Emphysematous gastritis: case report and review.

Emphysematous gastritis is a condition involving gastric wall inflammation, radiologic or intraoperative evidence of intramural gas, and systemic toxicity. A recent case of emphysematous gastritis in a 57-year-old diabetic man is reported, and 27 cases published since 1889 are reviewed. Predisposing factors include ingestion of corrosive substances (37%) and alcohol abuse (22%). Diagnosis of emphysematous gastritis is based on the clinical presentation of an acute abdomen with systemic toxicity and on radiographs demonstrating gas bubbles within the stomach wall. For the case reported herein, computed tomography was useful both in establishing the diagnosis and in following the resolution of emphysematous gastritis. Organisms most commonly involved were Escherichia coli (six cases), Streptococcus species (six cases), Enterobacter species (five cases), and Pseudomonas aeruginosa (three cases). The mortality was 61% (17 of 28 patients), and morbidity with gastric contractures occurred in 21% of cases (6 of 28). Optimal therapy has not been defined; however, antimicrobial chemotherapy and surgery, when appropriate, may improve survival rates.

Acute diverticulitis in patients under 40 years of age: radiologic diagnosis.

During a 4-year period, eight patients 40 years old or younger had surgically proved diverticulitis at our institution. None of these patients had connective-tissue diseases or were on medication (i.e., steroids) that would predispose them to diverticulosis. The presenting clinical symptoms in this group of patients were often misleading, and in only one of the eight cases was the correct clinical diagnosis made at the time of admission. Of the three diagnostic studies that were performed (barium enema, sonography, and CT), barium enema was the most accurate, yielding evidence for diverticulitis in six of seven cases. The degree and extent of diverticulosis in these patients was minimal compared with that in the older patients. CT showed abdominal abscesses in two patients; in one, a mistaken diagnosis of Crohn disease was made; in the other, diverticulitis was correctly identified. In the three patients in whom sonography was performed, the findings were negative for diverticulitis. Our experience suggests that the diagnosis of acute diverticulitis should be considered in patients with abdominal pain who are less than 40 years old.

The contralateral decubitus chest film.

The radiology and emergency medicine literature have emphasized the value of the cross-table decubitus chest film taken with the hemithorax containing the suspected pathology in the dependent position. When used in conjunction with the upright chest film, the contralateral decubitus film (with the side of interest up) often reveals more information than does the film with the side of interest dependent. The unsuspected bilaterality of pleural effusion, especially when subpulmonic, often is revealed, as is pathology in the lung base that is obscured by large effusion or cardiomegaly. Masses, cavities, and areas of consolidation may become apparent. Especially important in pediatric patients, vascular structures can be distinguished from infiltrate. The contralateral decubitus film should be obtained when examinations in other positions have yielded equivocal results, rather than repeating an examination. This avoids unnecessary radiation exposure and is cost effective. Because of their complementary nature, in many cases both decubitus views should be obtained.

Product selection criteria for intravascular ionic contrast media.

The chemistry, clinical use, pharmacokinetics, adverse reactions, dosages, and formulary recommendations for intravascular ionic contrast media routinely used in radiologic procedures are reviewed. The meglumine, sodium, or combined meglumine-sodium salts of triiodinated benzoic acid derivatives, diatrizoic and iothalamic acid, are commonly used as intravascular ionic contrast media for radiographic visualization of blood vessels and the urinary tract. Meglumine salts of iodoxamate and iodipamide are used for intravenous cholangiography. The iodine in the contrast medium is responsible for the absorption of x-rays and the resulting opacification of the organ system or other area under investigation. Adverse reactions to intravascular ionic contrast media broadly include hypersensitivity and chemotoxic reactions. The incidence of major life-threatening hypersensitivity reactions, such as severe hypotension, cardiac arrhythmias or arrest, pulmonary or laryngeal edema, and convulsions, is estimated at 0.01-0.1% of the population receiving these agents. Dose- and concentration-dependent chemotoxic reactions result from the direct effects of the contrast medium on the blood vessels or organs being perfused. The meglumine salts of diatrizoic acid and iothalamic acid are less toxic in the cerebral circulation than sodium salts; hence, diatrizoate meglumine or iothalamate meglumine are recommended for cerebral angiography. In coronary angiographic examinations, combined meglumine and sodium (6.6 parts meglumine to 1 part sodium) formulations of diatrizoate are recommended because they consist predominantly of the meglumine salt with minimal but adequate amounts of sodium to prevent ventricular fibrillation. Predominantly meglumine salts of diatrizoic and iothalamic acid are also used for peripheral angiography, computerized tomography, and digital subtraction angiography. The dosages of ionic contrast media vary considerably depending on the nature of the radiological examination, the respective technique employed, and the age and condition of the patient. The cost differences between diatrizoate and iothalamate media are typically minimal. Formulary recommendations regarding the appropriate chemical nature of these media are based on the reported adverse reactions with these agents.

Distribution of colonic polyps: increased incidence of proximal lesions in older patients.

Several recent studies have shown a proximal shift in the distribution of colonic carcinoma compared to older studies. Because of the association between polyps and cancer, the authors evaluated the distribution of colonic polyps in 3,664 consecutive patients who had a colon examination over a period of 14 months. A total of 967 colorectal polyps were found in 633 patients. In all, 502 polyps (52%) were proximal to the rectosigmoid. Older patients had significantly more right-sided polyps and fewer rectosigmoid lesions. Large polyps occurred more frequently in the right colon, and this was also statistically significant. Gender has no effect on polyp distribution. The authors conclude that the importance of screening for polyps, particularly on the right side of the colon, increases with age.

Gastric hemangioma associated with phleboliths.

We describe the third instance of successful preoperative diagnosis of gastric hemangioma based upon the identification of phleboliths associated with the lesion. Double-contrast radiographs of the stomach showed the extent of involvement by intramural hemangioma, which was subsequently resected.

A computer-based gastrointestinal information management system.

A clinical data base system was developed that integrates gastrointestinal radiologic examinations, endoscopic studies, and pathologic diagnoses. An interrogative language is used, so that data input occurs by response to a series of relevant questions and answers that are constructed by the clinical staff without programmer support. Data are stored in a hierarchical, natural-language (noncoded) format, making them easily understandable by all clinical groups. Since the computer system is interactive, there are on-line capabilities for data input at various times as well as for instantaneous retrieval of all data on a given patient. Retrieval (search) of data uses Boolean logic, allowing for intercorrelative studies among radiology, endoscopy, and pathology. Data can then be isolated in files in which the computer can generate demographic and statistical data by use of a series of programs. Both data search and analysis can be accomplished without programming knowledge. Not only are research functions served by the system, but educational functions such as preparation of conferences and lectures, professional quality assurance, and resident teaching through follow-up and missed-case review can be performed.

Radiologic recognition of colonic diverticula simulating polyps.

The differentiation of colonic polyps and diverticula on the double-contrast barium enema is generally straightforward, using current diagnostic criteria. However, diverticula may be misinterpreted on the double-contrast barium enema as polyps when they appear uncommonly as filling defects within the barium pool. As a result of such erroneous interpretation, the patient may subsequently undergo costly and inconvenient repeat barium enema or colonoscopy. Carefully studied scout films, oblique views, compression spot images, and postevacuation films generally can differentiate these diverticula from polyps. The usual reason that a diverticulum assumes the appearance of a polyp is that it contains impacted stool.

Compensation filtration for decubitus radiography during double-contrast barium enema examinations.

Lateral decubitus images obtained during double-contrast barium enema examinations may be difficult to interpret because of the large difference in density between the various parts of the radiographs. Several types of filters are described which can be used to rectify this problem, thus improving the quality of the decubitus radiographs and achieving a slight reduction in radiation exposure.

Gastroduodenal response to low-dose glucagon.

A prospective, double-blind clinical study of the double-contrast upper gastrointestinal examination involving 240 patients was performed using glucagon in doses from 0.025 to 0.125 mg, in 0.025 mg increments. Although motility was diminished, neither gastric distension or coating was improved with the use of glucagon. However, duodenal distension and coating were markedly enhanced. The response of the pylorus was individualistic. The pylorus remained patent in most patients, and glucagon would not prevent barium spillage in the duodenum. However, in those patients with a "competent" pylorus, increasing glucagon doses produced a delay in gastric emptying. Several other variables, including weight, age, and gender, were studied and were not believed to be of clinical significance. Spontaneous gastroesophageal reflux was also increased with the use of glucagon. Glucagon mainly enhanced duodenal visualization but had no beneficial effect on the stomach or pylorus. Absolute dose is the most important factor, and all observable changes can be seen once a certain threshold dose (0.05 mg) is reached.

Work in progress: radioisotopic evaluation of gastroplasty patients.

Radioisotopic gastric emptying studies, using technetium-99m-sulfur-colloid-labeled egg, were performed in 14 patients who had undergone gastroplasty. The radioisotopic method was found to be a good quantitative indicator of the amount of solids that empty from the stomach and a useful tool in the longterm follow-up of gastroplasty patients. It was particularly helpful in evaluating the efficacy of surgery in patients with poor postsurgical weight reduction.