Sonographically guided paracentesis for palliation of symptomatic malignant ascites.

The technique, results, and complications of 109 consecutive sonographically guided therapeutic paracenteses performed on 43 patients with malignant ascites are summarized. A 5.5-French Sacks One-Step Catheter was used in all cases but five in which tissue resistance prohibited passage of the catheter through the abdominal wall. The procedure was performed on an inpatient basis 70 times and in an outpatient setting 39 times. Colonic, ovarian, and breast carcinomas accounted for over 50% of the tumors resulting in malignant fluid collections. Three complications (hypotension, 2.6%) were directly related to the procedure; two of them were fatal (1.6%). The amount of ascitic fluid drained within the first 24 hr averaged 3.5 l at rates of 100-150 ml/sec. Ninety-five procedures (87%, in 39 patients) resulted in improvement of symptoms after drainage as manifested by decreased pain from abdominal distention, alleviation of nausea, improved appetite, or decreased dyspnea. The duration of symptomatic relief ranged from 4 days to 45 days (mean, 10.4 days). Sonographically guided paracentesis is an effective procedure that can be performed for short-term relief of symptoms caused by malignant ascites.

Single breath-holding scans of the abdomen using FISP and FLASH at 1.5 T.

Single breath-holding gradient echo techniques fast imaging with steady-state free precession (FISP) and fast low angle shot (FLASH) images were evaluated in the study of the abdomen in 16 patients (13 liver, two kidney, and one pancreas examinations). Gradient echo images were compared retrospectively with conventional spin echo images for image quality (depiction of pathology and representation of anatomic detail), and contrast characteristics were evaluated. All lesions were shown on gradient echo images, and in three of 16 cases gradient echo images were more diagnostic than spin echo images. On both FISP and FLASH images, most hepatic metastases were hyperintense relative to normal liver. The predicted flip angles for maximal contrast for the liver were modeled from signal intensity equations for FISP and FLASH and yielded predicted flip angles of approximately 40-55 degrees for FISP and 15-25 degrees for FLASH. Peak signal-to-noise ratio in liver of normal volunteers occurred at approximately 30 degrees for both FISP and FLASH. Single breath-holding gradient echo images are useful in the evaluation of abdominal structures and this study provides a framework for future work.

CT-guided laser therapy in resistant human tumors: phase I clinical trials.

Photodynamic therapy was performed on ten tumors in patients who did not respond to initial therapy and for whom no additional conventional therapy was available. A sensitizing agent (hematoporphyrin derivative [HpD]) was injected directly into each tumor under computed tomographic (CT) guidance to deliver high concentrations to the tumor and to minimize systemic toxicity. Three to 6 days after the injection, a clear Teflon sheath catheter was placed into the tumor under CT guidance. The tumor was exposed to red light (630-nm wavelength) through laser fiberoptics inserted in the sheath. The initial investigation confirmed the technical feasibility of CT-guided photodynamic therapy by means of intratumoral HpD injections and laser exposure through fiberoptics inserted in sheath catheters. The toxicity from a single treatment was minor, and the tumor response was encouraging.

Pneumoperitoneum following percutaneous endoscopic gastrostomy. A prospective study.

Percutaneous endoscopic gastrostomy (PEG) is a safe and widely used technique to establish an enteral feeding route. It has eliminated much of the operative morbidity associated with gastrostomy placed by laparotomy. The authors recently observed a patient who developed a benign pneumoperitoneum following PEG. Twenty-four patients were then prospectively studied after PEG to determine the incidence and significance of this finding. Nine patients (38%) developed radiologic pneumoperitoneum. Five patients (21%) had gross evidence of pneumoperitoneum, three patients had more subtle findings of small amounts of free air, and one patient had free air found by CT scan. No patient developed signs or symptoms of peritoneal inflammation. The authors conclude that pneumoperitoneum following PEG occurs frequently and that, in the absence of signs or symptoms of peritoneal inflammation, it is a benign finding which requires no further diagnostic or therapeutic intervention.

Diverticulosis of the vermiform appendix.

Vermiform appendix is an unusual site of diverticulosis. We present 3 examples of this entity and briefly review its pathogenesis and clinical significance. As a general rule, appendiceal diverticula are multiple, acquired naturally, and rarely associated with complications.

Neurosonographic recognition of subependymal cysts in high-risk neonates.

Serial neurosonography was performed in 210 high-risk, preterm neonates. Eleven (5.8%) demonstrated small cystic formations in the subependymal lining of the lateral ventricles. These subependymal cysts were unilateral and were detected at the exact site of a previous subependymal hemorrhage in two cases. These 11 infants were not significantly different in maturity, size, or clinical parameters from our main high-risk newborn population. Ten survivors had marked motor retardation at follow-up ages of 9-13 months, and one died from neonatal sepsis.

Pneumoperitoneum after percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is a safe and widely used technique to establish an enteral feeding route. It has eliminated much of the operative morbidity associated with gastrostomy placed by laparotomy. Although pneumoperitoneum can be seen after surgery and in association with certain endoscopic procedures, it has not been seen after percutaneous endoscopic gastrostomy. We describe a patient who developed a benign pneumoperitoneum after insertion of a percutaneous gastrostomy tube.

Caudothalamic groove: value in identification of germinal matrix hemorrhage by sonography in preterm neonates.

A prospective study of 25 consecutive premature infants under 1,500 g was undertaken to evaluate the frequency and sonographic appearance of subependymal germinal matrix hemorrhage. In all 12 sonographically positive cases, the hemorrhage was initially imaged in the area immediately anterior to the caudothalamic groove. Special attention to this area permits early detection of germinal matrix hemorrhage, and neurosonography of neonates should be considered incomplete unless this area has been thoroughly imaged.

Placental grading in the complicated or high-risk pregnancy.

A classification of the changes seen in the placentas of nondiabetic, non-high-risk obstetrical patients, and its relationship to fetal pulmonary maturity, has been the subject of two recent reports. Successful (100 per cent) correlation has been concluded from these studies when a Grade III placenta has been demonstrated in gestations of 33 weeks to term. To determine whether the same high degree of reliability would hold for the diabetic and high-risk obstetrical patient, 78 such patients were analyzed. All except one delivered at 33 weeks to term, and all had amniotic fluid lecithin-sphingomyelin (L/S) ratio determinations within 48 hours of sonographic placental grading and within seven days of delivery. Of the Grade III placentas (n = 13), 23 per cent had "immature" L/S ratios. However, there was no case of infantile respiratory distress syndrome (IRDS) in infants of patients with Grade III placentas. These findings suggest that placental grading may need to be part of a multifactorial assessment of fetal maturity in the diabetic or high-risk pregnancy.

Comparison of real-time and static-mode gray-scale ultrasonography in the diagnosis of cholelithiasis.

Real-time and conventional articulated-arm gray-scale static-mode scanning were performed on 100 patients in a prospective study to determine the complementary or duplicative roles of these two ultrasound modalities in the confirmation of clinically suspected cholelithiasis. Twenty-five abnormal findings were documented ultrasonographically, including 21 cases of cholelithiasis (12 confirmed by oral cholecystography and/or surgery), two cases of biliary sludge, one case of a gallbladder polyp, and one case of a probable blood clot. There was no instance of gallbladder lumen nonvisualization. Except in one case (that of a 420-pound patient), real-time ultrasonography documented all the gallbladder abnormalities shown by the articulated-arm static scans. In two cases, one corroborated by oral cholecystography, cholelithiasis was documented by real-time and not by static-mode ultrasonography. In most cases, real-time ultrasonography can be used to document the presence of cholelithiasis and obviate the need for conventional articulated-arm static-mode scanning.

Recurrent rectal carcinoma in an asymptomatic patient.

Pelvic recurrence is a common cause of symptoms and mortality in patients who have undergone surgical resection of rectal carcinoma. Diagnosis by physical examination and standard radiologic techniques is usually only possible when the recurrence becomes symptomatic because of its advanced state. Previous reports have documented the ability of computed tomography (CT) to depict accurately pelvic recurrence of rectal carcinoma in the symptomatic patient. Surgical resection of recurrence is usually noncurative but appears to result in a more prolonged survival if performed in the asymptomatic patient. We report a case of pelvic lymph node recurrence suggested by CT and confirmed by CT guided needle biopsy in an asymptomatic patient. Diagnosis of recurrence at this early stage by CT, supplemented with CT guided biopsy, may offer the patient an increased chance of survival following surgical resection.