Imaging appearances of ileouterine fistula complicating recurrent adenocarcinoma of the rectum.

Enterouterine fistulae are rare and nowadays are most commonly due to pelvic tumours. We review the literature and present the case of a woman who presented with an ileouterine fistula following surgery and radiotherapy for recurrent rectal adenocarcinoma. The presence of tumour within the fistula track may also have been a significant aetiological factor. Magnetic resonance imaging (MRI) is an excellent method to demonstrate the site and size of the track and has not, to date, been used to identify such a fistula.

Accident and emergency and general practitioner plain radiograph reporting by radiographers and radiologists: a quasi-randomized controlled trial.

Two specially trained radiographers at York District Hospital have been reporting appendicular plain radiograph X-ray examinations for Accident and Emergency (A&E) patients since February 1995. This study explores the potential for further expanding their reporting role. This was achieved by assessing the two radiographers' and a group of consultant radiologists' ability to report on a retrospectively selected random stratified sample of 400 A&E and General Practitioner (GP) plain radiograph X-ray examinations for all body areas. Using receiver operating characteristic (ROC) curve analyses there was no statistically significant difference at the 5% level between the area under the ROC curves for the radiographers and consultant radiologists when reporting A&E or GP plain radiographs. It may be feasible to expand the reporting role of suitably trained radiographers to include plain radiograph X-ray examinations for all A&E patients and for GP patients, with no detriment to the quality of reports.

Case report: accumulation of 99mTc-hydroxymethylene diphosphonate by liver metastases of prostatic adenocarcinoma.

We describe the case of a man with known prostatic carcinoma and bone metastases who was admitted with jaundice and hepatomegaly. A bone scan showed uptake of diphosphonate by the liver and ultrasound suggested the presence of diffuse metastatic disease. Liver biopsy revealed foci of carcinoma cells in the portal tracts which exhibited positive cytoplasmic staining for prostate-specific antigen, thus confirming the presence of metastatic prostatic adenocarcinoma.

A barium enema training programme for radiographers: a pilot study.

We describe a training programme designed to instruct radiographers how to perform the double contrast barium enema (DCBE). The programme was assessed by comparing the first 50 unsupervised examinations with studies performed by senior registrars in radiology. Comparison was made by marking each study blind in terms of barium coating, colonic distension and visualisation of the colon in double contrast. A note was also made of the number of exposures, screening time, examination time and complications. No difference was found in any of these parameters when comparing the two groups. A further 50 patients were assessed at one year and this showed that standards had been maintained in terms of the above criteria. Follow-up at 3 years in the initial group has shown no missed pathology. We believe that delegation of the performance of the DCBE to radiographers is both acceptable to the patient and safe.

Is the appendix where you think it is--and if not does it matter?

For over 100 years the recognized surface marking for the appendix has been McBurney's point (the junction of the lateral and middle thirds of a line joining the umbilicus with the right anterior superior iliac spine (ASIS)). In order to test its validity, the relationship between McBurney's point and the appendix was determined on 275 double contrast barium enemas (DCBE). A wide spread of distribution of the site of the appendix base was seen. Only 35% of appendix bases were found to lie within 5 cm of McBurney's point, and 15% were more than 10 cm distant. Seventy-five per cent of appendix bases were below and medial to a line joining the umbilicus with the right ASIS. These findings are in agreement with world-wide studies conducted by the World Organisation of Gastroenterology which showed that less than half of all patients with appendicitis have tenderness maximal over McBurney's point. A record was also made in 93 cases of the position of the appendix in relation to the caecum. The importance of these results in the diagnosis and management of patients with suspected appendicitis is discussed.

Gastroduodenal obstruction from ovarian cancer: imaging features and clinical outcome.

OBJECTIVE: The purpose of this study was to describe the imaging features and clinical significance of gastroduodenal obstruction from ovarian cancer. MATERIALS AND METHODS: Eleven women with symptomatic gastroduodenal obstruction were identified over a 3-year period of prospective clinicoradiological review of cases managed in a specialist gynaecological oncology unit, during which period 438 women with ovarian cancer were managed. Imaging features were verified by surgery, intervention and clinicoradiological follow-up for a minimum of 12 months or until death. Management and outcome were independently reviewed by a medical oncologist not involved in primary care. RESULTS: The frequency of gastroduodenal obstruction was 2.5% (11 of 438 women). Disease stages of these women at initial diagnosis were: stage II (four women), stage III (six), stage IV (one). Histology was grade 3 in eight of the 11 women. Symptomatic gastroduodenal relapse occurred at 9-103 months after initial diagnosis (median 20 months). There were five cases of predominant involvement of the gastric body and six of the gastric outlet and duodenum. In six cases, focal mass disease resulted in obstruction, in two cases there was diffuse gastric invasion, and in three cases encysted malignant ascites in the lesser sac caused gastric compression/obstruction - the 'squashed stomach syndrome'. Diagnosis of obstruction was with CT in 10 of 11 cases. Palliative interventional procedures relieved symptoms in these three cases, surgery was performed in three cases and the remainder were treated with chemotherapy and other palliative measures. Two women are alive and well at 16 and 38 months who had loculated ascitic disease. Otherwise median survival was 5 months after symptomatic gastroduodenal involvement. CONCLUSIONS: Gastroduodenal obstruction is rare in women with ovarian cancer. Identification and drainage of encysted lesser sac ascites as its cause may be associated with long term survival, otherwise the prognosis is poor. CT accurately demonstrates the level and cause of obstruction and gives information about the wider extent of recurrent disease.

Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents.

OBJECTIVE: Gastroesophageal anastomotic leak after cancer resection has a mortality rate of up to 60% and significant morbidity, whatever the mode of treatment. We assessed the efficacy of esophageal stenting as a therapeutic option to reduce the mortality and morbidity associated with symptomatic intrathoracic anastomotic leakage. SUBJECTS AND METHODS: During a 52-month period, 14 patients had placement of stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophagojejunal anastomosis. Thirteen of 14 patients had tumors that were histologically staged as T3 N1 M0 or worse. Significant anastomotic leaks were revealed by a contrast-enhanced study at 3-28 days after surgery. Stents were inserted in patients in whom the leakage was debilitating or initial conservative treatment had failed. Stenting outcome in terms of clinical and radiologic healing, hospital stay, survival, and complications was assessed. RESULTS: No procedural morbidity or 30-day mortality occurred. Immediate postprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing time of 6 days. Of the 13 patients, healing occurred within 10 days in 10 patients (76.9%). Eight of these 10 early closures received a knitted nitinol stent (p = 0.02). One patient (7%) died as a consequence of leakage at 135 days. Median survival for all 14 patients was 11 months (Kaplan-Meier method). Complications included five episodes of food blockages in three patients, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic stricture or occlusive epithelial hyperplasia. CONCLUSION: Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesophageal cancer. Knitted nitinol stents may be best suited to this purpose.