Low-volume hybrid bowel preparation combining saline laxatives with oral contrast agents versus standard polyethylene glycol lavage for colonoscopy.

PURPOSE: The aim of this study was to compare the quality of low-volume hybrid computed tomography colonography bowel preparation, using both laxatives and oral contrast, with standard polyethylene glycol lavage. METHODS: The study group consisted of 300 consecutive adults (mean age, 58.3 years) who underwent colonoscopy immediately after positive computed tomography colonography. Hybrid bowel preparation for study group was <1 L in total volume, consisting of osmotic cathartic (sodium phosphate or magnesium citrate) in conjunction with oral contrast (2% barium and diatrizoate). A control group of 300 adults (mean age, 58.3 years) underwent primary colonoscopy after standard 4-liter polyethylene glycol lavage without oral contrast. The prospective preparation quality rating by the endoscopist served as the reference standard. A rating of poor/marginal was considered inadequate and adequate/good/excellent was considered diagnostic. RESULTS: The frequency of inadequate bowel preparation was 4.3% (13/300) in the study group vs 12.3% (37/300) for the control group (P < .001). Specifically, preparation was poor or marginal in 10 and 3 cases in the hybrid cohort, respectively, and in 29 and 8 cases in the polyethylene glycol cohort, respectively. Preparation quality was scored as excellent in 32% (96/300) in the hybrid cohort and 23.3% (70/300) in the polyethylene glycol cohort (P < .05). CONCLUSIONS: At colonoscopy, low-volume laxative-oral contrast hybrid preparations are effective for bowel cleansing, perhaps even more so than polyethylene glycol lavage. Beyond improvements in quality, the low-volume preparation may improve patient compliance and would allow for immediate computed tomography colonography if colonoscopy is incomplete, without the need for additional oral contrast tagging.

Efficacy and safety of percutaneous transhepatic portal embolization before right liver resection using an ethibloc/lipiodol mixture: a single-center experience.

AIM: The purpose of this study was to evaluate the safety and efficacy of percutaneous transhepatic portal vein embolization of the right portal vein with an Ethibloc/Lipiodol mixture to induce hypertrophy of the left liver lobe in patients with primarily unresectable liver tumor. METHODS: 15 patients (8 primary liver tumors, 7 liver metastases) underwent portal vein embolization. Liver volumetry, duration of hospitalization, complication rates, relevant laboratory values were documented. RESULTS: In 13/15 patients (84.6%) embolization could be performed with a median of 8.8 ml (range 1.5-28 ml) Ethibloc/Lipiodol. One minor procedure-related complication (subcapsular hematoma) occurred, which did not affect the two-step liver resection. No patient developed acute liver failure after embolization or liver resection. The volume of the left liver lobe increased significantly (p = 0.0015) by 25% from a median of 750 ml (587-1,114 ml) to 967 ml (597-1,249 ml). 11/13 (81.8%) of the embolized patients underwent liver resection at a median of 49 days after embolization. Median hospitalization time was 4 days after embolization and 7 days after liver resection. Median overall survival of the 11 operated patients was 376 days. CONCLUSION: Percutaneous transhepatic portal vein embolization using an Ethibloc/Lipiodol mixture is a safe, feasible, and efficient interventional procedure.

Percutaneous portal vein embolisation in preparation for extended hepatic resection of primary nonresectable liver tumours.

BACKGROUND: In patients with malignant primary and secondary liver tumours or proximal bile duct carcinoma radical surgery is superior to all other therapeutic modalities in terms of survival and quality of life. Radical resection, however, often requires the removal of a large amount of liver parenchyma, resulting in a marked reduction of functional liver tissue with the risk of liver failure. AIM: Preoperative partial portal vein embolisation induces hypertrophy of the controlateral liver and thereby increases the safety of extended liver resections. PATIENTS AND METHODS: Between January 1997 and February 2001 we applied this strategy in 19 patients with primary and secondary nonresectable hepatobiliary malignancies, in whom the estimated amount of the remnant liver was < or =25% of the liver volume. RESULTS: The increase in volume ranged between 7 and 245%. Radical extended liver resection was performed in 13 patients (68%) without mortality. After a mean observation time of 22 months patient survival was 19 months with six tumour-related deaths during the second year after surgery. The remaining seven patients are alive and well with tumour recurrence in one. CONCLUSION: Preoperative partial portal vein embolisation allows more patients with previously unresectable liver tumours to benefit from a potentially curative resection.

Intralesional Ethibloc injections in primary aneurysmal bone cysts: an efficient and safe treatment.

OBJECTIVE: Ethibloc is a fibrogenic and thrombogenic agent recently proposed for the treatment of bone cysts. The purpose of this study is to report the results of direct Ethibloc injection in primary aneurysmal bone cyst (ABC) in children. DESIGN AND PATIENTS: Seventeen patients, aged from 2 to 18 years (mean 8 years), were treated with either a single injection (14 patients) or supplementary injections (3 patients) of Ethibloc. The histological diagnosis was assessed following surgical biopsy and was retrospectively reviewed. The mean follow-up was 5 years (range 18 months to 11 years). RESULTS: At 5 year follow-up, 14 of 17 patients demonstrated complete healing manifest by increased cortical and septal thickening. Surgical excision was required in three patients, in two of whom the ABC increased rapidly in size despite the injection, and in one of whom the healing was incomplete. We observed inflammatory reactions in 16 of 17 patients with local pain and fever. Three patients developed a small cutaneous fistula which resolved spontaneously in a few weeks. No major complications such as deep infection, pulmonary embolism, epiphyseal necrosis or malignant degeneration were observed. CONCLUSION: Percutaneous direct Ethibloc injection is a safe, efficient and noninvasive treatment for ABC. The authors highlight the frequent local reactions.

Peripheral blood eosinophilia associated with gastrointestinal administration of iodinated contrast media.

OBJECTIVE: This study was designed to assess whether gastrointestinal administration of iodinated contrast media results in peripheral blood eosinophilia. MATERIALS AND METHODS: We studied 110 patients in a retrospective review. Diatrizoate meglumine and diatrizoate sodium for abdominal CT were administered to 98 of these patients; 22 of the 98 had also been given the same contrast medium administered by enema. The remaining 12 patients were given diatrizoate sodium for gastrointestinal fluoroscopy. A control group of 65 patients underwent single-contrast barium upper gastrointestinal or enema examinations. WBC and eosinophil counts were determined approximately 24 hr before the examination and every 24 hr thereafter, through the ninth day. RESULTS: Eosinophilia was detected in 17 (15.5%) of 110 patients after gastrointestinal administration of iodinated contrast media. The prevalence of eosinophilia after administration of iodinated contrast media was statistically significantly different compared with that in the control group, in which none of the 65 patients had eosinophilia (p < 0.001). Eosinophilia was detected 48 hr after application of iodinated contrast agents and lasted through the sixth day, with a peak on the fifth day. The prevalence of eosinophilia was independent of route of application, dose, or type of iodinated contrast medium. Eosinophilia in all cases was clinically asymptomatic. CONCLUSION: Eosinophilia that is caused by gastrointestinal administration of iodinated contrast media is a transient, clinically silent phenomenon. It may lead to unnecessary workup for known conditions associated with eosinophilia.

Portal vein embolization with lipiodol for treatment of HCC--an experimental study.

A suspension of iodized oil and anticancer agent was injected into the portal veins of 20 rats with hepatic carcinoma. Oil drops were seen in tumor cell lines, small blood vessels inside the cancer nest, the sinusoid, and the central veins. After injection of oil suspension through the portal vein the distal small vessels were embolized and necrotic changes of tumor cells and their subordinate normal liver cells were observed. The results obtained in this experiment provided a good anatomical and pathological basis for treating liver cancers with the portal vein embolization with chemotherapeutic agents.

Time-lapse quantitative computed tomography lymphography: assessing lymphatic function in vivo.

RATIONALE AND OBJECTIVES: Immobility and massage produce different local limb lymph flow rates. We studied their influence on accumulation of radiopaque nanoparticulates in regional lymph nodes of normal rabbits. METHODS: Quantitative lymphography at 10-min intervals was used to follow the transport of subcutaneous (s.c.) nanoparticulates produced from insoluble esters of diatrizoic acid. In one design, both hindpaws received 0.5 ml of nanoparticulate s.c., and one hindpaw was massaged. In a second design, one hindpaw was injected and massaged while imaging the popliteal, presacral, and paraaortic nodes every 10 min. RESULTS: Gentle massage rapidly increased popliteal node accumulation in comparison with the immobile limb. On the massaged side, mean Hounsfield (HU) units, maximum Hounsfield units, and calculated iodine were significantly greater at 10 min and all subsequent times. In the node transfer experiments, it took 12, 30, and 45 min, respectively, to obtain 100-HU mean attenuation; 200-HU maximum attenuation thresholds were achieved at 20, 47, and 69 min, respectively. CONCLUSION: Quantitative computed tomography lymphography reflects local lymph physiology. Gentle massage of the s.c. injection site is a powerful lymphotropic stimulus.

Iodinated contrast medium as an aid to gallstone dissolution with methyl tert-butyl ether: in vitro study.

Methyl tert-butyl ether (MTBE) floats on bile, whereas gallstones sink. Therefore, stones and MTBE are separated by a layer of bile. This study investigates the effect of contrast medium on flotation of gallstones in bile and its role in stone and fragment dissolution with MTBE. Fresh human gallstones, both calcified and noncalcified, from different patients were tested in vitro for flotation in bile, with and without addition of contrast medium. All gallstones or fragments sank in bile before the introduction of contrast medium. Noncalcified stones floated when the contrast medium-bile volume ratio was 1:6 or more, while double this amount of contrast medium was required to float calcified stones. Fragments did dissolve somewhat in MTBE in the presence of bile alone, but when contrast medium was added, almost complete dissolution occurred. This is thought to be due to increased contact between the fragments and MTBE, both floating on the contrast medium-bile mixture. Contrast material may be a useful adjuvant in gallstone dissolution therapy with MTBE in vivo.

Gallbladder opacification in infants following high dose angiocardiography.

Seven infants in congestive heart failure underwent high dose angiocardiography for diagnosis of severe congenital heart disease and subsequently displayed delayed opacification of the gallbladder. Biliary excretion of sufficient volume to opacify the gallbladder occurred despite structurally normal kidneys and no evidence of renal failure. Decreased renal clearance of contrast due to generalized diminution of glomerular filtration is postulated. The high doses of contrast and slow renal clearance allowed a relatively increased rate of hepatobiliary excretion and subsequent observation of the opacified gallbladder on abdominal radiographs. This phenomenon may not be as uncommon as is generally thought but its timing and location often do not allow an opportunity to make this observation.

Regional lipiodolized chemotherapy for cholangiocarcinoma associated with oral contraceptives.

We describe a case of cholangiocarcinoma in a young woman, who presented with cholestatic jaundice following oral contraceptive ingestion. Following diagnostic laparotomy she received intra-arterial 'lipiodolized' chemotherapy. Intravenous mitozantrone was given for 2 years and she is asymptomatic, with computed tomographic evidence of tumour response, 27 months after diagnosis. We suggest that this form of treatment is of value for cholangiocarcinoma.

High-dose clinical urography with the low-osmolality contrast agent Hexabrix: comparison with a conventional contrast agent.

A double-blind clinical trial was performed in 60 patients to compare Hexabrix (ioxaglate meglumine and ioxaglate sodium) and Renografin-60 (diatrizoate meglumine and diatrizoate sodium). Use of Hexabrix produced higher urinary iodine concentrations, lower urine volumes at 30 minutes, and excretory urograms significantly better in diagnostic quality, as rated by four independent observers. There was no difference in nephrogram quality between contrast agents. Patients receiving Hexabrix had less of an increase in heart rate and demonstrated a slight rise in mean arterial blood pressure, rather than the biphasic rise then fall seen with Renografin-60. There was no significant change for up to 96 hours after urography in results of hematology, clinical chemistry, or urinalysis, except for an increase of 0.005 in urine specific gravity with Renografin-60. Patients reported significantly less body heat, heat in the injection arm, and overall discomfort with Hexabrix. There was a similar amount of nausea and vomiting in the two groups. Hexabrix also caused histaminic-type reactions in three patients.

Imaging of the bowel wall. Computed tomography and fat density oral-contrast agent in an animal model.

In this study, we reassessed the problems encountered in computed tomographic (CT) examinations performed with conventional bowel preparations, and developed a fat density oral contrast in dogs. Conventional high-density agents, water, fat (negative) density, and air were administered using a nasogastric tube to eight dogs (25 separate CT scans). Optimal and consistent identification of the gastrointestinal (GI) tract and mural visualization were achieved with 400 ml of 12.5% to 50% corn oil emulsions administered in four hourly divided doses. Mild diarrhea was observed with the 50% concentration only, but no untoward effect was noted clinically with 25% and 12.5% emulsions. Mixing the negative (fat) density oral contrast with the GI contents produced conditions optimal for high-CT contrast resolution of the GI wall. Standard intravenous administration of iodinated contrast agent enhanced mural visualization and, in conjunction with dynamic scanning, time density curves. This suggests that vascular perfusion could be portrayed. This animal model may be used for the experimental evaluation of a number of GI abnormalities, including ischemic, neoplastic, and inflammatory conditions.

Saliva secretion from the rat submandibular gland after retrograde infusion of radiographic contrast media.

Rat submandibular saliva was collected at various times after retrograde infusion of water-soluble (Renografin 60%) or lipid-soluble (Lipiodol UF) radiographic contrast medium. Significant alterations in flow rate occurred following heavy parenchymal filling with both types of contrast media. Occasional changes in protein concentration, lactoperoxidase activity, and K+ levels were also noted. These changes were relatively mild and transient, and gland function had generally returned to normal by one wk after infusion. No alterations in glandular function were detected after infusion of contrast medium to a degree (ductal filling) comparable to that usually employed in clinical sialography.

High-dose computed tomography in the evaluation of low attenuation lesions in the neck.

Recent reports have established the clinical utility of computed tomography (CT) in the evaluation of jugular vein thrombosis. Other abnormalities of the soft tissues in the neck can mimic this condition. This study reviews the pertinent normal soft tissue and vascular anatomy of the neck and describes the use of high-dose CT in the evaluation of low attenuation lesions in this area. Various abnormalities are compared and contrasted, including cystic hygroma, neoplasm, abscess, and venous thrombosis.

Direct cannulation and injection lymphangiography of the canine cardiac and pulmonary efferent mediastinal lymphatics in experimental congestive heart failure.

Lymphangiograms were made in dogs with experimental congestive heart failure by cannulation of the left cardiac efferent (LCE), left pulmonary efferent (LPE), or cardiopulmonary lymphatic and injection of radiopaque medium. The lymphoangiograms showed cardiac enlargement and dilated mediastinal lymphatic channels consistent with an increase in lymph flow. By consecutive injections in the LCE and LPE, wer demonstrated that a common channel, the cardiopulmonary lymphatic, is opacified by injection in either the LPE or LCE. This common channel has been called the "cardiac lymphatic" and used for the collection of "cardiac" lymph. The authors' experiments suggest that this cardiopulmonary lymphatic carries both cardiac and pulmonary lymph.

The incidence of contrast medium induced acute tubular necrosis following arteriography.

Twenty-one patients slated for high-dose arteriography were studied to investigate the impact of predisposing medical conditions upon contrast medium induced acute renal failure. The study suggests that predisposing medical conditions are the most important factor determining the incidence of acute renal failure and the probability, speed, and degree of recovery of renal function. Patients with diabetes mellitus incur the highest risk of contrast medium induced acute renal failure. A dose relationship is also suggested. Contrast medium doses containing more than 100 g of iodine uniformly produced acute tubular necrosis in patients with predisposing medical conditions. Conversely, contrast medium doses containing less than 80 g of iodine produced clinically manifest acute renal failure in only one of 14 patients with predisposing medical conditions. Subclinical levels of acute renal failure were recognized in a large number of patients by routine measurement of radionuclide filtration fractions, serum creatinine levels, and urine osmolality and sodium concentration.

Iosulamide: a new intravenous cholangiocholecystographic medium.

Iosulamide is a bis-benzoic analogue of metrizoate that shows clear advantages in animal tests over meglumine iodipamide. The intravenous toxicity of iosulamide meglumine is considerably lower than that of iodipamide (Cholografin) in the mouse and rat. The LD50 in mice for iosulamide meglumine is 11,500 +/- 844 mg free acid/kg and for iodipamide is 2380 +/- 290 mg free acid/kg. A threefold difference in toxicity was seen in rats; the LD50 for iosulamide meglumine is 13,600 +/- 1710 mg free acid kg and for iodipamide is 4430 +/- 310 mg free acid/kg. Iosulamide is a highly effective contrast agent for cholangiocholecystographic visualization in cats and monkeys. speed and degree of opacification are equivalent to that of iodipamide at equimolar doses. Studies of biliary and urinary excretion patterns indicate iosulamide is rapidly excreted compared to iodipamide, while at the same time providing equal concentrations in bile on an mg/ml bile basis. A more efficient blood to bile clearance rate and a shorter blood half-life for iosulamide may account for the lower circulating blood levels and rapid total excretion compared to iodipamide. Iosulamide's rapid blood-bile clearance coupled with its extremely low toxicity may allow rapid administration of high doses, affording superior visualization and safety compared to iodipamide. It may also provide visualization of the liver parenchyma with computerized axial tomography, due to the pharmacokinetic profile that provides for high liver clearance but low blood levels. The emetic potential of iosulamide meglumine is quite low compared to iodipamide. Iosulamide meglumine also lacks hypotensive activity. Little or no effect on blood pressure was seen with iosulamide meglumine in cats or monkeys, whereas iodipamide caused marked transient, or sustained, reductions. Iosulamide meglumine did not produce significant toxic effects when administered as single daily intravenous injections to albino rats for three weeks, or in 10-minute intravenous infusions to rhesus monkeys 10 times in 14 days. Clinical trials with iosulamide are under way.

Meconium ileus equivalent: treatment with Hypaque enema.

Meconium ileus equivalent is an unusual cause of intestinal obstruction in adults. In this paper we report of our experience with a 29-year-old male with a long-standing history of cystic fibrosis and recurrent abdominal pain. Following barium examination of the stomach and small bowel, the patient developed increasing abdominal pain and evidence of meconium ileus equivalent as the etiology of his small bowel obstruction. The obstruction was relieved by administration of a 20% sodium diatrizoate enema and oral saline cathartics. The clinical and radiographic findings of meconium ileus equivalent are reviewed, as is the use of water-soluble contrast agents in the management of this condition. The role of prior barium study in precipitating this condition is discussed.

Sequential changes in the CT numbers of the normal canine kidney following intravenous contrast administration. II: The renal medulla.

Following the intravenous administration of sodium and meglumine salts of both diatrizoate and iothalamate (at doses of 310-880 mg I/kg body weight) sequential changes in computed tomographic (CT) numbers of the inner medulla were determined in three dogs, using a 30-second CT scanner. Peak medullary enhancement was greater than, and usually occurred 1-2 minutes after, peak cortical enhancement. The CT number of the medulla increased linearly with increasingly large doses of the contrast agent. At peak enhancement, the meglumine salts produced a significantly lower (p less than 0.025) mean CT attenuation value of the medulla than did the sodium salts. The difference in mean attenuation values between the sodium salts and meglumine salts was maximum (50-60 HU)at peak enhancement. Our data indicate the known difference in renal handling of the meglumine and sodium salts is readily detectable by CT.

Passage of Gastrografin into the small mesenteric veins during an opaque enema.

An opaque enema was carried out with Gastrografin. The patient was a 2-year-old French boy. As the enema progressed we saw the small mesenteric veins opacify: no significant consequence followed. This is the first report of such an incident.