Large-bowel obstruction resulting from traumatic diaphragmatic hernia: imaging findings in four cases.

OBJECTIVE: Large-bowel obstruction is most often due to primary carcinoma, diverticulitis, or volvulus. In populations of patients in which trauma is prevalent, however, an additional important consideration is traumatic diaphragmatic hernia. We describe the findings on plain radiographs and single-contrast enema in four adults who had vague complaints of abdominal pain days to months after an abdominal stab injury and large-bowel obstruction resulting from herniation of colon or omentum through the left hemidiaphragm. MATERIALS AND METHODS: We retrospectively analyzed plain radiographs of the chest and abdomen that were obtained before confirmation of colonic obstruction by single-contrast enema, surgery, or both in four men. Herniation of colon or omentum through the left hemidiaphragm was confirmed at surgery in all four cases. RESULTS: Posteroanterior and lateral radiographs of the chest obtained as part of the initial evaluation showed, in all four cases, abnormalities of the left hemidiaphragmatic contour. These included elevation of the hemidiaphragm in one case, loss of definition of a portion of the hemidiaphragm due to adjacent confluent opacity in two cases, pleural effusion in two cases, and small cystic lucencies above the diaphragmatic contour in one case. Abdominal radiographs obtained at the same time as the initial chest radiograph showed normal findings in two cases and mild dilatation of gas-filled colon in the upper part of the abdomen in two cases. In three of the four patients, progressive dilatation of the colon to the level of the splenic flexure was seen on serial abdominal radiographs. Large-bowel obstruction was confirmed by single-contrast enema in three cases and surgery in four cases. Minimal dilatation of the large bowel in the fourth patient resolved the day after admission; however, progression to complete obstruction was shown by single-contrast enema the following day. CONCLUSION: Delayed herniation through a trauma-induced defect in the left hemidiaphragm can be an unsuspected cause of large-bowel obstruction. Abnormalities of the left hemidiaphragmatic contour on plain radiographs of the chest should suggest the diagnosis in patients who have abdominal pain, colonic dilatation, and a history of abdominal injury.

Perioperative pulmonary function in acute respiratory failure: effect of ventilator type and gas mixture.

Whether maintaining pulmonary nitrogenation and/or a stable ventilatory pattern during surgery would minimize changes in perioperative pulmonary function in two groups of patients with acute respiratory failure (ARF) whose lungs were being mechanically ventilated was examined. Group 1 (n = 39 cases) (inspired oxygen fraction [FIO2] less than or equal to 0.5, minute ventilation less than or equal to 15 l/min, peak inspiratory pressure less than or equal to 50 cmH2O, positive end-expiratory pressure [PEEP] less than or equal to 10 cmH2O) were assigned randomly to one of four intraoperative ventilator-gas mixture (FIO2 approximately 0.5) combinations: 1) Siemens 900C ventilator, N2/O2; 2) Siemens 900C ventilator, N2O/O2; 3) Ohio anesthesia ventilator, N2/O2; or 4) Ohio anesthesia ventilator, N2O/O2. Group 2 (n = 15 cases) (ventilatory requirements exceeding any of those in Group 1) had their lungs ventilated intraoperatively with the Siemens 900C ventilator and a gas mixture determined by their anesthesiologist (FIO2 approximately 0.6-1.0). In patients whose lungs were ventilated with the Ohio N2O/O2 combination, PaO2/FIO2 decreased significantly (P less than 0.05) from 358 +/- 93 mmHg (mean +/- SD) preoperatively to 282 +/- 77 mmHg intraoperatively. The level of PEEP increased significantly from 5 +/- 3 cmH2O preoperatively to 9 +/- 4 cmH2O intraoperatively (P less than 0.05). In patients whose lungs were ventilated with the Ohio N2/O2 combination, PaO2/FIO2 decreased significantly from 270 +/- 86 mmHg preoperatively to 174 +/- 74 mmHg intraoperatively. These variables did not change significantly in patients ventilated with the Siemens ventilator (groups 1 and 2). Pulmonary oxygen gas exchange returned to preoperative values by the first hour postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

The widened teardrop distance: a plain film indicator of hip joint effusion in adults.

The teardrop distance is defined as the distance from the lateral margin of the pelvic teardrop to the most medial aspect of the femoral head as seen on anteroposterior pelvic radiographs. The structure responsible for the teardrop is the anteroinferior portion of the acetabular fossa with contributions from the ischium and from the superior pubic ramus. Anteroposterior pelvic radiographs of 10 patients with documented cases of unilateral hip effusion were retrospectively evaluated for teardrop distance widening on the affected side. Proof of the presence of hip effusion was based on the results of percutaneous hip joint aspirations as described in the patient's medical records. A teardrop distance widening of 1 mm or more was always consistent with hip joint fluid. In addition, radiographs from 20 patients with no known hip abnormalities were reviewed as a control population. These showed side-to-side symmetry in 16 cases (80%) and widening of less than 1 mm in the remaining four cases (20%). Thus, hip joint effusion in adults can be accurately diagnosed from plain radiographs in the presence of a teardrop asymmetry of 1 mm or more and in the absence of degenerative joint disease.

Splenic trauma: evaluation with CT.

Fifty-five consecutive cases of surgically proved splenic injuries were evaluated with computed tomography (CT). CT permitted correct identification of 54 splenic injuries, with one false-negative and three false-positive cases. In the single false-negative case and in two of the three false-positive cases, CT scans correctly indicated the presence of a large hemoperitoneum and other abdominal visceral lacerations and so correctly indicated the need for surgery. Of the 55 proved cases, CT demonstrated hemoperitoneum in 54 (98%), perisplenic clot in 47 (85%), splenic laceration in 39 (71%), and subcapsular hematoma in 13 (24%). Perisplenic clot can be distinguished from lysed blood in the peritoneal cavity and is a sensitive and specific sign of splenic trauma, even in the absence of visible splenic laceration. The authors conclude that CT is a highly reliable means of evaluating splenic trauma.

Radiologic techniques in the treatment of the critically ill trauma patient.

Discussed in this article are portable chest x-ray for imaging abnormalities in pulmonary aeration, pleural disease, and the position of life-support apparatus and abdominal computed tomography and ultrasonography.

Spontaneous pneumothorax in AIDS patients with Pneumocystis carinii pneumonia.

Although spontaneous pneumothorax has rarely been reported as a complication of Pneumocystis carinii pneumonia in AIDS patients, recent experience suggests that its frequency is increasing. Seven such cases have been encountered in the past 1 1/2 years, whereas no cases were found in an earlier review at San Francisco General Hospital of 90 AIDS patients of whom 56 had Pneumocystis carinii pneumonia. The cause of this increasing frequency is unknown.

Ultrasound localization of occult breast lesions.

High-resolution real-time ultrasound with either a 7.5- or 10-MHz transducer was used to localize 7/9 nonpalpable breast masses previously detected by mammography and to determine where the biopsy needle should be inserted.

High resolution CT of thoracolumbar fractures.

Twenty-one patients with thoracolumbar spinal fractures were studied with computed tomography (CT). A vertebral body was involved in 20; 12 had additional fractures of the posterior elements. Five had multiple level injuries. Neurologic deficits occurred in nine and were more common in combined vertebral body and posterior element injury. Five patients had surgical exploration of the spinal canal. CT provided more information than plain films, which missed a vertebral body fracture in one of 20, spinal canal compromise in four of 17, and posterior element fracture in one of 12. CT showed the posterior element injuries in greater detail. CT with intrathecal contrast material showed dural tear in one case. Dural tears were found at surgery in two additional patients studied without intrathecal contrast. All three had lamina fractures and cauda equina symptoms. Prompt repair of associated nerve root herniation led to rapid recovery in two of these patients.

High resolution CT with image reformation in maxillofacial pathology.

Twenty-four patients with maxillofacial pathology were examined with computed tomography (CT) using thin (1.5-5.0 mm) sections allowing computer reformation of images in multiple planes. Eight patients also had pluridirectional tomography. The patients included 14 with facial trauma, four with acute paranasal sinus infections, and six with suspected neoplasms. High resolution CT with reformations allowed thorough evaluation of facial trauma. Fracture sites were correctly identified, as were the relation of fragments to vital structures. The form of structural facial alteration was easily assessed, optimizing the presurgical plan for reconstruction. In addition, CT allowed simultaneous evaluation of associated brain injury. In acute infectious processes and neoplasms, CT defined the extent of involvement and directed the type of therapy. In both situations, accurate assessment of bony destruction permitted definitive planning for bony debridement in infection and helped in the differentiation of benign from malignant processes in neoplasia. Density determination also allowed differentiation of neoplastic soft tissue from inspissated mucus within obstructed sinuses. Experience suggests that CT can be the definitive imaging method in the diagnosis of complex maxillofacial pathology when sufficient evaluation is unavailable from plain films. It was superior to thin-section pluridirectional tomography in several instances.

Angiographic evaluation of the ductus diverticulum.

The aortic isthmus in adults has a variable appearance on thoracic aortograms. Its configuration may show a concavity, a straightening or slight convexity, or a discrete focal bulge. The latter finding represents a ductus diverticulum and, in review of 103 aortograms, was found present in 9% of patients. At times a prominent ductus diverticulum may resemble, and be mistaken for, a traumatic pseudoaneurysm of the aortic isthmus. A traumatic pseudoaneurysm may be distinguished from a ductus diverticulum on aortography by demonstration of an intimal flap and/or delayed clearance of contrast material on subtracted films. However, a ductus diverticulum will exhibit neither of these features.

Improved survival in management of empyema thoracis.

Empyema thoracis following pneumonia, trauma, and surgical procedures continues to be a source of major morbidity and mortality. We retrospectively reviewed the hospital records of 100 patients treated for empyema thoracis at San Francisco General Hospital during the past 10 years. The causes of empyema in these patients were as follows: pneumonia 44%, trauma 24%, surgical and invasive procedures 15%, lung abscess 11%, and hematogenous spread 6%. Ten patients in this series died of sepsis from necrotizing pneumonia or overwhelming injuries caused by trauma. Streptococcus (31%), Staphylococcus (21%), and Bacteroides (15%) were the organisms most commonly isolated. Bacterial isolates were single in 55%, multiple 42%, and absent in 3%. The type of organism did not correlate with severity of disease or eventual requirement for thoracotomy, pleural débridement, or Eloesser procedure. Successful methods of treatment included aspiration in 9%, tube thoracostomy in 63%, pleural débridement and drainage in 7%, and an Eloesser procedure in 11%. Because our patients were often debilitated from chronic alcoholism, drug addiction, and major trauma, conservative management was initially tried. In most patients empyema resolved with tube thoracostomy. Pleural débridement should be reserved for patients with special problems such as multiple loculation or purulence inaccessible to percutaneous tube placement. the Eloesser procedure is indicated in patients who have an infected residual pleural space that persists despite adequate tube drainage.

Diminished radiopacity of contrast material: a urographic sign of ureteral calculus.

Eleven patients with unilateral ureteral calculus had excretory urography which showed the radiopacity of excreted contrast material to be diminished on the side of the calculus. This finding was of diagnostic importance in nine patients who demonstrated little or no dilatation of the urinary tract proximal to the calculus. Other forms of unilateral renal disease, such as acute pyelonephritis, can produce the same urographic finding.

Radiographic appearance of the chest after pleural space reduction procedures: construction of a pleural tent and phrenoplasty.

Construction of a pleural tent and phrenoplasty are surgical procedures performed to reduce intrapleural dead space after partial lung resection. Both alter the radiographic appearance of the chest and may cause erroneous diagnosis including pneumothorax, subphrenic disease, subpulmonic effusion, diagphragmatic hernia, or diaphragmatic eventration. Radiologists should be aware of the potentially misleading appearance that these surgical procedures may present.

The variable roentgen appearance of traumatic diaphragmatic hernia.

Alteration of the diaphragmatic contour should be added to the list of radiographic signs of traumatic diaphragmatic hernia (TDH). Such changes may sometimes be appreciated prior to gross herniation of abdominal viscera into the hemithorax. Alterations of the hemidiaphragmatic contour are non-specific, but suggestive of TDH in the appropriate clinical setting.

The role of emergency excretory urography in evaluation of blunt, abdominal trauma.

In our hospital, patients seen for blunt, abdominal trauma have an "emergency" urogram. The results of our review of 209 such patients with complete urographic evaluations indicate that (1) the clinical examination, urinalysis, and plain abdominal roentgenogram do not reliably allow one to predict which patients would show urographic abnormalities and (2) the clinical management of these patients is rarely altered by the knowledge of the results of the urogram.

Renal trauma and retroperitoneal hematomas-indications for exploration.

One hundred nineteen patients with renal trauma documented at laparotomy or by an abnormal excretory urogram were followed up sufficiently to allow assessment of their postinjury course. One-fourth of these patients had a laparotomy and Gerota's fascia was opened; one-fourth had a laparotomy and Gerota's fascia was not opened; and one-half had no laparotomy. Gerota's fascia was opened only after vascular control of the renal pedicle was obtained. Nonetheless, the loss of renal tissue in this group was high. Twenty-three of 34 patients (68%) required nephrectomy or partial nephrectomy, indicating the severity of their renal injuries. The loss of renal tissue was low in the two groups in which Gerota's fascia was not opened. Six of 85 patients (7%) developed complications eventually requiring nephrectomy or partial nephrectomy; an additional three patients (4%) demonstrated loss of renal tissue on followup urograms, the loss being minimal in all three cases. The relatively low morbidity in these 85 patients indicates that their original renal injuries were, for the most part, less serious than the injuries in the group in which Gerota's fascia was opened. This low morbidity also indicates that retroperitoneal hematomas in the area of the kidney which are nonexpanding, contained, and nonpulsatile need not be routinely explored.

Traumatic disruption of the thoracic aorta: significance of the left apical extrapleural cap.

The plain chest film may be critical in deciding whether a seriously injured patient should undergo aortography in order to exclude traumatic aortic rupture. The roentgen findings suggestive of aortic transection reflect the presence of mediastinal bleeding. A left apical extrapleural cap is frequently seen in these patients but heretofore has not been emphasized in the literature.