Differing effects on gall-bladder motility of lanreotide SR and octreotide LAR for treatment of acromegaly.

BACKGROUND: Octreotide treatment may be associated with gall stone development in up to 50% of patients with acromegaly. Two new sustained-release formulations of somatostatin analogue have been recently developed: lanreotide SR (Somatuline) and octreotide LAR (Sandostatin LAR). The incidence of gall-stone development in patients receiving these drugs has been shown to be less than 20%, but the duration of follow-up has been limited. OBJECTIVE: Prospectively to assess and compare the effects of the two new long-acting somatostatin agonists on gall bladder motility in patients with acromegaly. METHOD AND PATIENTS: Eleven patients with active acromegaly were studied. Three patients had asymptomatic gall stones at the start of the study. Ultrasound scans were performed before commencement of the treatment, and repeated during treatment with lanreotide SR and octreotide LAR. The presence of gall stones, fasting gall bladder volume (FV), residual volume (RV) and maximal percentage gall bladder emptying were measured. RESULTS: One patient developed asymptomatic small gall stones after treatment with octreotide LAR for 4 months. FV and RV were both significantly larger when patients received treatment with lanreotide SR or octreotide LAR compared with pretreatment values (P<0.05 for both). Maximal percentage gall bladder emptying was significantly reduced in patients receiving lanreotide SR or octreotide LAR compared with pretreatment (P<0.01), but was less impaired in patients receiving lanreotide SR than in those receiving octreotide LAR (P<0.01). CONCLUSIONS: Gall bladder motility is impaired in patients receiving either of these new long-acting preparations, and long-term follow-up will be needed to establish the true incidence of gall stones.

The role of transvaginal ultrasound in the investigation of women with post-menopausal bleeding.

One-hundred and eighty-two women with post menopausal bleeding were examined with transvaginal ultrasound (TVUS) over a 16-month period. The imaging findings were correlated with the pathological specimens. One-hundred and forty had pipelle aspiration cytology and 35 hysteroscopy, dilatation and currettage and seven a hysterectomy. Endometrial thickness on TVUS was classified as either thin (equal to or less than 5 mm), thick (greater than 5 mm), or not seen. A thin endometrium was noted in 87 patients, in whom no pathological abnormality was found in 84 (negative predictive value 95%). There were three cases of hyperplasia or polyps but no carcinomas occurred in this group (negative predictive value for carcinoma 100%). A thickened endometrium was noted in 82 patients. In this group there were five carcinomas, nine polyps and eight cases of endometrial hyperplasia (positive predictive value 29%). In five patients the endometrium could not be identified. One carcinoma occurred in this group. There were an additional eight patients who were taking tamoxifen who were grouped separately. If a clear symmetrical endometrial stripe measuring less than or equal to 5 mm in thickness on TVUS is seen the probability of malignancy is extremely low and endometrial biopsy can probably be avoided in this group particularly in the context of an isolated episode of postmenopausal bleeding. If the endometrium is not seen or is thicker than 5 mm then endometrial biopsy is indicated.

Paediatric xanthogranulomatous pyelonephritis.

Xanthogranulomatous pyelonephritis (XGP) is a well recognised but rare type of chronic pyelonephritis classically occurring in middle-aged women. It is increasingly being recognised in children in whom it can be mistaken for Wilms' tumour. Awareness of the possibility of this condition occurring in children may allow early recognition and possible treatment. Two cases of XGP in children are described and the literature reviewed.

The role of micturating cystourethrography in antenatally detected mild hydronephrosis.

BACKGROUND: The postnatal imaging of infants with antenatally detected mild hydronephrosis remains controversial. OBJECTIVE: Our aim was to establish the role and timing of micturating cystourethrography (MCUG) in mild hydronephrosis. MATERIALS AND METHODS: We performed a retrospective study of 61 infants (122 kidneys) referred with an antenatal diagnosis of hydronephrosis who showed persistent postnatal dilatation. All had follow-up postnatal ultrasound (US) and MCUG performed. The degree of dilatation at each follow-up scan was recorded. RESULTS: Of the 122 kidneys, 65 showed mild hydronephrosis. A substantial proportion of these (21.5%) demonstrated reflux. Serial US of these infants showed that the 6-week scan was the most informative and that any changes that warranted further investigation had occurred by this time. CONCLUSION: We recommend that all infants with mild hydronephrosis should undergo MCUG. MCUG need not be delayed until 3 months but could be performed following a 6-week US scan.

The post-angiocardiography urogram in children: should it be abandoned?

This study examines the value of the urogram radiograph taken after angiocardiography, in children with suspected congenital heart disease, to screen for co-existent urinary tract abnormalities. A retrospective audit of post-angiocardiography urograms over a three year period 1990 to 1993 is presented. 184 urograms obtained in 166 children were reviewed (86 males; mean age 18.1 months). Twenty-five urograms (13.6%) were obtained in cases where the urinary tract had previously been investigated. These urograms contributed no additional information. Image quality was suboptimal in 62 examinations (33.7%), due to gas, faeces or poor opacification, and two lesions were undetected on suboptimal radiographs. Urinary tract abnormalities were detected in 17 patients (10.2%). These lesions were also detectable at sonography. We suggest that routine post-angiocardiography urograms can be abandoned in favour of sonographic screening of the urinary tract in children with congenital heart disease.

Opportunistic screening for abdominal aortic aneurysm.

OBJECTIVE: To contribute to the current debate on screening for abdominal aortic aneurysm (AAA). SETTING: Radiology department of the John Radcliffe Hospital, Oxford. METHODS: The prevalence of AAA in 317 clinically referred male patients aged 65-74 undergoing abdominal ultrasonography with no clinical suspicion of an AAA was investigated over a period of one year. RESULTS: Over the year 15/317 (5%) patients were found to have an aneurysm (defined as aortic diameter (> or = 30 mm), with eight (3%) patients having an aortic diameter of > or = 40 mm. Six months later appropriate management for the AAA had been started for only four patients. A knowledge assessment questionnaire sent to 245 hospital clinicians and general practitioners showed that 17 (12%) of the 139 respondents would initiate no review of patients found to have an aneurysm of 30-39 mm and two would take no action with aneurysms of 40-49 mm. Thirty two (23%) respondents would seek advice on management for all categories of aneurysm, 14% from the radiologist. CONCLUSIONS: Opportunistic screening for AAA in men undergoing clinically indicated abdominal ultrasonography is easy, productive, without discernible cost, and discloses a prevalence of AAA comparable with that of population screening programmes. Routine opportunistic measurement of aortic diameter during abdominal ultrasonography in the at risk group would allow 12-15% of men aged 65-74 to be screened for AAA within five years without the need for any additional resources.

Pulsatility and resistance indices in intrarenal arteries of normal adults.

In order to establish the normal range of values of Pulsatility (PI) and Resistance (RI) Indices in the intrarenal vasculature, a study of 50 healthy volunteers (23 males, 27 females), divided into five groups of 10 according to age, was performed with Duplex Doppler ultrasound. Both kidneys were examined in all individuals and, in 12, indices were also compared between upper and lower poles of both kidneys. In addition, repeat examinations were performed in nine subjects on three different days, in order to assess the reproducibility of the method. No differences were found in the mean values of both indices between males and females, upper and lower poles, right and left kidneys. A statistically significant increase (p < 0.01, unpaired t-test) was demonstrated when the oldest age group (7th decade) was compared to the youngest age group (3rd decade). The method appeared remarkably reproducible for RI (4.2-7%), with wider variation in the PI (9.5-22.7%).

Menstrual irregularities are more common in adolescents with type 1 diabetes: association with poor glycaemic control and weight gain.

Ovarian function in post-menarchal girls with Type 1 diabetes was evaluated. Menstrual histories from 24 adolescents with Type 1 diabetes were compared with those from 24 age and sex matched controls. A fasting blood sample was obtained from subjects with Type 1 diabetes for the measurement of ovarian and adrenal sex hormones, LH and FSH, glucose and insulin, insulin-like growth factor-I (IGF-I), and insulin-like growth factor binding protein-1 (IGFBP-1); and an ovarian ultrasound scan was performed. Menstrual irregularity was more prevalent in patients with Type 1 diabetes than controls (54% vs 21%, p < 0.01) and their mean body mass index (BMI) was greater (22.3 +/- 0.5 (+/- SEM) vs 20.7 +/- 0.6 kg m-2, p < 0.05). Subjects with Type 1 diabetes with irregular menses (when compared with diabetic subjects with a regular cycle) had a significantly higher HbA1 (12.8 +/- 0.4 vs 10.5 +/- 0.5%, p < 0.01) and BMI (23.2 +/- 0.6 vs 21.4 +/- 0.6 kg m-2, p < 0.05) associated with a lower sex hormone binding globulin (SHBG) (37.2 +/- 4.0 vs 52.6 +/- 4.0 nmol l-1, p < 0.025) and IGF-I (1.4 +/- 0.2 vs 2.2 +/- 0.2 mUI-1, p < 0.025) and a higher LH:FSH ratio (2.6 +/- 0.5 vs 1.4 +/- 0.2, p < 0.05). Polycystic ovarian changes were identified in 10/13 (77%) of these patients with an irregular cycle. Menstrual irregularity is common in post-menarchal girls with Type 1 diabetes and is associated with poor glycaemic control and weight gain. The apparent high incidence of polycystic ovarian change requires further investigation.

Can ultrasound reliably detect renal scarring in children with urinary tract infection?

One hundred children with a proven urinary tract infection were studied prospectively using both ultrasound (US) and 99mTc dimercaptosuccinic acid (DMSA) scintigraphy to assess the efficacy of US in the detection of renal scarring. Sixty-nine girls and 31 boys with an age range of 0.5-11.8 years were studied. DMSA scintigraphy detected 19 scarred kidneys in 17 children. Scarring was classified as mild, moderate or gross. US detected a total of seven of the scarred kidneys (sensitivity 37%). US detected 0/6 kidneys with mild scarring, 1/7 kidneys with moderate scarring and 6/6 kidneys with gross scarring. Four kidneys with scarring on DMSA showed abnormalities other than scarring on US. 8/19 scarred kidneys were thought to be normal on US. It is important to detect renal scarring in young children and US cannot be relied upon for this purpose. It should therefore be supplemented with DMSA scintigraphy.

Prenatal deficiency of phosphate, phosphate supplementation, and rickets in very-low-birthweight infants.

A preliminary study showed that placental histology was abnormal for babies who subsequently had rickets. The findings--low plasma phosphate concentration; maximum percentage tubular reabsorption of phosphate; and high urinary calcium loss--are those of renal conservation of phosphate in the presence of phosphate deficiency. In a controlled trial no baby receiving phosphate supplements (50 mg per day) had radiological evidence of rickets whereas bone changes were apparent in 42% of the control group. Prenatal deficiency of phosphate, due to placental insufficiency, can be corrected by phosphate supplementation thereby preventing rickets of prematurity.

Ultrasound imaging of pancreas and biliary tract.

Ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) have been compared in the investigation of abnormalities of the pancreas and biliary tract. 208 patients undergoing ERCP were studied prospectively and all had an ultrasound examination in the 24 hours before ERCP. 15 patients had dilated bile-ducts for which no cause was seen on both ultrasound and ERCP; these patients were excluded. 120 of the remaining patients had an abnormal ERCP. In 101 ultrasound findings were in agreement (sensitivity 84%). 73 patients had a normal ERCP with ultrasound agreement in 70 (specificity 95%). The sensitivity and specificity of ultrasound is now such that patients can proceed directly to ERCP for diagnostic confirmation and papillotomy or endoprosthesis insertion where appropriate.

Ultrasound of the palpable abdominal mass.

A retrospective study was made of adult patients with a palpable abdominal mass referred by Hospital Practitioners to the ultrasound department over an 11 month period. One hundred and four patients were included in the study. Sixty-nine patients had an abnormality responsible for the clinically palpable mass and 35 patients did not . There was one false positive ultrasound diagnosis and one false negative. The correct organ of origin was suggested in 60 patients and the correct pathological diagnosis in 53 patients. The high positive predictive value (99%) and negative predictive value (97%) for the presence or absence of a lesion in these patients compare very well with the investigation of such patients by computed tomography and we suggest that ultrasound should be the initial investigation.

Hereditary pancreatitis: early ultrasound appearances.

The radiological findings in a family with hereditary pancreatitis (HP) are presented. The value of ultrasound in the diagnosis and in the screening of family members is illustrated, in addition to its use in following the clinical course and complications in a severely affected child. We demonstrate that pancreatic duct abnormalities, not previously described, are present prior to the appearance of the typical pancreatic calcifications of HP.

An unusual appearance of renal lymphoma.

The kidney is a relatively common site of extranodal involvement by lymphoma and various patterns have been documented (Richmond et al., 1962). We describe a patient in whom renal involvement by non-Hodgkin's lymphoma produced unusual appearances on ultrasound and computed tomography (CT). The possible causes and relevance of these findings are discussed.