surgical treatment. In the first a gastroenterostomy was complicated by reflux gastritis requiring a revision operation; in the second a gastrojejunostomy was successful. Electron microscopic studies of the vagus nerve in one of the cases showed a severe reduction in the density of unmyelinated axons, the surviving axons tending to be of small calibre. The severity of the abnormalities supports the view that diabetic gastroparesis is related to vagal denervation.