Barium study associated with water siphon test in gastroesophageal reflux disease and its complications.

PURPOSE: The aim of this study was to evaluate the role of digital cineradiography associated with the water siphon test (WST) in the diagnosis of gastroesophageal reflux and to compare the results with oesophageal motility study, pH monitoring and endoscopy associated with biopsy and histology. MATERIALS AND METHODS: One hundred and sixty consecutive patients underwent digital cineradiography with WST, motility study, pH monitoring and endoscopy with biopsy. The presence of gastroesophageal reflux, oesophagitis, Barrett's oesophagus and intestinal metaplasia was evaluated. RESULTS: WST vs. pH monitoring showed sensitivity of 71%, specificity of 31%, positive predictive value (PPV) of 53% and negative predictive value (NPV) of 50%; when middle-proximal refluxes only were considered, sensitivity decreased to 45% and specificity increased to 55%. Furthermore, the association between reflux and oesophagitis demonstrated by the chi-square (chi(2)) test proved to be statistically significant both for WST and pH monitoring, whereas the association between reflux and Barrett's oesophagus was not significant for either WST or for pH monitoring. With regard to intestinal metaplasia, WST (middle-proximal refluxes) showed higher sensitivity (64% vs. 58%) and specificity (63% vs. 51%) than pH monitoring, whereas the statistical association between reflux and metaplasia proved to be significant for WST but not for pH monitoring. CONCLUSIONS: WST is a simple, inexpensive and reliable test that might be useful in the diagnosis of gastroesophageal reflux disease (GERD). A positive WST might be an additional indication for endoscopy with biopsy.

Role of videofluorography swallow study in management of dysphagia in neurologically compromised patients.

PURPOSE: The aim of this study was to demonstrate the key role of the videofluorography swallow study (VFSS) in the management of patients with dysphagia and varying degrees of neurological deficit. MATERIALS AND METHODS: In 1 year (March 2004-March 2005) 47 patients with oropharyngeal dysphagia due to different types of neurological deficit and who required rehabilitation were studied. All patients underwent: (1) clinical history assessment, (2) speech therapy assessment and (3) VFSS using digital fluoroscopy (25 frames per second). Patients were divided according to the Waxman classification into seven levels of dysphagia, and the most suitable type of feeding was selected (normal diet, restricted diet, artificial nutrition). At discharge, the possibility of changing the dietary regimen followed in hospital was evaluated based on clinical progress, radiological follow-up and the degree of improvement obtained. RESULTS: VFSS confirmed aspiration in 21/47 (44%) patients, of whom four (8%) had not been suspected at clinical-speech therapy assessment. In 13/47 (28%) patients, VFSS identified changes at the oral (three patients) or pharyngeal stage (three patients) or both (seven patients) but with no signs of silent aspiration. In the remaining 13 (28%) patients, VFSS did not show any changes in swallow dynamics. On the basis of these data, together with the follow-up at the end of rehabilitation treatment, different nutritional strategies were adopted: artificial nutrition [percutaneous endoscopic gastrostomy (PEG) or nasogastric tube], a restricted-consistency diet or normal diet. CONCLUSIONS: Our experience shows that VFSS precisely classifies the degree of dysphagia that conditions the dietary management of each neurologically compromised patient.

Multidetector-row CT enteroclysis: indications and clinical applications.

This paper examines the diagnostic potential of multislice computed tomography enteroclysis (MSCT-E) to detect and assess different diseases affecting the small bowel, emphasising the increasingly important role assumed by the technique in the study of this anatomical region. After a short summary of the technical aspects, we discuss the different findings that can be observed during an MSCT-E study and that enable detection of small-bowel disease and, if necessary, assessment of the extent and stage of disease.

[Esophageal digital videofluorography with water siphon test in the post-operative evaluation of the anti-reflux laparoscopic surgery]. / La videofluorografia esofagea digitale con water siphon test nella valutazione postoperatoria della chirurgia antireflusso laparoscopica.

BACKGROUND: In recent years digital videofluorography (VFG) with water siphon test (WST) has been proposed just for diagnosing hiatal hernia and/or gastroesophageal reflux. PATIENTS AND METHODS: Fifteen patients undergone Laparoscopic Nissen (LN) for complicated GERD associated to hiatal hernia, were referred for VFG and WST in order to evaluate the functional results of surgery. At one-month videofluorographic control thirteen patients had just a minimal prolonged esophageal transit time but only six of these had an early postoperative dysphagia, whereas at six months control the prolonged esophageal transit time was present in three patients two of which complained a very light dysphagia. One patient at one month control had a severe dysphagia, her videofluorography showed a very prolonged esophageal transit time and she had to redo surgery. She had a complete resolution of dyspagia and at the six months videofluorographic control she had a normal esophageal and esophagogastric transit time. One patient, underwent surgery in another hospital, complained a persistent and moderate dysphagia and at one month videofluorografic control was evident a malposition of wrap around the upper part of the stomach and a WST positive for reflux and at six months control clinical finding was worst. He will be evaluated for further endoscopic or surgical treatment. CONCLUSIONS: In our experience we believe that VFG is a valid test to identificate the postoperative outcomes giving the surgeons a visual evaluation of their work.

MRI findings in lingual venous malformations.

OBJECTIVES: To describe the plain and enhanced MRI findings of lingual venous malformations and to discuss the importance of contrast medium in the differential diagnosis of high intensity lesions of the tongue on T(2) weighted images. METHODS: The clinical records and MR images of eight patients affected by a lingual venous malformation were retrospectively reviewed. Patients presented with a palpable submucosal bluish-red soft mass in the tongue. MRI examinations were performed on a 0.5 T superconducting unit. Plain and enhanced SE (spin echo) T(1) weighted and FSE (fast spin echo) T(2) weighted images were acquired in axial, sagittal and coronal planes. Axial SPGR (spoiled gradient recalled echo) T(1) weighted images were also obtained before and after intravenous (i.v.) injection of paramagnetic contrast medium. RESULTS: Five of eight venous malformations were located at the tip of the tongue. The other three involved the whole tongue and had an extralingual extent; two extended into the submandibular space and one into the glossoepiglottic valleculae. The largest diameter ranged from 2.5 cm to 8 cm. All lingual venous malformations presented as lobulated masses that were slightly hyperintense or isointense on T(1) weighted images and highly hyperintense on T(2) weighted images with respect to normal tongue and/or surrounding muscles. They showed a slow and homogeneous filling following iv injection of contrast medium. Millimetre-sized hypointense foci and linear hypointense strands were sometimes noticed, which were owing to phleboliths, flow void or septation. CONCLUSION: Knowledge of MRI findings of lingual venous malformations is useful for differential diagnosis with other high intensity lingual lesions on T(2) weighted images. This discrimination is achievable using iv paramagnetic contrast medium.

Digital cineradiographic swallow study: our experience.

PURPOSE: Swallowing disorders can be secondary to different types of diseases in which, at least initially, patients succeed in establishing voluntary or involuntary compensatory mechanisms that enable them to maintain a sufficient nutritional state. When the compensatory mechanisms become insufficient massive food aspiration into the airways can occur and suffocation may prove to be the main pathology. It has been calculated that in the USA about 8,000-10,000 people die each year due to suffocation. The dynamic radiological examination of swallowing is considered important not only for diagnosis, but also for planning a rehabilitation therapy and type of nutrition for the patient and for verifying the results of the therapy. The aim of this study is to analyse the results of our experience in the use of the digital cineradiography system to evaluate patients with normal and pathological swallowing. MATERIALS AND METHODS: We reviewed the digital cineradiography of 220 patients that at no time had undergone surgery and presented no organic pharyngeal or oesophageal disease (excluding hiatus hernia). All the exams followed a standard protocol that included the dynamic evaluation of the larynx, soft palate, pharynx, and gastro-oesophageal junction with a cineradiographic sequence of 12 frames/second with a 512x1024 matrix. There was also an archive of the film in a post-processing console. The patients received single photograms (printed on laserfilm), videotape recordings or CD-ROM of the dynamic exam. RESULTS: 137 (62%) of the patients did not present swallowing alterations although only 7 patients had a negative examination. In 35 cases hiatus hernia was appreciable while in 69 cases the hernia was associated with gastro-oesophageal reflux. In 23 cases aspecific functional disorders of the oesophagus were demonstrated and in 3 cases achalasia. The remaining 83 patients (38%) (37 males and 46 females, average age 57.02 yrs) presented alterations of the oral and/or pharyngeal stages of swallowing: reduction in soft-palate motility (2 cases), unilateral paralysis of the vocal chords (1 case), incontinence of the bolus during the oral stage (8 cases), lingual movement anomalies (4 cases), subepiglottic penetration (62 cases), asymmetric epiglottic tilt, aspiration of the contrast medium in the airway (17 cases), reduction of laryngeal and hyoid bone movement (9 cases), bolus retained in the valleculae and pyriform sinus (13 cases), cricopharyngeal spasm (6 cases), pharyngeal paralysis (1 case); hiatus hernia was also evident in 20 cases and gastro-oesophageal reflux was associated in 13 of them. Overall, 36% of the cases presented an isolated form while 64% of the cases presented a complex dysfunction with several simultaneous alterations. DISCUSSION AND CONCLUSIONS: The videofluorographic swallow study is an important step in the diagnostic evaluation of a dysphagic patient not only as regards the analysis of the main alteration and its capacity to confirm the presence or absence of contrast medium aspiration in the airway, but also because it provides important information on rehabilitation and nutritional orientation (oral/no oral), as well as on the results of the therapy. The recent diffusion of the digital X-ray equipment has made possible its use for the study of the organic and functional diseases of the upper alimentary tract. Currently a standard protocol for the study of swallowing with digital fluorography is not available. The technique we applied, already verified in a significant number of dysphagic patients, has allowed us to distinguish patients with normal swallowing from those with disorders of the oral and pharyngeal stage, and thus to identify disturbance and establish an appropriate rehabilitation treatment.

Isolated hydatid disease of the spleen: CT findings in 4 patients and differential diagnosis.

AIM: To report our experience with four cases of isolated hydatid disease of the spleen studied by spiral Computed Tomography (CT) and to review the literature with special attention to the differential diagnosis with other focal lesions of the spleen. MATERIALS AND METHODS: The spiral CT images and clinical records of four patients (1 man, 3 women; age range 26-45 yrs) affected by isolated hydatid disease of the spleen were retrospectively evaluated. None of the patients had a history of hydatid disease. All the patients were evaluated by plain and enhanced spiral CT of the abdomen. All patients underwent preoperative chest X-ray and surgery; all surgical specimens were studied by histology. RESULTS: Spiral CT depicted all the hydatid lesions of the spleen. It showed the location, size, low density of their content without enhancement after iv contrast medium injection, the possible presence of daughter cysts, the appearance of the wall with calcifications, and excluded the presence of complications. The preoperative chest X-ray was negative for focal pulmonary lesions in all cases. Pathology confirmed the diagnosis of hydatid disease in all cases. CONCLUSIONS: According to our results and to the literature, spiral CT plays an important role in the pre-surgical evaluation of patients with hydatid disease of the spleen, and provides useful information for differentiating the disease from other isolated cyst-like lesions of the spleen.

Pitfalls and limitations of Magnetic Resonance Imaging in bucket-handle tears of knee menisci.

PURPOSE: The aim of the present study was to assess the accuracy of magnetic resonance imaging (MRI) in the diagnosis of bucket-handle tears of the knee menisci, determining the sensitivity and specificity of the imaging for each of the signs typical of these tears. MATERIALS AND METHODS: MR examinations of 495 patients suffering from knee traumas were assessed retrospectively. Forty-eight patients had arthroscopically-proven bucket-handle tears of the meniscus. MR examinations were performed using a 0.5-T superconducting magnet, with T1-weighted spin-echo (SE) and gradient-echo (GE) T2*-weighted sequences. Imaging findings used for the diagnosis were: a) double posterior cruciate ligament sign; b) flipped meniscus sign; c) presence of a displaced fragment of the meniscus in the intercondylar notch, visible in coronal and axial images; d) truncated triangular shape of the peripheral non-displaced portion of the meniscus, visible in coronal images. RESULTS: A total of 43 out of 48 bucket-handle tears of the meniscus were correctly diagnosed at MR, thus overall MR accuracy was 98%. In 12 (28%) cases three signs were present simultaneously the double posterior cruciate ligament (sensitivity 28%, specificity 99%, accuracy 93%) + the displaced fragment in the intercondylar notch (sensitivity 69.8%, specificity 98.7%, accuracy 96.2%) + the truncated triangular shape of the peripheral portion of the meniscus (sensitivity 74.4%, specificity 98%, accuracy 96%). In 18 (42%) cases two signs were present together the displaced fragment of the meniscus + the truncated triangular shape of the peripheral portion of the meniscus. In 13 (30%) cases only one sign was presenting two cases the truncated triangular shape of the peripheral portion of the meniscus and in 11 cases the flipped meniscus sign (sensitivity 25.6%, specificity 93.4%, accuracy 87.5%). No statistically significant differences were found comparing the results for tears of the medial meniscus with those for the lateral meniscus. CONCLUSIONS: MR imaging is highly accurate in diagnosing bucket-handle tears of the menisci due to its ability to identify a displaced fragment of the meniscus in the intercondylar notch or flipped over the anterior horn of the meniscus of origin. We speculate that bucket-handle tears not found by MR imaging are cases where the meniscus was displaced after MR examination.

Intra-articular osteoid osteoma: diagnostic imaging in three cases.

PURPOSE: To report our experience pertaining to three cases of intra-articular osteoid osteoma assessed by means of integrated imaging and review of literature. MATERIALS AND METHODS: Medical records, radiologic and nuclear medicine findings pertaining to three cases of intra-articular osteoid osteoma were retrospectively evaluated and compared with those of surgery. All the patients (2 males, one female; age range 8-38 ys) affected by intra-articular osteoid osteoma respectively of the elbow, tibio-talar joint and hip were evaluated by means of radiographic examination and Magnetic Resonance Imaging (MRI). SE T1-w and T2-w, GRE T2*-w, GRE 3D T1-w and STIR pulse sequences were used and axial, coronal and sagittal images were acquired. Two patients underwent CT scan. One patient underwent skeletal scintigraphy. All the patients underwent surgery. RESULTS: In 2 out of 3 cases plain radiography allowed the radiologist to suspect the presence of the lesion. In the remaining one, plain radiography failed to detect both the nidus and the perilesional osteosclerosis; nevertheless, a small osteochondral erosion of the humeral condyle suggested the presence of joint inflammation, thus leading to further investigation. CT scan well depicted the presence of the nidus and, in one case, the presence of joint effusion. MRI was always able to detect the nidus, which presented as lesion of low to intermediate signal in T1-w images, low signal in the T2-w images in one patient and high signal in the remaining two; in these latter STIR images showed high intensity nidus and edema of neighbouring cancellous bone. Furthermore, in all patients MRI clearly depicted joint effusion. Skeletal scintigraphy demonstrated both the lesion and the inflammatory involvement of neighbouring soft tissue. In all patients histologic specimen confirmed the diagnosis of osteoid osteoma with joint inflammation and synovitis. CONCLUSIONS: According to our results and literature data the pre-surgical diagnosis of osteoid osteoma is very difficult to achieve. Indeed, only the combination of clinical information and radiologic and nuclear medicine findings enables the radiologist to make the right diagnosis.

[Adult intestinal intussusception: comparison between CT features and surgical findings]. / L'invaginazione intestinale dell'adulto: confronto tra aspetti TC e reperti chirurgici.

PURPOSE: To report our experience in the use of CT in the evaluation of adult intestinal intussusception. A correlation between radiologic findings and surgery was attempted in order to verify our diagnostic hypothesis. MATERIAL AND METHODS: Intestinal intussusception was diagnosed by CT between September 1993 and December 2000 in 10 patients (6 men and 4 women, age range 18-82 years). For 9/10 patients the diagnosis was confirmed by surgery; in one patient the condition resolved spontaneously as confirmed by a follow-up CT performed 24 hours after the first. Six patients were studied by a third generation CT and four by a helical CT unit. Five patients were administered iodinated oral contrast medium and in seven i.v. iodinated contrast medium. Diagnosis was hypothesized at CT on the basis of the following aspects: target, sausage, and pseudokidney. RESULTS: Surgery confirmed the CT diagnosis of intussusception in 9/10 patients; in the patient with transient intussusception a spontaneous resolution was confirmed at follow up CT after 24 h. In the 10 patients studied the following CT aspects were observed in the bowel involved by intussusception: a target aspect in 4 patients; a sausage aspect in 4 patients; in one of them a peritoneal effusion was also present; a pseudokidney aspect was observed in 2 patients, with a long tract intussusception and peritoneal adipose tissue; in both a hyperdensity of the peritoneal adipose tissue and enlarged vessels, that were herniated within the lumen of the bowel, were recognized. At surgey the causes of intestinal intussusception were: malignant tumors of the colon (4 cases), hamartomatous polyps of the small bowel (2 cases), mixoid fibrolipoma of the colon (one case), leiomyoma of the distal ileum (one case). In one patient no cause could be identified at CT, but the condition was found to co-exist with acute appendicitis at surgery. CONCLUSIONS: CT is an accurate technique in the evaluation of intestinal intussusception in adults. It allows to identify the condition, its site, and sometimes the type of the lesion causing the intussusception, and any vascular alteration, thus playing an important role in establishing the most appropriate therapeutic strategy.

[Thrombolytic therapy in myocardial infarction. Computerized tomography of encephalic complications]. / Terapia trombolitica nell'infarto del miocardio. Aspetti con Tomografia Computerizzata della complicanze encefaliche.

PURPOSE: To evaluate the CT findings of intracerebral hemorrhage in patients undergoing thrombolytic therapy for acute myocardial infarction and to correlate the type of intracerebral hemorrhage with clinical outcome. MATERIAL AND METHODS: We retrospectively reviewed the clinical records and CT scans of intracerebral hemorrhage on a total of 302 patients who underwent thrombolytic therapy for acute myocardial infarction at our institution from January 1996 to September 1999. In each patient we evaluated: the number, sites and size of hemorrhage, and the presence and severity of mass effect. The site of the hemorrhage was classified as intraparenchymal, intraventricular, subdural and subarachnoid. RESULTS: Six patients (2%, mean age 74, range 66-80) developed intracerebral hemorrhage. There was a total of 22 hemorrhages: 1 subdural hemorrhage, 6 subarachnoid, 11 intraparenchymal and 4 intraventricular. Excluding intraventricular hemorrhage, 14/18 hemorr-hages were located supratentorially. In five patients there was a fluid-blood level. Three patients had severe mass effect with midline shift. Symptoms presented within 24 hours from the administration of thrombolytic therapy in all patients. All the patients who died had a large hematoma with a severe mass effect and a severe midline shift at CT scan. In the remaining patients, the hematoma was of medium size and no mass effect was seen. CONCLUSIONS: The most common site of hemorrhage was supratentorial and intraparenchymal. Large volume intracerebral hemorrhage, multiple hemorrhages and mass effect with midline shift were associated with increased mortality. The most commonly observed finding was a fluid-blood level hematoma.

[Radiographic patterns in patients after antireflux surgery]. / Aspetti radiologici normali e patologici nei pazienti sottoposti a chirurgia. antireflusso.

PURPOSE: To evaluate the usefulness and diagnostic accuracy of the radiologic examination of the oesophagus and stomach in the follow-up of patients who had an anti-reflux procedure with the purpose of identifying the normal radiographic pattern, possible surgical complications and the causes of failure of the surgical treatment. MATERIAL AND METHODS: From February 1999 to September 2000, we radiographically reviewed 11 patients (5 men and 6 women) age range 17-69, mean age 49, who had a surgical procedure of fundoplication for hiatal hernia and/or gastroesophageal reflux (7 Nissen procedures, 2 Belsey-Mark IV, 1 Toupet, 1Dor). Four surgical procedures were laparoscopic, seven were open. All patients were reviewed with single contrast (barium sulphate 60% weight/volume) and/or double contrast technique (effervescent powders + barium sulphate 250% weight/volume) and with the acquisition of radiographs in upright, supine, prone, oblique and lateral positions. RESULTS: 5 of the patients who had a fundoplication procedure suffered complications. In one patient the fundoplication was tight; in two patients the fundoplication had broken and migrated in the thorax; in one the fundoplication had loosened; in one patient it had looseed and migrated in the thorax. In the remaining 6 cases, the passage of the barium column through the fundoplication was normal, as well as the intra-abdominal position of the fundoplication. CONCLUSIONS: The possibility to perform laparoscopic fundoplication procedure has increased the number of patients selected for surgical treatment. Successful relief of gastroesophageal reflux symptoms can be achieved in 90% of patients treated with antireflux fundoplication. Less than 10% of cases may have complications, with recurrence of gastroesophageal reflux manifestations. The radiographic examination of the esophagus and stomach still represents an effective diagnostic test in the follow-up of these patients.

[Closed loop intestinal obstruction: role of computerized tomography]. / Le ostruzioni intestinali ad ansa chiusa: ruolo della Tomografia computerizzata.

PURPOSE: The obstruction of a bowel segment at both ends results in a closed loop obstruction. Progression to strangulation frequently occurs if surgical intervention is delayed. The role of plain radiography in the diagnosis of closed loop obstruction and strangulation has been shown to be limited, while the recent literature has demonstrated the growing role of computed tomography (CT). This paper reports our experience in the study of closed loop obstruction by CT. MATERIAL AND METHODS: The CT studies of 12 patients with surgically confirmed closed loop obstruction were retrospectively reviewed. The following CT signs were used for the diagnosis: a) fluid-filled distended loops, b) C-shaped incarcerated loop, c) radial distribution of several dilated bowel loops and mesenteric vessels converging toward the point of obstruction, d) triangular or fusiform tapering of the closed loop and/or whirl sign in the site of obstruction. RESULTS: On the basis of these signs, the diagnosis was made in 11 of 12 patients. Only 1 patient, who had a negative CT study, was positive at a subsequent enteroclysis. CT findings of strangulation were associated in 3 cases: slight wall thickening with vascular congestion and mesenteric ascites, confirmed at surgery. DISCUSSION AND CONCLUSIONS: Small bowel obstruction can be distinguished into simple and closed loop obstructions. The latter is a more severe condition which is often complicated by strangulation with vascular impairment, edema and intramural and mesenteric hemorrhage. Consequent arterial insufficiency rapidly leads to ischemia, infarction and necrosis. The radiologist plays a role in the early recognition of the closed loop obstruction and of any sign of strangulation. The role of CT in the diagnosis and workup of patients with suspected intestinal occlusion has been analyzed in the literature with reported 63% sensitivity, 78% specificity and 66% accuracy. CT is also capable of revealing the causes of occlusion in 73-95% of cases. The above CT signs, as confirmed in our experience, allow to identify closed loop obstruction and also small bowel strangulation, thus supplying a valuable contribution to diagnosis and accurate preoperative evaluation. We conclude that CT can accurately demonstrate the presence of closed loop obstruction and can be the technique of choice in patients in whom obstruction is associated with clinical signs suggestive of strangulation.

[Severe myogenic pain in an unfit subject after intensive and prolonged abdominal muscle exercise]. / Marcata sofferenza miogena in un soggetto non allenato dopo intenso e prolungato esercizio fisico di flesso-estensione dei muscoli addominali.

The authors report the case of an unfit patient who, following intensive and prolonged physical exercise involving the abdominal muscles, presented a massive and diffuse subcutaneous edema (abdomen, scrotum, chest and face) together with abdominal and thoracic pain which increased in response to finger pressure. In addition, this was accompanied by a marked increase in CK, CK-MB and LDH, and TGO and TGP. Chest or heart pathologies were excluded by monitoring ECG and other clinical parameters, like heart rate and blood pressure, and by performing a chest X-ray. Muscular ultrasonography confirmed the massive subcutaneous edema and abdominal MR showed a slight edema in the suprasacral region, as well as confirming the subcutaneous edema. Hematological data gradually reduced and returned to normal after a week. Edema and pain also regressed gradually: the former finally disappeared after one week and the latter after five days. The authors conclude that clinical and laboratory findings were particularly severe because the subject was unfit and subcutaneous edema was larger than the free liquid in the abdominal cavity because the latter was absorbed by the peritoneum which acted as a dialysing membrane.