False aneurysm of the pancreaticoduodenal artery complicating therapeutic endoscopic retrograde cholangiopancreatography.

A 76-year-old woman underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures for palliation of a carcinoma of the pancreas. At the first procedure a pre-cut sphincterotomy was performed because deep cannulation of the biliary tree was impossible. An endoscopic plastic biliary stent was inserted at the second ERCP. The patient developed abdominal pain and a post-procedure CT demonstrated a pseudoaneurysm. This was not present on the pre-procedure CT and was thought to arise from the pancreaticoduodenal artery as a complication of the pre-cut sphincterotomy. Visceral angiography confirmed the origin of the aneurysm from a branch of the inferior pancreaticoduodenal artery. The aneurysm was successfully embolised. To our knowledge, this is the first time that this complication has been reported.

The value of prone imaging in CT pneumocolon.

AIM: To evaluate the value of prone imaging in computed tomography pneumocolon. MATERIALS AND METHODS: In the U.K., patients commonly undergo computed tomography (CT) pneumocolon in the supine position alone. A prospective analysis of both supine and prone CT images was performed. The degree of distension and the presence/absence of fluid/faecal residue were documented. RESULTS: Twenty-five patients were examined in total. In all cases, all five segments of the colon were well visualized on combined assessment of supine/prone images. Diagnostic distension was obtained in all five segments of the bowel in 69% of cases in the prone position, but in only 24% of patients in the supine position. The rectum and sigmoid colon were well distended in 100 and 88%, respectively, on prone CT, but in only 58 and 35% of cases, respectively, on supine CT. Problems encountered by fluid/faecal residue were eliminated on prone CT. CONCLUSION: Adjunctive prone pelvic CT should be performed in all patients undergoing CT pneumocolon unless the supine images can be fully reviewed and shown to be satisfactory before the patient leaves the CT department. If a single positional sequence is to be performed, then prone CT is the position of choice.

Paradoxical puborectalis contraction is a feature of constipation in patients with multiple sclerosis.

OBJECTIVE: To study the disturbed anorectal physiology associated with constipation in multiple sclerosis. METHODS: Anorectal function in 10 patients with clinically definite multiple sclerosis and constipation has been compared with 10 normal persons and 11 patients with idiopathic constipation, without multiple sclerosis. RESULTS: All 10 constipated patients with multiple sclerosis had difficulty evacuating barium paste during defaecography. In four of these there was complete failure of puborectalis relaxation when straining to defaecate, and in another four there was incomplete puborectalis relaxation. There was no evidence of lower motor neuron involvement of pelvic floor muscles in the multiple sclerosis group. CONCLUSIONS: Paradoxical puborectalis contraction is common in patients with multiple sclerosis in whom constipation is a symptom. This may be a feature of the disturbed voluntary sphincter control mechanism, analogous to detrusor sphincter dyssnergia in the bladder.

The use of air or CO2 as insufflation agents for double contrast barium enema (DCBE): is there a qualitative difference?

One hundred consecutive out-patients referred for double contrast barium enema (DCBE) were randomized in a double-blind prospective study to receive either air or CO2 as an insufflation agent. Each examination was performed by the same radiologist and radiographer. The two groups were equally matched for age and sex. Each completed examination was independently assessed by three radiologists for a variety of parameters. The results show that the patients receiving air as an insufflation agent had better overall colonic distension than the group receiving CO2 and that this was statistically significant (P = 0.0004). There was no significant difference in the mean time taken to perform the examination in the two groups nor was there any significant difference in mucosal coating or preparation. In conclusion, our results suggest that poor colonic distension is a potential problem when CO2 is used for DCBE and that this cannot be solely attributed to the time taken to perform the examination. Poor distension could lead to diagnostic errors and this may outweigh the advantages in patient acceptability when using CO2 as an insufflation agent.

Defecography in multiple sclerosis patients with severe constipation.

PURPOSE: To evaluate defecography in assessment of anorectal function in patients with multiple sclerosis (MS) who have intractable constipation. MATERIALS AND METHODS: Eleven patients with MS and constipation (10 women, one man) underwent defecography. A total of 130 mL of barium, liquid (20 mL) and paste, was introduced into the rectum. A dab of barium marked the external anal orifice, and, in the women, a tampon soaked with contrast medium marked the vagina. Video radiographic images and supplemental 100-mm static camera images were obtained. RESULTS: During defecation, six patients had no puborectalis muscle effacement, four patients had partial effacement, and one patient had complete effacement. No rectal emptying occurred in five patients, and emptying was incomplete in the rest. Three patients developed an intussusception, and two developed a posterolateral pouch. CONCLUSION: Defecography readily demonstrates rectal outlet obstruction and the failure of the puborectalis and anal sphincter muscles to relax. These are frequent findings in MS patients with intractable constipation.

Partial malrotation associated with pseudo-obstruction of the small bowel.

Intestinal pseudo-obstruction is defined as a syndrome in which there are signs and symptoms of intestinal obstruction without an actual obstructing lesion. In many cases it is associated with other disease entities but may be idiopathic. We report a case associated with partial malrotation of the gut which has not been described in the literature before.

Review article: endoscopic ultrasound of the stomach.

Endoscopic ultrasound (EUS) is the adopted term for the technique which enables endoluminal ultrasound to be performed using a specially designed endoscope with a fixed piezoelectric transducer. Since initial reports described the use of this technique in patients, its use in clinical practice in Europe, the Far East and the USA has been steadily increasing over the past few years. At present the technique is only practised in a very few centres in the UK but it is likely that this will increase in the future. This article describes the present day value of EUS in evaluating gastric pathology.

Endoscopic ultrasound for localisation of islet cell tumours.

In a prospective study endoscopic ultrasound localisation of pancreatic endocrine tumours was attempted in 21 patients with clinically suspected islet cell tumours. Most patients were referred after the failure of conventional imaging methods. Endoscopic ultrasound correctly identified the site of 12 of 15 insulinomas, one glucagonoma, and a diffuse pancreatic abnormality in a patient with multiple endocrine adenopathy. There were two true negative examinations and one technical failure. The sensitivity of endoscopic ultrasound was much greater than that of computed tomography or conventional transabdominal ultrasonography.

Barium meals in the elderly--a quality reassurance.

The consecutive double contrast barium meal examinations of 100 elderly patients (aged over 65 years) and a group of 33 younger adult patients were analysed by two observers for technical quality and pathological abnormalities. Technical quality declined with patient age, especially in those over 75 years, but was sufficient to enable diagnosis of abnormalities in 60% of the elderly group. It is concluded that, in the majority of elderly patients, the technical quality of double contrast barium meal examinations is sufficiently high to offer considerable diagnostic utility.

A hypoechoic area within the head of the pancreas--a normal variant.

Using conventional pancreatic ultrasonography 32 healthy volunteers were studied to assess the prevalence of a previously undescribed well demarcated hypoechoic area within the head of the pancreas. There was definite evidence of a hypoechoic region in nine subjects (28.1%), possible evidence in five (15.6%) and no evidence in 18 (56.3%). In accordance with the structural differences that have been described between the embryologically derived ventral and dorsal pancreatic segments it is proposed that this area of hypoechogenicity is the ventral portion of the pancreas. To date any focal hypoechogenicity within the head of the pancreas has been considered abnormal, but in view of these findings we feel it is important to recognise that a well demarcated hypoechoic region within the head of the pancreas can be a normal variant.

Defecography in normal volunteers: results and implications.

Forty seven healthy young volunteers underwent defecographic examination to determine the range of normal findings. Normality was shown to encompass radiological features often considered pathological. These features included broad ranges of anorectal angle and pelvic floor descent which overlap with reported pathological states. Furthermore, the formation of rectocoeles during defecation was a very common finding in women. Finally, a subgroup of the volunteers had marginal anorectal function. The marginal anorectal function and certain radiological findings such as rectocoeles or intussusceptions may predispose to later problems, or contribute to clinical problems when combined with other factors such as dietary fibre deficiency. The radiological findings raise a number of questions with respect to different aspects of the functioning of the continence and defecation mechanisms.

Defaecography: setting up a service.

Defaecography is a simple procedure to perform and provides morphological information on the mechanism of defaecation from which physiological parameters can be inferred. This article discusses the value of the technique, and aims to give practical help to those considering introducing such a service.