Reporting requirements for skeletal digital radiography: comparison of soft-copy and hard-copy presentation.

PURPOSE: To assess diagnostic performance and reader preference when reporting results from digital hard-copy and two soft-copy formats of skeletal digital radiography. MATERIALS AND METHODS: The data comprised hand radiographs of patients undergoing renal dialysis. Normal hand radiographs obtained in trauma patients were assessed as control images. One hundred fifteen images acquired with a photostimulable-phosphor computed radiography system were analyzed. Image selection and initial assessment were by consensus of two experienced radiologists, who graded the radiographic changes of hyperparathyroidism with the Ritz scoring system. The images were then presented to four readers in three formats: hard-copy output and soft-copy presentations at 2K2 and 1K2 resolutions. These readers scored pathologic change and image preference. The results were analyzed with the receiver operating characteristic technique. RESULTS: There was a significant improvement in diagnostic performance for both soft-copy formats relative to the hard-copy format (P < .001). No significant difference in diagnostic performance was found between the two soft-copy formats. There was a significant preference for both soft-copy formats relative to the hard-copy format (P < .01), with the 2K2 soft-copy images preferred to the 1K2 images (P < .01). CONCLUSION: Soft-copy reporting can provide superior diagnostic performance even for images viewed at a modest (1K2) resolution. The lack of difference between the two soft-copy formats has important economic implications with respect to departmental hardware requirements.

The radiological treatment of hepatic artery aneurysms.

Improvements in the quality and availability of cross-sectional imaging should result in more frequent detection of hepatic artery aneurysms before rupture. Interventional radiological treatment for extra-hepatic lesions has not previously been discussed in the literature. We present two cases of extra-hepatic hepatic artery aneurysms treated using different endovascular techniques and discuss the relative merits of these approaches.

Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain.

The value of serum liver function tests and abdominal ultrasound as screening tests of the need for endoscopic retrograde cholangiopancreatography (ERCP) was determined in patients with unexplained abdominal pain without associated jaundice. In 1989 and 1990 1005 ERCPs were undertaken, of which 138 (14%) were for this indication. The duct or ducts of interest were delineated by ERCP in 95% of patients. The lesions found were bile duct stones in 10 patients, chronic pancreatitis in five, pancreatic carcinoma in one, peptic ulcer or duodenitis in four. A satisfactory ultrasound examination had been performed in 94% of patients. For chronic pancreatitis, its sensitivity was 60% and specificity 95%. For choledocholithiasis, the ultrasonic detection of duct dilatation or stones had a sensitivity of 90% and specificity of 86%. Of the liver function tests, the alkaline phosphatase was more sensitive (67%) than the transaminases (44%) in indicating the presence of bile duct stones and had a high specificity (95%). None of the 10 patients with duct stones had normal ultrasound and normal alkaline phosphatase. Thus it was found that demonstration of a normal common bile duct by abdominal ultrasound and normal serum alkaline phosphatase together have 100% specificity in excluding bile duct stones. Using such knowledge over the two year period of this study would have spared 36 patients the need for ERCP.

Familial visceral myopathy. A family with involvement of four generations.

A family with the autosomal dominant form of familial visceral myopathy is described involving four generations. The members illustrate several different clinical presentations including severe constipation, diarrhea, alternating constipation and diarrhea, volvulus, urinary tract infection, and retention of urine. One patient's history suggested that the uterus may have been involved. Diagnosis of this rare disease requires an awareness of the variable presentation and a careful histological examination of full-thickness sections of bowel. The potential pitfalls in both histological and clinical diagnosis of this condition are demonstrated in this family's history. The extensive involvement of small and large bowel in at least two family members is unusual in the autosomal dominant form of the disease, but their course has so far been favorable, lending further evidence to the impression that prognosis is good. This is of importance for genetic counseling of families who have this very rare disease.

Description and appraisal of a prototype digital fluorographic system.

A prototype system for digital fluorography (DF) has been developed from commercially available DSA equipment coupled to a standard screening unit. We present our initial clinical experience of this system with particular reference to the ergonomics, the image quality and the effect of image processing. We have concentrated upon dynamic studies such as upper gastrointestinal tract barium studies where the logistic advantages of the system are considerable. We have found DF to be ergonomically more efficient than conventional techniques. Using careful image processing the 512*512 matrix images were considered diagnostic for most studies assessed.

Iopamidol as contrast medium in endoscopic retrograde pancreatography: a prospective randomised comparison with diatrizoate.

In a prospective double-blind comparison of contrast media for retrograde pancreatography, 85 consecutive patients undergoing endoscopic retrograde cholangio-pancreatography (ERCP) were randomised to receive either the non-ionic medium, iopamidol (Niopam) or the ionic medium, meglumine diatrizoate (Urografin). The quality of pancreatograms obtained was assessed "blindly" using a specially devised scoring system, and patients were observed for clinical and biochemical evidence of acute pancreatitis following ERCP. Pancreatogram scores were similar in the "Niopam" and "Urografin" groups. No patients developed clinical evidence of acute pancreatitis. Eighteen hours after ERCP median increments in serum amylase and lipase in the "Niopam" group were significantly lower and hyperamylasemia and hyperlipasemia significantly less frequent than in the "Urografin" group. Niopam may be a safer contrast medium than Urografin for retrograde pancreatography, particularly in patients in whom the risk of acute pancreatitis is high. However, in view of its relatively high cost, further direct clinical evidence of reduced toxicity is required before Niopam can be recommended for routine use at ERCP.

Endoscopic retrograde cholangio-pancreatography in pancreatitis with persistent or recurrent pain.

We have reviewed the endoscopic retrograde cholangiopancreatograms (ERCPs) of 115 patients already known to have pancreatitis, who were referred because of persistent or recurrent pain, in order to determine the prevalence of those lesions that have been regarded as amenable to conservative surgery. Such lesions were seen on the pancreatograms of 35 patients and on the cholangiograms of 29 patients. In all, 53 patients (46.1%) had 'treatable' lesions demonstrated at ERCP. Preoperative ERCP is helpful in demonstrating operable features in both pancreatic and biliary systems, and should be part of any prospective long-term study of pain relief in pancreatitis.

Ultrasound detection of choledocholithiasis: prospective comparison with ERCP in the postcholecystectomy patient.

The role of ultrasound as a screening test for choledocholithiasis was prospectively assessed by comparing the results of upper abdominal ultrasound with direct cholangiography in 59 unselected symptomatic postcholecystectomy patients. Ultrasound detected duct stones in 13 of 29 patients (sensitivity, 45%) and their absence in 29 of 30 (specificity, 97%). A positive ultrasound diagnosis of choledocholithiasis was correct 13 times out of 14 (predictive value, 93%) whereas a negative diagnosis was correct on only 29 of 45 occasions (predictive value, 64%). No significant learning effect was seen. Intestinal gas obscuring the distal common duct was the most important factor limiting the ability of ultrasound to detect duct stones. Duct stones were present in 25 of 35 patients shown to have a dilated common duct on ultrasound, and in 4 of 24 with nondilated ducts; the predictive value of duct dilatation at ultrasound for duct stones was therefore 71% and that of nondilatation in excluding stones was 83%. Dilated intrahepatic bile ducts were demonstrated at ultrasound in only 17% of patients with choledocholithiasis. We conclude that ultrasound cannot reliably diagnose or exclude bile duct stones and is an inadequate screening test for the symptomatic postcholecystectomy patient.

Bile duct calibre: the discrepancy between ultrasonic and retrograde cholangiographic measurement in the post-cholecystectomy patient.

The discrepancy between bile duct measurements obtained by ultrasound and retrograde cholangiography in post-cholecystectomy patients was prospectively evaluated by performing real-time biliary tract sonography on 50 patients 2-3 h prior to endoscopic retrograde cholangiography (ERC). A significant discrepancy was detected (P less than 0.001) which was greatest in 14 patients shown by cholangiography to have duct dilatation without evidence of biliary tract disease (P much less than 0.001). Factors contributing to the discrepancy included: measurement of different regions of the duct by the two techniques, loss of duct wall elasticity producing a 'floppy duct' phenomenon, the capacity of the biliary tract for rapid spontaneous change in calibre, radiographic magnification and ultrasonic underestimation of duct diameter. The sonographic diameters were significantly correlated to the diameters measured by ERC (r = 0.73). Although ERC generally agreed with ultrasound in the diagnosis of duct dilatation (specificity 90%), there was significant disagreement between the two techniques in the detection of non-dilatation, dilated or 'dilatable' systems being missed by ultrasound in 11 out of 21 (52%) of cases in which they were found by ERC. Our results suggest that, in the investigation of the symptomatic post-cholecystectomy patient, direct comparison of bile duct size measured by ultrasound and ERC is of limited clinical value.

Medium term complications of endoscopic biliary sphincterotomy.

One hundred and fifteen patients were reviewed between 18 months and five years after successful endoscopic biliary sphincterotomy for choledocholithiasis, postcholecystectomy in 93 (81%). Thirteen (14%) postcholecystectomy patients and 11 (50%, p less than 0.001) with intact gall bladders are dead (cause of death was ascertained in each case). Of the others, 43 were interviewed and 48 completed a postal questionnaire. Stone free common ducts had been documented in 69 (76%), presumed in 16 (17%), and not achieved in six (7%, excluded from analysis). None of the responding patients had developed serious new problems. Current symptoms of those with and without gall bladders and those with 'documented' and 'presumed' duct clearance are similar. In no case has an episode of cholangitis since sphincterotomy been confirmed and only one patient has had documented recurrent duct stones. Continued incompetence of the sphincter was shown radiologically by the presence of bile duct gas in 14 (41%) of 32 patients. These results suggest that medium term complications of endoscopic sphincterotomy are unusual.

Prospective comparison of three non-invasive tests for pancreatic disease.

Ultrasonography, computed tomography (CT), and an oral pancreatic function test were evaluated prospectively in 107 consecutive patients suspected of having pancreatic disease, the final diagnosis being made independently of these tests. Seventeen patients proved to have either chronic pancreatitis or a pancreatic neoplasm. Five had an unfused ventral pancreas and 10 had "minimal change" pancreatograms. Seventy five patients did not have pancreatic disease. Among the 17 patients with pancreatic disease the sensitivities of ultrasound, CT, and the pancreatic function test were 70%, 71%, and 76% respectively; among those without disease values of specificity of the three tests were 75%, 87%, and 72%. All three tests failed to detect most of the patients with unfused ventral pancreases or minimal change pancreatograms. The predictive values of a positive result for the three tests were 43%, 67%, and 34%. The predictive value of a negative result was greater than 90% for all the tests. Results improved when CT was combined with either of the two other tests. These findings show that CT is the most accurate of the three tests in diagnosing pancreatic disease but that a combination of ultrasound and the oral pancreatic function test offers a more widely applicable and almost as accurate alternative.

Acute pancreatitis following endoscopic retrograde cholangiopancreatography.

An analysis of endoscopic retrograde cholangiopancreatography (ERCP) examinations suggests that repeated contrast injection into the pancreatic duct during attempts to cannulate the bile duct is of major importance in the aetiology of acute pancreatitis after ERCP, even in the absence of pancreatic acinar opacification. The technique of ERCP can easily be modified to avoid repeated pancreatic duct injection and, by doing so, an increase in the incidence of acute pancreatitis has been reversed.

The endoscopic retrograde cholangiogram and pancreatogram in chronic liver disease.

The endoscopic retrograde cholangiogram and pancreatogram of 22 patients with primary biliary cirrhosis, 33 patients with other forms of chronic liver disease and 28 'normal' controls were compared. The incidence of radiological intrahepatic duct abnormality is similar in patients with primary biliary cirrhosis and in other forms of liver disease, but is present in only a minority of both groups. A 'notch' or smooth indentation on the extrahepatic bile ducts at the porta hepatis was present in 58% of patients with primary biliary cirrhosis but in none in either of the other two groups. Three out of seven patients with sclerosing cholangitis showed minimal-change pancreatitis. Pancreatic abnormalities were otherwise infrequent.

The diagnostic yield of ERCP in the investigation of unexplained abdominal pain.

One hundred and forty patients with undiagnosed severe chronic abdominal pain who had not undergone previous biliary surgery were investigated by ERCP. A diagnosis was achieved in 34 patients (24 per cent) including 8 with previously undiagnosed peptic ulceration and 5 with gallstones. Twenty-five patients (18 per cent) had an abnormal pancreatogram, including 1 with pancreatic cancer. The incidence of pancreatogram abnormalities suggestive or diagnostic of pancreatitis was particularly high (60 per cent) in patients with a history of alcohol abuse. ERCP has a valuable role in the investigation of patients with 'obscure' abdominal pain.