Percutaneous transhepatic cholecystostomy for acute complicated calculous cholecystitis in elderly patients.

OBJECTIVE: To assess the immediate and long-term outcomes of elderly patients with acute complicated cholecystitis treated by percutaneous cholecystostomy. To assess the results of bile cultures obtained in this group of patients. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Thirty-two patients, with a mean (+/- S.D.) age of 78 +/- 8 years (range, 58-92 years), and who presented with acute cholecystitis complicated by empyema formation. Sixty-six percent had associated disorders, which rendered them at high risk for surgical intervention. INTERVENTION: Percutaneous transhepatic catheter drainage of the gallbladder, with a mean drainage time of 20 days (range 0-84 days). In addition, endoscopic sphincterotomy with removal of common bile duct stones was performed in six patients and percutaneous aspiration of an associated liver abscess in four cases. RESULTS: Percutaneous cholecystostomy was followed by rapid regression of clinical symptoms and of radiologic abnormalities in all patients. Sixteen cases (50%) underwent elective cholecystectomy 1-12 weeks after cholecystostomy. One of them died of aspiration pneumonia, whereas 15 had no post-operative problems and were discharged 9 days (mean) after surgery. Forty-four percent (14/32) were considered inoperable: they remained completely free of biliary symptoms and died of unrelated illness (22%) after a mean follow-up of 6 months (range, 1-22 months) or are still alive (22%) with a mean follow-up of 15 months (range, 5-36 months). Bile cultures were positive in 75% of the patients. Escherichia coli, other aerobic Gram-negative micro-organisms, and anaerobic bacterial species accounted for 35% (16/46), 28% (13/46), and 20% (9/46) of the isolated bacteria, respectively. All aerobic Gram-negative species tested in vitro were susceptible to gentamicin and to temocillin. CONCLUSIONS: Percutaneous transhepatic cholecystostomy is a safe and effective procedure in the treatment of elderly high-risk patients with acute cholecystitis complicated by empyema formation. It can be followed by elective cholecystectomy, if possible, or by expectant conservative management in patients who are inoperable because of systemic disease.

Yersinia enteritis.

Y. enterocolitica has been shown to be a fairly common human pathogen in many countries. The clinical picture produced by Y. enterocolitica infections is quite variable. An acute abdominal disease (acute gastroenteritis or colitis, or a pseudoappendicitis due to acute terminal ileitis) and, less commonly, erythema nodosum and arthritis are the most important manifestations of the disease. On radiologic examination mucosal lesions of the terminal ileum are found in most patients with gastrointestinal symptoms. The colon is less frequently involved. The most typical lesions consist of shallow, small, round ulcers characteristic of the disease. Microscopic examination may suggest yersiniosis but does not show pathogenic signs. Y. enterocolitica can be detected by stool cultures or by serologic examinations. The disease is usually mild. If specific therapy is indicated the disease usually responds well to antibiotic therapy.

Radiologic investigations and pathologic results of experimental chronic pancreatitis in cats.

RATIONALE AND OBJECTIVES: The purpose of this study was to evaluate a variety of methods to induce chronic pancreatitis and its radiologic expression by experimentally inducing this condition in cats. MATERIALS AND METHODS: Chronic inflammatory and fibrosing pancreatitis was produced in cats by intraductal injection of 1.5 mL of 94% ethanol in one group or by a combination of intraductal and intraparenchymal injection of ethanol together with partial obstruction of the main pancreatic duct to 70% of its original lumen by fixation of a small catheter in the papilla. For comparison, other cats underwent total obstruction of the main pancreatic duct. All groups, as well as untreated control cats (n = 3), underwent repeat laparotomy to obtain biopsy specimens. RESULTS: Cats with total obstruction showed progressing fibrosis with dilatation of ductules occasionally infiltrated with granulocytes. From 26 weeks on, acini and islets of Lnagerhans became atrophic. Radiographs showed progressive but diffuse dilatation of ducts, ductules, and side branches. Cats from the other two groups had interlobular inflammation and fibrosis with flattened and irregular ductular epithelium. Later, ductular proliferation occurred, interstitial inflammation subsided, and fibrosis increased. Radiographs showed very irregular ducts and ductules with stenosis and dilatation. From 26 weeks on, no substantial differences were observed between the cats who received only intraductal injection of ethanol and the cats who underwent the combination of procedures. CONCLUSION: The histopathologic and radiographic alterations that evolved from damage to the ductal epithelium in the cat resembled the features of chronic pancreatitis in humans and differed from those caused by total obstruction of the main pancreatic duct in cats.

Intravenous digital subtraction angiography.

The authors report the preliminary results obtained with a prototype of a digital subtraction unit in intravenous aortography. This new method in its actual state of development is not able to replace conventional arteriography. The new technique can be applied in selected clinical conditions where conventional arteriography is contraindicated or impossible. Further improvement of the spatial resolution of the digital image and reduction of the amount of contrast medium may extend clinical applications of this method which may be able to reduce substantially the cost and morbidity of angiography.

Applications of specific vascular opacification in CT of the upper abdomen.

Selective visualization of the arterial and venous structures by CT slices during the early vascular phase after a bolus injection has proven to be a great value in resolving the problems of false images, created by incorporation of these vascular structures in the silhouettes of abdominal organs. This constitutes an important advance in the study and differentiation of pseudopancreas pathology, pseudolacunar images in the hapatic parenchyma and in the study of the porta hepatis.

Comparison of ultrasound and E.R.C.P. in the detection of the cause of obstructive biliary disease.

The value of ultrasound (US) in determining the cause and site of biliary obstruction was critically evaluated and compared to endoscopic retrograde cholangiography (ERCP), in a prospective study performed on 120 consecutive patients. The final diagnosis was based on surgery, endoscopic retrograde cholangiography or a combination of other examinations. Ultrasound successfully differentiated obstructive from non obstructive jaundice in 96% of the patients, comparing well with the results ERCP. US correctly defined the cause of obstruction in 71% of the patients with ductal stones, in 90% of the patients with tumoural bile duct obstruction, but only in 59% of the patients with chronic pancreatitis.

The role of radiology in Campylobacter enterocolitis.

A series of 18 patients with diarrhoea and positive stool cultures for Campylobacter jejuni is presented. The most important radiological features were thickening of ileal mucosal folds, of interhaustral indentations and of the ileocaecal valve, lymphoid hyperplasia and microulcerations. Radiology, as well as endoscopy, are both nonspecific in Campylobacter jejuni enterocolitis. The importance of radiology is to exclude more typical features of other causes of inflammatory bowel diseases. Moreover, before the result of the stool culture is available, the radiological features should suggest the suspicion of an acute infectious enterocolitis by Campylobacter jejuni as possible diagnosis.

Three cases of non-tumoural tight stenosis of the bifurcation of the hilar bile ducts.

Stenosis of the bifurcation of the hepatic bile duct is usually caused by malignant lesion. We report on three different causes of benign stenosis of the hepatic confluence with a similar radiological pattern on direct cholangiography. The first case is considered a spontaneous neuroma, the second a periductal abscess, and the third case a postoperative stricture Bismuth type 4.

Radiological aspects of Zenker's diverticulum.

In a retrospective study of 143 patients with Zenker's diverticulum followed for a period of 20 years, we classified the diverticula into 4 categories (A, B, C and D) using Brombart's scheme as a basis; the difference between the first two categories, however, was made on the basis of a morphological-dynamic criterion rather than a purely morphological one. Furthermore, a quantitative index was introduced to define the size of the diverticulum. In two cases we noted a substantial increase in volume with the transition from category C to D after more than 3 years, but we were unable to demonstrate an evolution from category A to B, nor from B to C. Our study confirms, on a large scale, the presence of three possible pathogenetic mechanisms, as proposed earlier in the literature: decreased relaxation of the upper esophageal sphincter as the most frequent factor in all categories except category A, and delayed opening or early closing of this sphincter as less frequent factors. The good relaxation of the upper esophageal sphincter in our category A, the different sex ratio and the absence of evolution in this category suggest that category A does not necessarily evolve further.

Intermittent subobstruction and cholestasis as complications of duodenal amyloid tumours.

Amyloidosis confined to the duodenum is uncommon. In the present report the history of an 83-year old patient, admitted for vomiting and heavy epigastric pain, is described. Radiographic and endoscopic investigation revealed two polypoid lesions in the duodenum (D2). Biopsies showed diffuse amyloid deposition in the lamina propria, muscularis mucosae and submucosa of the duodenum as well as vascular deposits. No other localisations were documented. Amyloid tumours of the gastrointestinal tract are rare but may lead to serious symptoms.

[Benign stomach tumors: histology, diagnosis and surgical experience]. / Benigne maagtumoren: histologie, diagnostiek en heelkundige ervaring.

Benign neoplasms of the stomach lead to atypical symptoms. Radiological and endoscopic investigations are always recommended. Our surgical experience with 11 epithelial and 26 mesenchymal benign neoplasms is discussed. A local excision could be carried out in 24 patients, of whom 4 developed postoperative complications and one deceased. Ten cases required a partial and 3 cases a total gastrectomy. This was mainly due to the localisation or the extent of the lesions. One surgical complication occurred and one patient died. Relapse was never observed in the long-term (i.e. 6 years) follow-up of 29 patients. Nonetheless, a yearly radiological or endoscopical control is advocated since hyperplastic polyps can relapse as exaggerated healing of an ulcer, and because especially leiomyomas, neurilemmomas en lipomas carry a substantial risk of malignant degeneration.

[Amyloidosis of the stomach: presentation of a case]. / Amyloidosis van de maag: voorstelling van een geval.

We consider here a case presenting X-ray abnormalities in the stomach caused by amyloidosis: decreased distensibility of the stomach wall and absence of folds. These X-ray findings are non-specific. They can also be observed in cases of chronic gastritis and tumor infiltration.

The evolution of radioprotection.

In comparison with the first half of this century the frequency of X-ray induced lesions diminished spectacularly both in patients and in radiologists in the second half; this was due to more and more rigorous radioprotection. The present measures of radioprotection may be divided into two groups according to their appliance to the patient or the operator. Prevention of irradiation of an unknown pregnancy is the responsibility of the clinician (application of the 10 days rule) but equally of the radiologist (warning poster in the radiological department, query of possible pregnancy). The sensitivity of the imaging material has been raised by adaptation of film, intensifying screens, grids and the use of image intensifier with TV-chain and photofluorography. The quantity of X-rays to the patient may be directly lowered by reducing the time and dose of fluoroscopy, the number of radiographs, by using a diaphragm, by covering some organs with lead shields and by choosing different examination modalities. Dose reduction to the patient may also be achieved by modifications of the quality of the X-ray beam (filter, KV/MA) and by proper indication of the examination. Patient's dose can be calculated by phantom simulation and by chromosomal blood study. The operator is never allowed to put his unprotected hand in the X-ray beam. The amount of scattering radiation to the operator will be lowered by several of the above mentioned measures reducing the patient's dose and by choosing the most favourable direction of the axis X-ray tube-image intensifier. Direct protection of the operator is achieved by lead-glass screens, lead flaps around the patient, lead gloves, apron and glasses and by raising the distance between the operator and the X-ray tube. Early detection of unusual radiation is possible by systematic dosimetry.

[The history of gallbladder and bile duct diagnosis]. / Geschiedenis van de galblaas- en galweg-diagnostiek.

In the first period (1896-1910), investigation was made through plain abdominal film with description and differential diagnosis of the different calcifications in the right hypochondrium. Second period (1911-1924): indirect signs of liver and gallbladder pathology were described. Via pneumoperitoneum and gastro-intestinal opacification the pathology in the right hypochondrium was delineated and interpreted. Third period (1924 until now): due to the development of contrast agents for the gallbladder and biliary tree, these organs could be directly visualized either by intravenous injection, or by peroral administration; sometimes direct injection of contrast in the bile ducts was used.

Ischemic jejunitis caused by primary small bowel volvulus.

A case of ischemic jejunitis caused by primary small bowel volvulus is presented. The radiological signs of ischemia persisted after detorsion. Contrast examinations of the small intestine demonstrated severe jejunitis with ulcerations, segmental narrowing and fistulas. This last sign is a rather uncommon event in ischemic disorders. The radiological signs of acute ischemia of the small intestine are discussed.

Pictorial essay. Roentgenologic appearance of traumatic diaphragmatic rupture.

The difficulties in recognizing a diaphragmatic rupture are well known and mostly due to a lack of typical clinical findings and an aspecific chest X-ray. This paper gives a brief review of the radiological techniques which can be helpful in the early diagnosis of traumatic rupture of the diaphragm.

Gastric volvulus as a complication of a left superior lobectomy in a patient with pre-existing hiatal hernia.

The case of a 75-year-old man with a history of hiatal hernia, who develops an acute gastric volvulus 17 days after a superior lobectomy of the left lung, is described. No similar cases were found in literature.

Sonographic diagnosis of ischemic colitis.

An abdominal ultrasound examination performed on two patients with abdominal pain showed segmental wall thickening of the colon that proved to be due to ischemic colitis. In one case, the typical "target lesion" was recognized. These findings could be confirmed with computed tomography, whereas a single contrast enema was unable to demonstrate the ischemic disease. In the second case, a typical five-layered structure of the bowel wall could be demonstrated. It is concluded that US can be useful in the early diagnosis of colonic ischemia.

Biliary ascariasis.

A patient with biliary ascariasis was observed. The diagnosis was strongly suggested on endoscopic cholangiography. X-ray examination of the small bowel confirmed intestinal infestation and the stools were positive for ascaris lumbricoides. The incidence, symptomatology, diagnostic features, complications and therapy of biliary ascariasis are briefly discussed.

Esophageal metastasis from breast carcinoma.

A case of esophageal metastasis from a breast carcinoma is presented. Location was, as usual, midesophageal. The interval of time between breast carcinoma and the onset of esophageal symptoms was rather long. Barium swallow examination enabled correct diagnosis, whereas several series of superficial endoscopical biopsies were negative. Diagnosis was confirmed by deep endoscopical biopsy.