Fistula to the pancreatic duct from a peptic ulcer. Case report and literature review.

We report a case of pancreatic duodenal fistula as a complication of peptic ulcer disease. Complete healing of the ulcer and fistula was achieved with intensive medical therapy. No surgical intervention was required. The unique radiographic and endoscopic features of the case are presented and pertinent literature is reviewed.

Heterotopic gastric mucosa in the duodenum: radiographic findings.

Heterotopic gastric mucosa in the duodenal bulb was detected by endoscopic examination in 25 adult patients and was confirmed by biopsy in 17 of these patients. The endoscopic findings were correlated with the radiographic features of the lesion on upper gastrointestinal barium studies. On radiographs, this entity usually presented as clusters of 1- to 3-mm plaques raised above the smooth and featureless duodenal mucosa; this was seen in 17 (68%) of 25 patients. A less frequent finding was patches of coarse nodular mucosa with superficial erosions or an ulcer crater (five cases [20%]). The heterotopic gastric mucosa was visible as polypoid masses in two patients and as prominent areae gastricae covering the base of duodenal bulb in another.

Appendicitis as the initial manifestation of Crohn's disease: radiologic features and prognosis.

Twenty-five patients 15-47 years old presented with appendicitis as the initial manifestation of Crohn's disease. This entity accounted for 1.8% of all appendicitis patients undergoing surgery at our institution during a recent 9-year period. Preoperative radiologic studies in 18 (72%) of 25 cases showed abnormalities indicating the presence of appendicitis or periappendiceal abscess, but not the specific diagnosis of Crohn's disease as the underlying cause. Histopathologic evidence for an isolated, transmural, or granulomatous appendicitis was found in 20 patients; in two of these there was a local recurrence within 3 years after surgery, while 18 others have remained asymptomatic during follow-ups of up to 8 years. In the other five patients Crohn's disease caused appendicitis with concurrent inflammation of the cecum or terminal ileum; three of these cases were complicated by progressive granulomatous ileocolitis within 2 years. The data presented herein indicate that Crohn's disease can originate in and be confined to the appendix, yet manifest clinical symptoms leading to emergency laparotomy; preoperative radiologic findings are similar to those of suppurative appendicitis, but visualization of a markedly thickened appendiceal wall with patent or irregularly narrowed lumen supports the diagnosis of Crohn's appendicitis; and primary Crohn's disease of the appendix has a favorable long-term prognosis after simple appendectomy, despite a 10% incidence of recurrence as granulomatous ileocolitis.

Cisplatin, vinblastine, and mitoguazone chemotherapy for epidermoid and adenocarcinoma of the esophagus.

Thirty-six patients with adenocarcinoma or epidermoid carcinoma of the esophagus were entered into a phase II trial evaluating the combination of cisplatin 100 mg/m2 intravenously (IV) day 2, vinblastine 1.6 mg/m2 IV days 1 to 4, and mitoguazone (MGBG) 500 mg/m2 IV days 1 and 8. Twenty-nine patients (group A) were newly diagnosed with local-regional disease only and were candidates for transhiatal esophagectomy (THE). These patients received two courses of chemotherapy at 3-week intervals prior to surgery. Response was assessed by measuring changes in the primary tumor length and depth on serial biphasic contrast esophagrams and comparing this result with tumor measurements obtained from the surgical specimen. Complete (CR) and partial responders (PR) received three additional postoperative cycles. Seven patients had recurrent or metastatic disease (group B) and were treated every 4 weeks until disease progression. Of 34 patients evaluable for response, there was one pathologically confirmed CR and 15 PRs (47%). This consisted of 12 of 27 (44%) group A patients (seven of 11 epidermoid, five of 16 adenocarcinoma) and four of seven (57%) group B patients (two of four epidermoid, two of three adenocarcinoma). Toxicity included leukopenia in one third of treatment courses and thrombocytopenia in 21%. Nausea and vomiting occurred in 60% of patients, diarrhea in 18%, transient nephrotoxicity in 18%, peripheral neuropathy in 12%, and ototoxicity in 3%. Twenty-five group A patients underwent resection. Four chemotherapy nonresponders (NR) and one PR had known disease left at surgery; all others (80%) had gross total removal of their disease. The median survival time (MST) of the 29 group A patients was 14 months, with 21% alive at 36 months. The MST of group A chemotherapy responders was 15 months compared with 9 months for NRs (P = .032). Initial sites of recurrence in 14 patients were local-regional in six, distant only in six, both local-regional and distant in two. This regimen, administered in maximally tolerated doses, was active in epidermoid and adenocarcinoma histologies, recurrent disease and newly diagnosed patients. However, nearly all responses were PRs and the MST of resected patients was similar to a prior series of patients treated with esophagectomy alone. Observations from this pilot trial and those of others have led to a follow-up study, in progress, evaluating intensive preoperative chemotherapy and concurrent radiation therapy (RT).

Pancreas divisum: incidence, detection, and clinical significance.

Pancreas divisum is a congenital anomaly in which the ventral and dorsal pancreas drain separately into the duodenum. It is the most common congenital variant of pancreatic ductal fusion and drainage anomalies. With widespread use of endoscopic retrograde cholangiopancreatography, pancreas divisum is being detected with increasing frequency. Ten cases of pancreas divisum detected among 500 endoscopic retrograde cholangiopancreatography examinations performed between 1979 and 1985 at our institution were critically analyzed. Patients with symptomatic pancreas divisum (group 1) were typically young (mean age 29 yr), usually female, and had no history of significant alcohol abuse. Those with incidental detection of pancreas divisum (group 2) were older (mean age 62 yr), usually male with hepatobiliary disease, and had a history of significant alcohol ingestion. The radiological feature of pancreas divisum is characterized by a short (1-6 cm) and thin (2 mm diameter) pancreatic duct (duct of Wirsung) that branches off into regular arborization and drains only the posterior part of the head of the pancreas. This appearance is quite typical; however, this may be simulated by other conditions such as previous pancreatic trauma, partial pancreatectomy, or pancreatitis with irreversible damage to the duct, pseudocyst, and pancreatic carcinoma. The differentiation between true and false pancreas divisum is important because of its clinical implications.

Barrett's esophagus complicating achalasia after esophagomyotomy. A clinical, radiologic, and pathologic study of 70 patients with achalasia and related motor disorders.

Of 70 patients with achalasia and related motor disorders, 3 developed Barrett's esophagus 5, 8, and 15 years after esophagomyotomy. One of the three had dysplastic changes in the Barrett's mucosa. Although an increased incidence of gastroesophageal reflux, esophagitis, and stricture are well-known complications after esophagomyotomy, the development of Barrett's mucosa has been only recently recognized. Diagnosis of Barrett's esophagus in such patients is difficult and requires a high index of awareness by the radiologist and an endoscopic biopsy for definitive diagnosis. The cumulative effects of achalasia and Barrett's esophagus predispose these patients to higher risks of developing esophageal carcinoma.

Secondary neoplasms of the esophagus.

A review of 62 cases of esophageal involvement by secondary neoplasms is reported. The common routes of esophageal involvement are by direct extension of the tumor from the contiguous or adjacent organs (45.2%), via mediastinal nodes (35.5%), and hematogenous spread from a distant primary (19.3%). In the first 2 modes of esophageal involvement, the diagnosis is usually obvious but hematogenous metastases to the esophagus usually pose a diagnostic challenge. Radiologically, hematogenous metastases show a spectrum of features consisting of a short segment of progressive stricture with normal to minimally irregular mucosa, a submucosal mass with or without ulceration, a polypoid mass or masses, and defects in esophageal motility including secondary achalasia. Since endoscopy and biopsy have limited diagnostic yield, radiologic diagnosis plays a key role in the diagnosis of secondary neoplasms of the esophagus irrespective of their mode of spread to the esophagus.

Duplex ventral pancreas.

Complete duplication of the ventral pancreatic ductal system in 2 patients is reported. Both patients, during evaluation for recurrent abdominal pain, underwent endoscopic retrograde cholangiopancreatography that revealed typical changes of chronic pancreatitis and pseudocysts confined to 1 ductal system with the other ductal system completely normal. Both ductal systems filled with contrast medium via a common opening at the major papilla. A rudimentary minor papilla was present, but cannulations were unsuccessful. This unusual anomaly of the ventral pancreas with its embryologic basis, diagnosis, and clinical implications is discussed.

Cytomegalovirus cholangitis in a homosexual man with acquired immune deficiency syndrome.

A 29-year old white homosexual man with acquired immune deficiency syndrome presented initially with right upper quadrant pain and progressive cholestasis. Diffuse mucosal irregularities were seen at endoscopic retrograde cholangiography. Histopathological examination of the gallbladder and wedge liver biopsy showed evidence of cytomegalovirus infection. A repeat endoscopic retrograde cholangiography for persistent symptoms of right upper quadrant pain and cholestasis showed progressive mucosal irregularities of the intra- and extrahepatic bile ducts consistent with progressive cholangitis. Subsequently the patient developed evidence of disseminated infection and died. Postmortem examination revealed histologic features of cytomegalovirus infection in lungs, pancreas, small bowel, adrenal glands, and liver. Immunohistochemical staining of liver confirmed the presence of cytomegalovirus infection of the biliary duct system.

Gastric xanthomatosis and cholestasis. A causal relationship.

We report two cases of gastric xanthomatosis which developed in patients with marked cholestasis. In both cases, one with acute and one with chronic cholestasis, the gastric xanthomas disappeared with resolution of the cholestasis. A review of the literature is also provided.

Esophagitis caused by nonsteroidal anti-inflammatory medication: case reports and review of the literature on pill-induced esophageal injury.

We report six cases of pill-induced esophageal injury, two of which were caused by the nonsteroidal anti-inflammatory medications ibuprofen and piroxicam, which have not been implicated previously in pill-induced injury.

Evaluation of response to preoperative chemotherapy in esophageal and gastric cardia cancer using biphasic esophagrams and surgical-pathologic correlation.

Twenty-two patients with newly diagnosed carcinoma of the esophagus and gastric cardia were treated with combination chemotherapy prior to transhiatal esophagectomy. The clinical response to chemotherapy was determined by obtaining measurements of the vertical length of tumor, tumor depth, lumen size, and extent of ulceration on serial biphasic contrast esophagrams. Response was defined as a greater than 50% decrease in the sum of the products of the maximum vertical length and depth of the esophageal tumor mass. To obtain an assessment of the accuracy of the radiographically determined tumor measurements the esophagram results were correlated with surgical pathologic tumor measurements in 19 patients. The technique of esophagram and the determination of tumor measurements were standardized by having one radiologist perform and interpret all studies. All patients were clinically staged using the TNM classification system of the American Joint Commission on Cancer Staging. Three patients had T1 lesions, fifteen were classified as T2, and four as T3 lesions. Radiographic measurements of the tumor from the preoperative esophagram were correlated with the surgical pathologic specimen in five patients prospectively and 14 patients retrospectively. Response was seen in nine patients. The radiographically measured vertical length of the tumor was within 1 cm of the surgical specimen measurement in four of five (80%) prospectively evaluated patients and in nine of 14 (64%) retrospectively evaluated patients. These results suggest that chemotherapy-induced tumor regression can be objectively evaluated with a reasonable degree of accuracy using serial biphasic esophagrams.

Pseudomyxoma peritonei. Radiologic features.

Diagnostic radiologic features of pseudomyxoma peritonei consist of diffusely scattered plaques of calcifications in the abdomen, poorly defined soft tissue masses and ascites on plain abdominal radiographs, characteristic scalloping of the hepatic margin, numerous multilocular cystic masses with rims of curvilinear calcifications and compression of abdominal viscera without evidence of invasion at computed tomography, and an echogenic mantle with ascitic septations at ultrasonography. In an appropriate clinical setting, this spectrum of radiologic features is highly specific for the diagnosis of pseudomyxoma peritonei.

Herpetic esophagitis: a diagnostic challenge in immunocompromised patients.

Viral esophageal infection is common in immunocompromised patients. Twelve patients with esophagitis secondary to herpes viruses are described. Odynophagia, dysphagia, and gastrointestinal bleeding were the most common symptoms. Multiple infections particularly with candida were present in three of the 12 cases (25%). Typical "volcano ulcers" at endoscopy and discrete diffusely scattered shallow ulcers seen on double contrast esophagram are highly suggestive of herpetic esophagitis. Single contrast esophagram plays no specific role in the diagnosis of herpetic esophagitis. An analysis of clinical, endoscopic, radiological, and pathological features is presented.

Intussusception in adults.

A review of 25 adult patients with intussusception is reported. Intussusception in adults constituted 16.6% of 150 intussusception cases observed during 1956-1985. The underlying pathologic processes were identified in 23 patients (92%). Etiologically, adult intussusception could be categorized into four groups: (1) tumor-related (13 cases, 52%); (2) postoperative (nine cases, 36%); (3) miscellaneous--Meckel diverticulum (one case, 4%); and (4) idiopathic (two cases, 8%). The tumor-related intussusceptions were caused by benign tumors in five and malignant tumors in eight patients. Postoperative intussusceptions were related to various factors including suture lines, ostomy closure sites, adhesions, long intestinal tubes, bypassed intestinal segments, submucosal edema, abnormal bowel motility, electrolyte imbalance, and chronic dilatation of the bowel. The sites of involvement of intussusception were jejunogastric (one), jejunojejunal (seven), ileoileal (four), ileocolic (10), and colocolic (three patients). Four patients had synchronous multiple (ileoileal and jejunojejunal), four had compound (ileoilealcolic), and two had recurrent intussusceptions. When an intussusception is encountered in adults, an underlying pathologic process usually can and should be determined for proper management.